The Injured Self: The Psychopathology and Psychotherapy of Developmental Deviations

THE INJURED SELF

THE INJURED SELF The Psychopathology and Psychotherapy of Developmental Deviations

Dov R. Aleksandrowicz and Malca K. Aleksandrowicz With a contribution by Dasi Ravid

First published in 2011 by Karnac Books Ltd 118 Finchley Road London NW3 5HT Copyright © 2011 by Dov R. Aleksandrowicz and Malca K. Aleksandrowicz

The right of Dov R. Aleksandrowicz and Malca K. Aleksandrowicz to be identified as the authors of this work has been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. British Library Cataloguing in Publication Data A C.I.P. for this book is available from the British Library ISBN-13: 978-1-85575-842-1 Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India Printed in Great Britain www.karnacbooks.com

Permissions Aleksandrowicz, M. K. (1975). The little prince: psychotherapy of a boy with borderline personality structure. International Journal of Psychoanalytic Psychotherapy, 4: 410–425, reprinted by kind permission of Jason Aronson. From Aleksandrowicz, M. K. (1975b). Reprinted, in a revised form, by kind permission of Rowman & Littlefield Publishing Group. Reprinted from Aleksandrowicz, D. R. and Aleksandrowicz, M. K. (1989). Copyright by the authors. Reproduced (with modifications) from Aleksandrowicz, Aleksandrowicz, M. K. (1989). Copyright by the authors.

D.

R.

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Aleksandrowicz, D. R. (2009). Mastery. Archives of Psychiatry and Psychotherapy, reprinted by kind permission of the publishers. Reprinted (modified), with Aleksandrowicz, D. R. (2009).

kind

permission

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Aleksandrowicz, D. R. (2010). Early Development. Archives of Psychiatry and Psychotherapy, reprinted by kind permission of the publishers. All patient information, i.e., names, initials and other identifying information, has been carefully disguised.

CONTENTS

PREFACE

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ABOUT THE AUTHORS

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CHAPTER ONE Psychotherapy of a borderline child: Uri

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CHAPTER TWO Early development and the developmental matrix

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CHAPTER THREE Clinical manifestations of developmental deviations

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CHAPTER FOUR Emotional effects of developmental deviations: the injured self

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CHAPTER FIVE Effect of deviations on the progression of developmental stages 73

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CHAPTER SIX Coping with maladaptive development

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CHAPTER SEVEN Raising a child with idiosyncratic development: a mission barely possible

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CHAPTER EIGHT Diagnosis of developmental deviations

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CHAPTER NINE Developmentally informed therapy

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CHAPTER TEN Psychotherapy of a girl with minimal ADHD: Giselle, the “Girl who Tamed Dinosaurs”

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CHAPTER ELEVEN Reconstruction in psychoanalysis: Ms. C., the “Slow Scientist”

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CHAPTER TWELVE Psychoanalysis of a patient with borderline personality disorder and minimal encephalopathy: Mr. G., the “Great White Hunter”

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CHAPTER THIRTEEN Shahar: art therapy of a boy with Attention Deficit Hyperactivity Conduct Disorder

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CHAPTER FOURTEEN Parent counselling and early intervention

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CHAPTER FIFTEEN Mastery, aggression, and narcissism

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CHAPTER SIXTEEN Cognition in psychoanalysis and psychotherapy

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CONTENTS

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CHAPTER SEVENTEEN Neurobiological perspective

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CHAPTER EIGHTEEN Conclusions

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GLOSSARY

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REFERENCES

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INDEX

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This book is dedicated to our children, Orley Kathleen, Anna Osnat, and Dan David, for their unflagging love and support

PREFACE

The ideas presented in this book are the outcome of years of conducting psychotherapy and psychoanalysis with adults and children, working with mother–infant groups, and studying infant development. Working with mother–infant pairs as an observer, rather than as a therapist, is for a psychoanalyst what time travel would be for an archaeologist, albeit infinitely more accessible. One is privileged to observe the early relationship in statu nascendi, as it unfolds, whereas reconstructing it in psychoanalysis is a slow, complex process, burdened by false starts, doubts, and painstaking (sometimes painful) examination of the countertransference. Observing “normal” infants in their natural environment allows one also to appreciate the rich variety of infant personalities and their impact on the caregivers. Working as therapists, we came to the realization that the basic psychoanalytic concepts such as psychic conflict, unconscious motivation, and childhood trauma, albeit invaluable and indispensable for understanding and for resolving psychoneurotic symptoms, do not alone explain adequately the wide range of maladaptive behaviours and relationships or the vicissitudes of caregiver–infant relationships. ix

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We join the ranks of those clinicians and investigators, like Brazelton and Cramer (1991), Escalona (1969), J. Osofsky and Danzger (1974), Korner (1971), Stern (1977), Thomas and Chess (1977), and Weil (1978), to mention only some prominent ones, who emphasized the variability of innate endowment and its impact on development. Our own work in the field of infant development (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1975, 1976), in which we employed the Brazelton Scale (Brazelton & Nugent, 1995), and our later work with mother–infant enrichment groups (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1987) allowed us to observe innate temperamental variability and developmental aberrations at an early stage. We were fortunate to follow some of our infant subjects for a while, but most of our clinical work was done with adult and child patients whose early development we did not observe first hand. In many of those cases we tried to reconstruct and unravel the complex interaction of a patient’s presumably innate characteristics with the personality of a parent as it transpired from the patient’s description and, often more conspicuously, from the transference paradigm. Clinical case studies of psychotherapy or psychoanalysis focusing on innate idiosyncrasies and their impact on emotional development are, to say the least, extremely rare (M. K. Aleksandrowicz, 1975b; Palombo, 1979; Palombo, 2001; Rothstein & Glenn, 1999). Our own attempts to introduce into therapeutic work the concepts of developmental individuality and of biological factors influencing personality were not always enthusiastically accepted. I vividly remember being castigated (many years ago) by a seminar leader at the Psychoanalytic Institute in Israel. Our class was studying a clinical paper by a very prominent child analyst, and I commented that the author had misdiagnosed as neurotic a child who was affected by Minimal Brain Dysfunction (as learning disabilities and attention deficit were called in those days). My disrespect for authority was ill-received by the teacher. Yet, both learning disabilities and the syndrome of Attention Deficit Disorder are known to be common conditions, as are several other developmental impairments, in our experience. It seems unavoidable that a substantial proportion of patients referred to psychotherapy or psychoanalysis will turn out to be affected by innate impairments. Therefore, we are confronted with the question of how such innate factors have shaped

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the personality and the symptoms of the patient and how to deal with this in therapy. Our book attempts to answer such questions. Chapter One is the point of departure for this book, namely, the story of a difficult and at times stormy psychotherapy of a child with serious psychopathology resulting, in part, from developmental idiosyncrasies. In Chapter Two, we present an outline of early emotional development, emphasizing the interdependence of motor, sensory, and cognitive development on the one hand and of emotional and social development (i.e., object relationship) on the other hand. Such a view of early development is required in order to fully appreciate the impact of idiosyncrasies of any developmental sequence upon the shaping of personality. Developmental idiosyncrasies of clinical significance can be divided grossly into two kinds, namely, extreme variation of a “normal” temperamental trait, such as activity-passivity, impulsivity, or stimulus sensitivity, or subtle impairments and delays. In Chapter Three, we describe the clinical effects, direct and indirect, of developmental idiosyncrasies and present illustrative clinical vignettes. Early impairments have profound effects on the way infants or children experience themselves. Warm, empathetic parents may comfort the child but will never be able to convince him that he is competent and that his efforts produce something deserving of admiration, if the child himself knows that it is not so. In Chapter Four, we discuss the impact of developmental deviations on emotional development and on the forming of the Self, and in Chapter Five the effect of developmental deviations on the progression of developmental stages. Chapter Six describes some devices adopted by children and adults in order to cope with the difficulties created by developmental deviations; such difficulties include functional impairments, dysfunction of ego regulatory functions (e.g., impulse control), and narcissistic injury. A developmental idiosyncrasy may impair the relationship of a child with his caregivers from the very beginning of life. In Chapter Seven, we discuss the impact of a child’s innate characteristics on the parents. Some developmental impairments, such as sensory overreactivity or poor motor co-ordination, seldom attract attention,

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and their implications for a child’s emotional development are often overlooked. Other impairments such as learning disabilities are conspicuous and easily diagnosed; not often, however, are the educators, who deal with such problems, fully aware of their emotional implications. Educators also often overlook the fact that developmentally impaired children are aware long before entering the formal education system that something in them is inadequate or different compared with other children. Chapter Eight discusses issues of diagnosis as well as some common misunderstandings with regard to interpreting clinical data. Chapter Nine is an introduction to the topic of therapy and presents an outline of what we call a “developmentally informed” approach to therapy of children affected by developmental impairments, as well as aspects of psychotherapy of children and adults. We emphasize the need to “validate” (a term coined by Linehan (1997)) innate impairments and to mitigate their effects, instead of futilely trying to “remove” them. In the chapters that follow we present examples of our clinical work: A case of a girl presenting with a mild Attention Deficit Hyperactivity Disorder (Chapter Ten), a therapeutic reconstruction in a neurotic patient undergoing psychoanalysis (Chapter Eleven), and the psychoanalysis of a patient with Borderline Personality Syndrome and, presumably, a minimal congenital encephalopathy (Chapter Twelve). Chapter Thirteen, written jointly with Ms. Dasi Ravid, an art therapist, describes the therapy of a young child affected by ADHD with pronounced behavioural symptoms. Chapter Fourteen discusses counselling of parents based on understanding of innate characteristics of the child, an understanding that helps to develop a non-judgemental, empathetic therapeutic alliance. This chapter also offers some suggestions for early intervention. Chapters Fifteen and Sixteen deal with theoretical topics, namely, the urge to master as related to psychoanalytical drive theory, and the role of cognitive processes in psychotherapy, respectively. In Chapter Seventeen, we discuss the implications of recent advances in neurobiology for the issues discussed in the book. The last chapter (Chapter Eighteen) presents concluding remarks.

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Some of the chapters have been published previously; credit is given when appropriate. This book was written for mental health students and practitioners; we hope, however, that it will also interest other professionals, such as educators and paediatricians, and that many parents will find it helpful. To make this book accessible to a broad spectrum of readers, we have tried to minimize the use of technical terms, though we could not avoid them altogether. We use quotation marks when mentioning some less generally known psychoanalytic terms to indicate that we refer to the concept as used by the author who coined it, e.g., Freud or Mahler. Some of our readers may not be familiar with certain terms, and not all analysts agree on the precise meaning of some concepts. Therefore, we include a brief glossary of such psychoanalytic concepts and explain our use of such terms. In most discussions we refer to an infant as “he” for brevity’s sake, but we imply “he or she” unless we refer to one gender specifically. By the same token, we refer to the primary caregiver as “she”, though men can be effective primary caregivers; no gender bias is implied. We use, reluctantly, the impersonal term “caregiver” rather than “mother” most of the time, in recognition of the fact that in our age other people, such as fathers or grandmothers, fulfil that role in numerous families. We generally refer to the therapist or investigator impersonally, but in some clinical descriptions, in which the therapist’s role was more emphasized, we found it more appropriate to use the first person pronoun. The reader may notice that we quote numerous relatively old studies, such as those of Mahler, Pine, and Bergman (1975) and Bowlby (1982). This does not reflect any lack of appreciation for more recent work but reflects the fact that the foundations of child development theories have been laid down by those pioneering investigators. Their followers have added valuable extensions and elaborations without, however, changing the principal elements of the theory. We are indebted to many colleagues and students for sharing their clinical experiences with us, to our mentor and friend Dr. T. Berry Brazelton who counselled us and encouraged our venture into developmental individuality, and to the public health nurses whose enthusiasm and skill were crucial in the success of the infant–mother groups. We owe many helpful ideas and literature references to our

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daughters Dr. Orley Marron and Ms. Anna Aleksandrowicz as well as to Dr. Assaf Marron. Our discussions with our colleagues in the Israeli Forum of Neuro-psychoanalysis were greatly stimulating, Ms. Karen Marron did an outstanding job of bibliographical research and editing the manuscript, while Ms. Layal Abu Khalil helped with preparing background material. Most of all, we are indebted to our patients who persisted tirelessly in the painful labour of unravelling the past. Dov R. Aleksandrowicz, M. D.

ABOUT THE AUTHORS

Dr. Malca K. Aleksandrowicz obtained her Ph.D. in Child Development and Clinical Child Psychology from the University of Kansas in Lawrence, KS. She was a pioneer of child development in Israel and a co-founder of the Division of Human Development of the Israeli Psychological Association. Dr. Aleksandrowicz taught infant development at the School of Education of Bar-Ilan University in Ramat Gan, Israel, organized the “Tippukhia” mother-infant groups at Bar Ilan University and in Mother-infant Health Centers in the Hasharon District. She organized a comprehensive intervention project in an underprivileged community, the “Palm Hill” project, in the framework of the Urban Renewal Project in Jaffa, Israel. She worked in private practice as a psychotherapist and supervisor. Dr. Aleksandrowicz passed away in 1993 in Israel. Dr. Dov R. Aleksandrowicz was trained in psychiatry at the Menninger School of Psychiatry in Topeka, KS, and in psychoanalysis at the Eitingon Institute of Psychoanalysis in Jerusalem, Israel. He served as the Director of Education at the C. F. Menninger Memorial Hospital, and later as Associate Professor and Chairperson xv

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of Psychiatry at the Ben Gurion University in Beer Sheva, Israel. Following this, he directed the Children’s Service at the Shalvata Mental Health Center in Hod Hasharon, Israel, and was a consulting psychiatrist to the City of Tel Aviv Educational Psychology Service. He was the President of the Israeli Psychoanalytic Society, and is a training and supervising analyst at the Israel Institute. He is also a member of the American Psychoanalytical Association and the International Psychoanalytical Association. He is a recipient of the Gustav Bychowski Prize in Psychoanalysis. Dr. Aleksandrowicz is a founding member of the International Neuro-Psychoanalysis Society, and a co-founder of the Israeli Forum of Neuro-Psychoanalysis. Dr. Aleksandrowicz is the author of numerous professional publications, in five languages. He lives in Ramat Gan in Israel, and divides his free time between family, writing, and sculpting. Dasi Ravid graduated from the Kibbutzim College of Education in Tel Aviv, Israel, received a B.Ed. in Creative Expression, and received an Art Teaching Diploma from the Oranim College of the Kibbutz Movement and the University of Haifa. Ms. Ravid serves as Senior Art Therapist at the Child and Adolescent Unit, Barzilai Medical Center, Ashkelon, Israel. She supervises trainees in Art Therapy and teaches University students. Ms. Ravid lives with her family at the Gvaram Kibbutz, in Southern Israel.

CHAPTER ONE

Psychotherapy of a borderline child: Uri

Prologue When Uri’s former therapist found a note saying that Uri had called from a military base, she became concerned. Was the phone call a signal of distress? Could this sensitive youngster make it in the rough world of military service? Her concern was understandable, because most of Uri’s early childhood had been an unrelieved misery, and his treatment stormy and arduous. As it turned out, there was no reason for concern after all. Uri, having learned that the therapist had recently moved to a city near his base, had called to tell her proudly that he had been admitted to the Israeli Air Force Academy, the most selective and demanding military flight training program there is. Looking back at Uri’s therapy we believe that its success and the stability of the treatment gains were due to an integration of psychoanalytic and developmental insights. The analytic approach was applied to interpretation of conflicts and defences. The insight into developmental pathology helped to shed light on the aberrations of emotional development and their impact on Uri’s self-image and family interaction. The diagnosis of idiosyncratic development was 1

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crucial in building up and sustaining a therapeutic alliance with the child and his parents, and relieving the sense of perplexity, impotence and hopelessness that dominated the family atmosphere. Understanding the deviational development and its impact was also essential in order to mobilize the considerable resources with which the child and his parents had been endowed. Therefore, we present in detail the case of Uri and his treatment to illustrate the practical as well as scientific need to integrate psychoanalytic and developmental approaches.

Reason for referral Uri was referred for treatment because of enuresis at the age of nine. There were other problems, too: a morbid envy of his thirteen-year-old sister, temper tantrums at the slightest frustration, and perseveration. If he got stuck on a topic—for example, Jeeps—it was “Jeeps” for breakfast, lunch, and dinner until the whole family dreamt at night about “Jeeps”. His scholastic achievements and social adaptation at school were good. He was particularly interested in math but refused to draw pictures, sing, or write stories.

History and family background Uri started his life as a second-born and after his mother had a miscarriage. While pregnant with him, Uri’s mother again had some bleeding and was confined to bed for a few weeks, but Uri was born at full term. According to his mother, Uri was a “strange” baby. He slept most of the time, but when awake he was not very responsive, nor was he cuddly. At one year of age he was a chubby boy and began to walk, but he stopped shortly after and began again at eighteen months. His peculiarities were clearly noticed at the age of eight months when the family visited an out-of-town relative, and Uri spent the entire day in the strange place screaming; he stopped only when the family reached home. From then on he showed a deep fear of strangers that persisted for years to come. Other peculiarities became apparent, as well: Uri did not allow anyone (including his parents) to pick him up or hug him, and he maintained distance from people.

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When strolling, his head was bent down, eyes cast on the pavement. He demanded that “sameness” be maintained, and he reacted with fear and anger to changes in his immediate environment. Uri was terrified of moving objects such as ceiling fans and department-store escalators and was very sensitive to noise. At the age of nine months he developed a fear of being left alone in his crib and for ten consecutive nights refused to go to sleep until heavily sedated. Subsequently, until the age of five, he woke up almost every night, at times screaming. Training for cleanliness began at eighteen months. Uri resisted; Mother fought but gave up. He would retain his faeces for two to three days and then excrete in his pants. This pattern continued well into his fifth year. He stopped wetting during the day around his fourth year but remained a bed-wetter. Uri began to talk at the age of two-and-a-half to three, and the parents could not recall any peculiarities in his speech. He showed a remarkable memory for numbers and dates. He was also very musical, and at the age of four-and-a-half he began to play the piano. He quit after six months but would become very agitated when his sister missed a note or if anyone in the household sang off-key. At the age of three, Uri began to attend nursery school. He would not play with the other children nor sing or paint; instead, he spent most of his time with different mechanical tools. When interrupted, Uri would throw a temper tantrum. At that time, he also began to collect keys of different sizes and functions. His conversation was almost exclusively around this topic, and every acquaintance brought him keys. All in all, he had two hundred keys. At age five, he was hospitalized in a psychiatric ward for one week because of his “key mania” and other peculiarities and was diagnosed as having “Minimal Brain Dysfunction”. His electroencephalography (EEG) showed a partial suppression of the regular rhythm, particularly on the left side, with irregular activity of 4–6 C/sec, more pronounced on the left posterior side. At five, Uri started to attend kindergarten. His interest in keys declined, and Uri now occupied himself with numbers and dates, irritating everybody with this topic. However, he began to sleep better and also became more sociable. A new problem appeared: accidents, first a cut requiring emergency treatment, then frequent bone fractures and cuts.

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When Uri was asked to do something contrary to his wishes (or when the sameness was disrupted), he would react with screaming or with a physical attack. This led to violent clashes with the mother, particularly in regard to body contact. Mother bathed, soaped, combed, and even kissed Uri, despite his resistance, well into his tenth year. The constant struggle between Uri and his family finally brought him into therapy.

Parents Father, a gifted, intelligent man, was the administrative director of a large general hospital. He was described by Mother and by himself (and later when observed by the therapist) as a kind, loyal, warm person, but very anxious and passive (though not in his work). In his role as a father, he appeared weak and preferred to withdraw rather than confront the problematic son. Mother was an attractive, intelligent but unsophisticated housewife with only a high school education. She was the kind of woman “who knows what she wants”, has her own views about the upbringing of children, and is not easily swayed by new educational fashions. However, she was not rigid and could accept reasoning. Mother was also quite aggressive in a sarcastic way and embittered about being forced into the controlling role in the family. She preferred her daughter, who was described by the parents as “normal” (in contrast to Uri), a compliant, sweet, uncomplicated girl.

Adventures in psychotherapy Uri was a beautiful boy with a slightly oversized head, blond, curly hair, and big round brown eyes with an expression of curiosity and naiveté, reminiscent of Saint-Exupery’s “Little Prince” (Saint-Exupery, 1943). He came to the first therapeutic session reluctantly but immediately opened up, almost shouting at the therapist: “I am a bed-wetter and I am sick and tired of it. Every morning I must rinse my sheets, but that is not what bugs me. I am angry because on weekend mornings, Mom, Dad, and my sister sit down at the breakfast table while still in their pajamas; I am the only one who must change because they say I stink.” In the first few sessions

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Uri expressed his envy and anger at the sister and told about a recurrent traumatic dream (its relation to the sister became apparent only later on): “A black water boiler is hanging over my head and about to explode.” Uri also talked about his fear of the buzzing sound of the fluorescent lights and of thieves. He did not allow his father to leave the therapy room and, in the presence of his father, without any inhibitions, inquired about “facts of life”. The topic was pursued in the next few sessions, and Uri expressed his deep fear of thieves, robbers, and empty spaces. One day he declared, “I have not wet my bed in the last three nights,” and clearly waited for a compliment. Instead, the therapist commented that she likes Uri whether he is wet or dry, because Uri is a likeable boy. Taken by surprise, Uri admitted, “I am not always so likeable,” and continued to describe his mischievous behaviour, letting his imagination loose, and plunging into aggressive sadistic fantasies. At the next appointment, he was angry at the therapist: “How come,” he complained, “I have been here already six times and last night I wet my bed again?” Quickly calculating Uri’s age, the therapist responded: “Well, you are 78,840 hours old. Do you expect to be cured in six hours?” Uri accepted the mathematical reasoning but demanded that the therapist predict the exact time needed for the cure. In answer to this request he was told that the therapist was not a god who could perform miracles. After the role of the therapist was redefined, Uri was reminded that the success of the therapy depended on his efforts, too. Thus the therapy touched upon the problem of the therapist’s lack of omnipotence, which soon led to discussions of Uri’s thoughts of grandeur. In the next few sessions Uri dedicated most of the time to glorifying his wristwatch (anti-magnetic, waterproof, Swiss-made), while at the same time belittling the therapist’s watch. Resistance mounted, but Uri continued to come, albeit reluctantly, and kept on talking about the same topics: idealizing one object or person (e.g., a neighbour’s dog, the teacher) and belittling another (the therapist’s dog, Mother). He was confronted with the explanation that in order to “feel big” he has to make others look small. The motive of “my watch is better than yours” was interpreted on the level of castration-fear, i.e., Uri’s body is more complete and thus better than the female’s body (sister, mother, and the therapist). An outburst of anger was Uri’s reaction to this interpretation, but the next

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association had to do with his sister’s vagina “which is red like a bleeding wound.” The therapist by then had realized that an angry response to an interpretation indicated a confirmation of the interpretation, which, in turn, produced further associations or even an actual change in behaviour. After two months of therapy a new topic appeared: suspicion. Uri inquired constantly whether Mother discussed his secrets or shared mutual secrets with the therapist. He was still bed-wetting and the time was now ripe to give him a new interpretation: wetting was his body’s way of telling him that something was so terribly frightening that Uri refused to even think about it. Instead, his body spoke for him. To this Uri volunteered the explanation that something bad may happen to his penis and that by urinating in bed he “checks” the state of his penis. And then Uri spoke about his mother’s “meanness” and her threats that, “If you keep pulling the penis you are bound to have wounds.” It was then suggested that bed-wetting was also a way of punishing Mother while at the same time masturbating. Uri’s loud voice attempting to drown out the therapist’s voice assured the latter that the interpretation was correct. During the next few sessions Uri dealt mostly with his feelings toward his parents: If Mother was positively described, Father was negative, and vice versa. The main complaint against Father was his weakness and over-anxiousness. The complaint against mother was that she preferred girls and loved Sister more than Uri. The “splitting” to “all good” or “all bad” was particularly clear in the family therapy session (which took place approximately once a month), and the origins of “splitting” as a defence mechanism were pointed out. Around this time, i.e., toward the end of first year, there was an increase in Uri’s compulsive masturbation at any time and circumstance, and Mother warned and threatened. Uri was convinced that masturbation would result in the loss of his penis. The therapist rejected this hypothesis, supplying Uri with the interpretation of castration fear as it is perceived by little boys—and little girls— and, of course, the purpose of the female sex organs for reproduction. Uri rejected this explanation but brought up the topic of his intense envy of his sister and expressed his wish to be a quiet, selfcontrolled child. When offered the interpretation, “You want to be like your sister so mother will love you as much or more,” Uri

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became angry and started bossing the therapist around, reasserting his omnipotence. The topic of omnipotent thinking became again the centre of therapy in the next few sessions, while resistance to dealing with it was at its peak. Uri’s need to control the environment was so strong that he even became infuriated when the cabinet door handles in the family’s kitchen were changed from red to black, and complained that they were black before, so why keep changing. The therapist explained to Uri that his need for sameness was a remnant of his past and asked him why he wanted things to remain unchanged, to which Uri answered: “I guess I get frightened when things are no longer the same. I guess ‘cause I lose control over them!” He was then asked if being an almighty king was really such a good bargain. Uri admitted that it was not: kings are above everybody; therefore they don’t have any close friends. They are lonely and envied but not really loved, and Uri wanted so much to be loved. However, Uri was still far from accepting the fact that he was just another mortal. At home, clashes with Mother were a daily routine. Old problems were now revived. Uri accused his mother of trying to poison him with her “broiled liver” and demanded only soups or desserts. Besides the problem of constipation, bed-wetting recurred. The family was gathered for an emergency family therapy session, and the session, as usual, started with mutual accusations. The therapist pointed out that neither was it Uri’s fault that he was born so sensitive and consequently was difficult to handle, nor was it the parents’, who did not know how to cope with Uri and tried every possible approach. After this statement (which was repeated in practically every family therapy session), tension was reduced, and the family started to work constructively. Uri was confronted with the interpretation that he was refusing to grow up—he wanted to stay a baby who eats liquids, lies in his urine and retains his treasured faeces. The mechanism of projection was also explained to him. But the anxiety kept on mounting, and he suspected a man in the bus station of approaching him. (It was not, however, entirely clear whether the man was in fact a paedophile who responded to Uri’s inquisitive eyes or whether the whole incident was just a paranoid delusion.) During the second year of treatment, at the time of Uri’s intense projective preoccupation, he also became extremely sensitive to dirt

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(or supposed dirt) and to almost indiscernible odours, dramatically expressing his disgust by spitting on the floor as if he were ridding himself of a noxious substance. Interpretations concerning reaction formation to dirt as well as the origins of his projection were loudly rejected; in light of Uri’s known sensitivities from his infancy, he might actually have experienced those odours more intensely than other people. One day Uri inquired whether circumcision could cause leukaemia. Not realizing the full implication of his question (since Uri was always worried about disease), the therapist just reassured the anxious child that leukaemia is a rare disease entirely unrelated to circumcision. That day, while running after a ball, Uri was hit by a car. His leg was fractured in two places, and Uri had to stay in the hospital for one month. The therapist visited him there and found a frightened little boy with a thigh-high cast on his leg. When Uri returned to therapy, he recounted several incidents of almost being run over by cars, “and you see,” he bragged, “I was not killed.” Again the interpretation of his thoughts of omnipotence was offered; again he became aggressive, but now he was asked why he reacted with anger when his immortality was challenged. Uri did not respond, but the following session he brought a dream: “Mother is on the staircase, a thief comes and snatches her purse; she offers him money, he takes the money but snatches the purse too and runs away.” Uri brought a number of associations leading to a conflict around his sex organ, that is, a conflict around acceptance or rejection of masculinity. The “snatching hand” in the dream is the same hand that was once fractured. “It is now stronger and quicker than before,” and with this hand Uri can play tennis “better than Dad.” At first, it sounded like a typical Oedipal fantasy; however, the “thief” in the dream stole the purse for his own body as well, and the meaning of it was revealed by association to the next dream. Uri saw “a black dog snatch something from my hand.” Again, at first glance, the dream expressed castration fears; however, it led to a more complex bisexual fantasy. Uri asked what happens to a fighter pilot who needs to urinate while flying at the speed of Mach 1. Does the pilot urinate in his pants? Since the therapist was silent, he himself answered: “The pilot must urinate in his pants or else he will die because his penis will become stiff and dry up. The dirty water in the kidneys will go up into the stomach, fill it up and then the

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stomach will explode, unless, of course, the bad water can come out through the penis.” And so Uri described his fear regarding erection and why he would immediately attempt to undo any by urinating. Therapist and patient now spent hours analysing thoughts and fears in regard to the bisexual identity conflict. Consequently, Uri was beginning the process of accepting and redefining his sexual identity. He was now less afraid of physical closeness to people of either sex. One day he stood very close to the therapist while his hand was busy scribbling. It suddenly dawned on the therapist that Uri wanted her to touch him. And so, for the first time since psychotherapy began, the therapist put her arm around Uri’s shoulders. He did not move; he wanted to be hugged! A few days later, the father came with tears in his eyes and told the therapist that Uri had asked to be loved and had even kissed Father for the first time in Uri’s life. At that time, the full-length cast was removed from Uri’s leg and replaced by a walking cast. Uri was worried that his leg would become short or crooked. He was also depressed, did not eat well, could not concentrate on his homework, and had difficulty falling asleep as well as waking up. During this convalescence, Uri became completely dependent on his mother for all his bodily needs. He also refused to stay alone at home. One day he sadly commented, “It is good to die. A dead person does not have to worry about pain anymore. Grandma is seventy years old. She is lucky, she does not have much time to suffer, she will soon die.” Uri spoke about the advantage of leaving this world, concluding with a heartbreaking matter-of-fact statement: “I am so different from the other children, I am really nuts and always will be.” The therapist asked him if his friends thought so, too. No, they did not, Uri responded; as a matter of fact, they visited him often and even begged Uri to play with them. The therapist pointed out that even though Uri was, in some ways different from other children, it did not necessarily make him “bad”, “crazy”, or less lovable. And then Uri brought another dream: “A thief was standing near my sister’s bed. The therapist illuminated him with a flashlight and the thief disappeared, became a bone, and only a shoe was left of him—a new blue shoe like my sister’s shoe.” The association dealt with his incestuous feelings, his guilt, and the punishment of becoming a skeleton. However, the “thief” motif repeated itself here too.

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Uri wanted to steal his sister’s shoe-vagina. Uri also wanted to be a girl. He repeated the accusation that his mother preferred girls since she liked his sister better. Resistance now reached a new peak. Father had to force Uri to come. First, Uri ran out of the room, and after a short while returned and started accusing the therapist of plotting against him; then he physically attacked her. The therapist had to twist Uri’s arm backward to hold him still. She then interpreted his aggressive act as appropriate for an infant and said that the attack was actually directed against his mother, whom he perceived as “bad” whenever he perceived Father as “good”. Thus Uri was confronted again with his “splitting” defence mechanism. Gradually he relaxed and the therapist released her grip. The next session Uri was almost apologetic and said: “I am sorry, I did not mean to hurt you. I just wanted to show Daddy that I am not afraid of you—that I am on his side …” Uri now expressed the wish to marry his father. That night he could not urinate, and he screamed in terror “that it was burning there”; consequently a physician was called in. He gave the boy some Valium, which Uri suspected might poison him. His behaviour was increasingly dominated by projection, and again the roots of his projection were interpreted to him. He then spoke about the contradictory wish: On one hand, he wanted to be a boy, proud and happy with his penis; but being a boy also meant being aggressive and nasty and unloved by Mother, who preferred the quiet, obedient sister. So in order to be loved by Mother he had to give up his masculinity. But giving up his penis and becoming pregnant meant death because the “dirty water” would fill up the stomach and it would explode. The dream about the “exploding water boiler” now became meaningful. Giving up his masculinity had another advantage; it could prevent the dangerous competition between father and son. Uri was re-experiencing acute Oedipal conflict, but two obstacles were hindering its successful solution: (a) Uri had not outgrown his narcissistic wish for omnipotence, which he projected and experienced as a terrifying threat from an almighty father; (b) Father was not a perfect model for identification. In the next few weeks Uri struggled with the problem of identification, trying gradually to pull together all his father’s qualities,

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assets, and shortcomings into one unit. Uri was trying to see his father as one whole object. At that time, during the second year of therapy, Uri was overcoming many fears. He went to the dentist and had his cavities filled without even a local anaesthesia, while in the past general anaesthesia was needed. He took swimming lessons (before, he had refused to go into deep water) and was about to participate in a swimming competition. Four hours before the competition, however, Uri ran, fell down and fractured his hand. He came with the new cast, smiled apologetically, and explained that this was the same hand he had once fractured on the hospital grounds. It turned out that his first accident had occurred at the hospital where his little cousin, a four-year-old boy, was dying of leukaemia. Uri was forced by his mother to visit this cousin. The cousin died, explained Uri, “because he was a bad boy and God took him away.” Uri then expressed his fantasy that if he hurt himself, God would not be angry with him anymore and would not take him away as he had the cousin. The issue of the Oedipal conflict was taken up again. Uri’s fear lest Father do unto Uri what Uri wanted to do unto Father was tied in with Uri’s infantile thoughts of omnipotence. The next few sessions dealt with Uri’s struggle to find an adequate solution for his Oedipal conflict. From time to time, Uri fell back on primitive defence mechanisms and particularly on projection. Other areas of functioning were successfully mastered. He was now a top student in school and was willing to express himself in singing, painting, and writing stories; Uri was also liked by both teachers and students. The relationship with his sister also improved. He was no longer so morbidly envious of her. He became closer to Father and they shared some activities. The clashes with Mother diminished. Uri also began to play a musical instrument; he joined a children’s orchestra and within three months caught up with the most advanced students. The last half year of therapy was dedicated to the consolidation of acquired insights and the new, more adequate patterns of behaviour. Uri understood that his exceptional inborn sensitivity was no fault of his and realized that his parents’ behaviour was often a reaction to his own. Uri now accepted both parents as people made of opposing qualities. “Splitting” was no longer a necessary defence mechanism.

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At this time, in family therapy, the therapist insisted that Mother stop bathing the boy and increase her physical distance from him, thus in a sense freeing him from her excessive maternal indulgence and over-protection. Encouraged by the therapist, she found a parttime job. At first, Uri resented the fact that he had to come home to an empty house and at times had to prepare a sandwich for himself. However, within a few weeks he became used to his independence and even took pride in his increasing responsibilities. Close to termination (about two years from the beginning of therapy), the therapist suggested that Uri undergo psychological tests and an EEG. Uri turned out to be a bright child with a high intellectual potential, anxious, with somewhat weak controls and a “trace of organicity”. The EEG was normal. A few days after the test, Uri, who had never left home before, joined his Boy Scout troop for a one-week campout. When he returned, he came to say goodbye to his therapist. She then asked him if he had been worried about bedwetting. Uri looked at her, smiled teasingly and said, “What kind of a psychologist are you, anyhow? Don’t you know that I quit wetting a year ago!”

Discussion and conclusions On reviewing Uri’s history one is struck by the gradual but dramatic change around the age of five. The withdrawn, peculiar, panicstricken child who lived in a world of his own began to develop social relationships and to participate in age-appropriate activities, albeit at the price of phobias, temper tantrums, and family conflicts. Mother seems to have played a major role in Uri’s adjustment to reality. Mother was not a “patient”, accepting person. As a matter of fact, she was a strong-minded, controlling, and aggressive, yet warm woman, who did not give in to Uri’s way of life. Never allowing Uri to withdraw, she insisted on physical closeness, and she did not give in to Uri’s food fads. The family regarded Uri as somewhat peculiar, but they followed the mother’s example and expected from Uri what they would have expected from a normal child. Father gave in more to Uri’s demands and terrorizing, to avoid head-on collisions. Mother was disappointed at Father’s weakness and angry with him for shifting Uri’s upbringing onto her. Consequently, there were bitter clashes between the two on this specific

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topic (which also became the focus for other marital disagreements). Had we not known about Uri’s early development, we might have been tempted to construct a pathogenic hypothesis for Uri’s problems as follows: An aggressive, controlling, ambivalent mother; a weak, withdrawing, anxious father; marital problems; and Uri, being a sensitive child, would be seen as the victim of this pathological environment. A closer analysis, however, revealed that Uri’s sensitivity, detachment, and odd behaviour dated from early infancy and might well represent symptoms of brain dysfunction, which was documented later. Therefore, we may assume that Uri’s inborn characteristics elicited conflict-ridden parental attitudes and set in motion a vicious circle of a disturbed relationship. In his last book, Kanner said, “Making parents feel guilty of responsibility for their child’s autism is not only erroneous but cruelly adds insult to injury” (Kanner, 1973, p. 139), and this statement may well be applied to families of all children with deviant development. It is quite plausible that the energetic behaviour of Uri’s mother, far from damaging the child, actually helped to pull Uri out of his autistic world, though at the price of building up a borderline personality whose functioning depended extensively on “primitive” defence mechanisms (O. F. Kernberg, 1984). The role played by primitive defence mechanisms had a considerable influence on the course and handling of therapy. Initially, the therapist reacted to the manifest Oedipal material (which consisted of both the “positive” and “negative” relationships), but, as therapy continued, the preOedipal conflicts came into the foreground and more primitive defences were revealed under the guise of Oedipal wishes. The most conspicuous regressive defence was represented by Uri’s thoughts of omnipotence, manifested also by disregard for danger. When Uri’s recklessness and accident-proneness were analysed, it became apparent that they served a dual purpose. One was to relieve guilt and to head off fears of death or castration (e.g., his question, “Does circumcision cause leukaemia?”); the other purpose was to reassure Uri of his immortality (“You see, I was not killed.”). Idealization and devaluation of the love object were other prominent mechanisms also related to the grandiose-narcissistic state. Uri’s attitude toward the therapist was one of boundless admiration, bitter envy and defiant depreciation: “My watch is better than

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your watch.” Uri’s self-concept vacillated between pathetic feelings of worthlessness (“I am nuts …”) and bragging. The idealizationdevaluation also led to splitting into the “all good” and “all bad” objects, which culminated in a physical attack on the therapist in order to gain Father’s affection. Uri’s omnipotent, grandiose fantasies and wishes have to be understood as compensatory attempts to cope with severe narcissistic injuries incurred as a result of grossly deviant development. This not only resulted in a distorted, negative self-image, but also hurt the relationships with his parents. His feelings of having been loved less than his sister were based on reality; it is not easy to remain affectionate when the child rejects physical contact, screams, or becomes immersed in incomprehensible activities. The last line of defence was represented by denial and projection. The denial was often apparent when Uri’s grandiose aspirations were challenged. Projection led to transitory delusion: fear of being approached by a homosexual, accusations of poisoning against the mother and complaints of evil smells. The delusions may have been facilitated by Uri’s unusual sensitivity to stimuli such as noise, movement and smell. As these primitive defences emerged, the therapist found herself forced to modify the treatment technique. Uri’s intense attachment was manifested by an overwhelming negative transference, and accuracy of interpretations was more often than not confirmed by Uri’s uncontrollable rage. The therapist felt that holding back interpretations because of the patient’s intense resistance and loss of reality judgement would lead nowhere. Moreover, it could have cast her in the role of the father who capitulated in the face of Uri’s rage. She therefore went on persistently interpreting the negative transference, challenged the reality distortions (mainly within the treatment situation itself), and pointed out how Uri’s rage was provoked by any threat to his narcissism and how he used it to terrorize and manipulate the environment. The direct challenge of primitive defences meant that she had to absorb intense aggression and at times had to control Uri physically. She was reassured, however, when she saw the patient becoming more relaxed and warm following such violent confrontations. One more comment about Uri’s aggression: It was provoked not only by a narcissistic injury but also by any attempt at physical

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closeness. Therefore, it seems probable that Uri, with his insecure ego boundaries, perceived closeness as a threat to his individuality; the fear of fusion mobilized aggression, which allowed Uri to keep a “safe” distance, albeit a lonely one. It is therefore possible that the decrease of aggression was brought about by the gradual clarification of his sexual identity and acceptance of his masculinity, which, in turn, helped to strengthen his self-identity and ego boundaries. The more primitive mechanisms could be discarded, thus allowing a better ego-integration. Summing up, it seems that Uri’s emergence from his autistic world was encouraged by his mother’s firm attitudes and consistent behaviour. From there, Uri moved into borderline personality organization with “the pathological condensation of pre-genital and genital aims under the overriding influence of aggressive needs” (O. Kernberg, 1968). The parents could not cope adequately with this situation. Mother expressed her ambivalence openly, Father in a more subtle way by withdrawing. Uri reacted to their behaviour, and the whole family was trapped in a vicious circle. Psychotherapy was aimed at arresting the merry-go-round, thus letting off its participants. The success of the treatment was facilitated by Uri’s desperate wish to be “like the others” and by admirable family cooperation. And so “The Little Prince” finally descended from his lonely star to join the crowded world of ordinary people.

CHAPTER TWO

Early development and the developmental matrix

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he twentieth century, heralded as “the century of the child” (Key, 1911), lived up to that name. The past decades have witnessed a growing interest in the study of children in general and infants in particular, reflected in an expansion of developmental studies. Volumes have been written on child development, and prestigious journals devoted to the subject are being published. The exponential growth of scientific data necessitates a re-assessment of psychoanalytic theory of emotional development. The early developmental theories formulated by Freud (1905, 1915) and his students, as well as those of most later psychoanalytical writers, were, by and large, inferred from reconstruction arrived at during the process of psychoanalysis of adults or older children. Mahler, Pine, and Bergman (1975) were the first psychoanalysts to conduct systematic observations of infants and toddlers. Studies conducted more recently by psychoanalysts such as Stern (1977, 1985) and Shuttleworth (1989) attempt to integrate data from systematic observations of infants and toddlers with data derived from adult or child analysis and are, therefore, more valid empirically than earlier studies. Even so, the subjective experience of the preverbal infant eludes our investigative tools, and theories of early emotional 17

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development are based, at best, on extrapolation and conjecture, and at worst on fantasies and projections of the adult patient or of the investigator. In spite of these limitations, systematic observations of the infant’s behaviour, of his emotional expressions, and of his response to his caregivers provide us with valuable data that have greatly modified our early views on emotional development. Infant development studies of the past few decades, although much too numerous to review here, have yielded several salient insights, which can be summarized as follows: a. Infants are not mere recipients of maternal care; they play an active role in eliciting a caregiver’s so-called “parenting response” and hence participate in shaping their own environment. b. It is a mistake to consider infants as merely immature, undifferentiated organisms. Such an “adultocentric” view overlooks the fact that infants come into the world well equipped for their role, and their very immaturity is an asset facilitating their development. c. There is considerable variability in the innate endowment of infants, a variability that can have profound effects on the infant’s relationship with caregivers and on future development. d. The infant develops along several dimensions simultaneously: perceptual, cognitive, motor, emotional, and social. These developmental lines are not merely contemporaneous and parallel; they connect intimately, creating a matrix of reciprocal influences. We will discuss these points in what follows. We will also attempt to integrate psychoanalytic theories of emotional development with developmental studies derived from infant observation.

The infant as an active agent (items (a) and (b)) Bowlby (1982) revolutionized psychoanalytic theory of emotional development when he demonstrated that the human infant, like all newborn mammals, actively seeks physical closeness to his mother or her substitute. The human infant is equipped with effective means to evoke a “parenting response”, thus enabling him to achieve the goal of closeness. Most newborn mammals have distinct physical features, such as a relatively large head and large eyes, as well as

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clumsy movements, which signal: “I am a baby.” Most of us respond with an inclination to play with or to hug a bear or lion cub, whether a toy or a live animal, and it takes some exercise of cool reason to realize that a live lion cub may not respond in a positive way to our attempt to play with it. The popularity of stories such as Bambi (Salten, 1928) is a testimony to the powerful human urge to nurture and comfort a baby in distress. An infant’s most obvious method of attracting attention is crying, but it is by no means the only one. The following anecdote may serve as an example of the infant’s gaze as an instrument for evoking a “parenting response”. While sitting in a sidewalk café, we noticed a middle-aged woman behaving oddly: she suddenly began making funny faces, smiling, and moving her hands in strange, repetitive ways. Most probably, she had not become suddenly deranged; she had spotted an infant a couple of tables away looking at her intently and was “seduced” by his gaze. H. Papousek and M. Papousek (1983) and Koester, H. Papousek, and M. Papousek (1989) studied adult “parenting responses”, such as opening the eyes widely or speaking to babies in a high-pitched voice, and came to the conclusion that these are instinctive, “wiredin” reactions, initially preconscious, of which the person becomes aware only after they take place. The newborn reacts to the caregiver’s ministrations with positive or negative affect; in this manner he provides the caregiver with cues that gradually shape her care-giving. The infant, in turn, learns to perceive cues from the caregiver (e.g., “Milk is coming!”) and to respond appropriately. This “private language” is vividly demonstrated by the “games” mothers play with babies, mutually stimulating and taking turns at vocalizing. Stern (1977, 1985) calls this a “dance”—a very apt metaphor. Schore (2003) studied the neurophysiology of caregiver–infant interaction and came to the conclusion that the right hemispheres of both mother and infant are intimately involved in what he considers “a dialogue of right hemispheres”. In conclusion, one might say that the infant and his caregiver are a single functional system to which each party actively contributes his or her individual characteristics, and in which each shapes the other’s behaviour by a set of cues and rewards.

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Developmental individuality (item (c)) All people may well be created equal, but no two infants are born alike. This simple fact has been only slowly accepted by the scientific community. In the years following World War II and the institution of the Nazi pseudoscientific philosophy of “racial inferiority” and of “constitutionally defective individuals”—a philosophy that led to the cold-blooded murder of the mentally handicapped and to genocide—all studies of innate differences were viewed with suspicion of being tainted with racism. Thus, the prevalent view at the time ascribed all developmental difficulties and later psychopathology to failure of adequate care-giving or to traumatic experiences in early life. All these do happen and often have deleterious effects on emotional development, but it would be a serious mistake to ignore the role of innate factors in psychopathology. The science of behavioural genetics offers so far scant information, but it is developing rapidly thanks to constantly improving techniques of genetic mapping and is making increasingly significant contributions to the understanding of personality (McGuffin, Riley & Plomin, 2001). Moreover, not all innate individuality is genetically determined: the intrauterine environment and perinatal events also affect the development of the brain and hence the innate endowment. Innate characteristics can be assessed at birth. Brazelton and his collaborators devised a behavioural scale that makes it possible to assess individual variations in neonates as early as a few hours after delivery (Brazelton, 1973; Brazelton & Nugent, 1995). In one of our previous studies (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1976) we found five statistically interconnected factors, i.e., clusters of Brazelton scale items, which might be seen as a profile of developmental individuality. The factors that clustered together were the following: 1. “Orientation responsiveness” to human auditory and visual stimuli, also to a bell and a rattle’s sound and sight. This factor also included the Alertness score. 2. “Habituation”, that is, inhibition of response to repetitive visual and auditory stimuli during sleep, “ignoring” a stimulus that no longer provides the infant with new information. In infants, this

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“shutting out” behaviour is an important adaptive mechanism. Babies cannot physically leave a situation that provides them with stimulation that may become distressful. 3. “Excitability”. This factor we assumed to be related to a diffuse excitatory state of the central nervous system (CNS). Behaviours that load into the “Excitability” factor include Irritability; Rapid changes in skin colour, reflecting changes in peripheral circulation; Changes in states, i.e., sleep to alertness or sleep to crying and/or activity; Rapidity of build up, that is, how many unpleasant stimuli produce crying. Consolability, the amount of intervention needed to comfort the infant, loads into this factor in the opposite direction; that is, the more excitable the infant, the more intervention he needs to console himself. 4. “Motor organization”. This factor emerged more clearly on the 10th and 28th days of testing. Behaviours loading into it included General tonus, Motor maturity, ability to hold head erect when Pulled to sit. At times, other behaviours such as Defensive movement (i.e., removal of a cloth put on the infant’s face), Cuddliness, and Activity joined this factor. The lack of consistent clustering of behaviour in the first days of life may be due to (a) the fact that motor organization during the first days is rather low; or (b) the effect of the different pain-relieving drugs administered to the mothers during labour and delivery. 5. “Relaxation”, a cluster of items not consistently correlated during the testing sequence. At times, Smiling in combination with Selfquieting ability and with Cuddliness loaded into this factor. At other times, Hand-to-mouth facility joined it. The Brazelton scale may well be called “an infant (innate) personality profile”. Brazelton’s work was followed by other investigators who described methods of assessment in infancy and even during intrauterine life. Prechtl and Einspieler (1997) conducted studies of foetal and infant movements and, on the basis of their findings, described a method to assess temperamental characteristics and to predict abnormal development later in life (Bos, Einspieler & Prechtl, 2001; Prechtl, 1990). Piontelli (1987, 1992) observed foetal movements to assess temperamental characteristics and reported cases in which a continuity of such temperamental traits could be seen later during early childhood. Werner et al. (2007) studied

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foetal heart rate and its predictive value regarding temperament. Other instruments to measure early temperamental traits were described by Bayley (1993), Carey and McDevitt (1978), Gartstein and Rothbart (2003), V. J. Molfese and D. L. Molfese (2000), and Rothbart (1981). Most studies of the effect of individuality on development, like the study of Colombo and Fagen (1990), follow the accepted scientific methodology. They observe a relatively large sample of subjects, focus on one variable, e.g., vigour, and try to eliminate the effects of other, confounding variables, such as parents’ personalities or the influence of siblings, in order to tease out the effects of the variable under observation. Clinical observation offers an entirely different perspective: one is compelled to conclude that the “confounding” variables are the ones that determine how much and in which way a specific developmental idiosyncrasy will affect the development of personality. The following vignette from our clinical experience may illustrate the idea: We and our colleagues had observed that hypotonic infants with slow motor development tended to be dependent longer than others and to be insecure and passive as children or adolescents. This, however, may not always be the case: Lillian was the first-born baby of a professional couple. Her prenatal history was unremarkable, and she appeared to be a healthy, alert baby. Her verbal development was precocious, but it soon became apparent that her motor development was exceedingly slow. She could sit only at the age of twelve months and could not walk until nearly twenty-four months of age. In spite of this she was a vigorous baby, interested in her environment and capable of letting the caregivers know of her wishes. She eventually closed the gap in her motor development, though she never became proficient in any athletic activity. An outstanding student and vigorous young woman, she graduated from college, became a business executive, and established a family in which she was a dominant presence, like her mother before her. We believe that Lillian’s development being so different from that of most infants with poor motility was due to cognitive precociousness, to her unusually vigorous temperament, and later perhaps to identification with her mother.

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The developmental “matrix” (item (d)) The study of human development, like other scientific investigations, is becoming increasingly specialized. The vast amount of information generated makes it virtually impossible for any investigator to keep abreast of advances made in other fields. Moreover, the refined methods for collecting and interpreting data cause investigators to drift apart into isolated areas of study, often divided by barriers of terminology and conceptual frameworks. A particularly conspicuous “language barrier” separates those investigators who study observable behaviours from those, such as psychoanalysts, who try to infer a baby’s emotional experiences and the emergence of so-called “psychic structures” from repressed memories retrieved in the course of therapy. Paradoxically, the spectacular advances in specialized developmental research reveal also its limitations. Specialized research achieves levels of validity and reliability unprecedented in the history of behavioural sciences, but the significance of such findings can only emerge from a broad, comprehensive approach, cutting across the boundaries of individual disciplines. An experimental investigation may show when and how a certain function matures or a structure comes into being, but it will not explain why; that is, it will not identify the evolutionary advantage of the timing of that specific function. A developmental sequence makes sense only when examined in the context of the functioning of the organism as a whole. Even the development of neural structures becomes meaningful only when it correlates with behavioural development. For instance, it has been found that the newborn guinea pig, which can move about, has many more dendritic spines in its cerebral cortex than does a newborn mouse, whose eyes are closed and which is comparatively much more helpless. At the age of two weeks, however, when the mouse’s eyes open, the density of dendritic spines in its cortex is similar to that of a newborn guinea pig (Schuez, 1978). One possible approach to investigate the relationships among different lines of development is to examine synchrony of developmental stages. In some instances, the maturation of one function may be a prerequisite for the development of another one; in other cases it only facilitates the development. Synchronization of development

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stages may not necessarily be due to any physiological link between them but may have evolved as a result of adaptive pressures. It may be advantageous for an organism to complete a specific developmental task before reaching a turning point in another area of maturation. In spite of the vast amount of developmental data, or perhaps because of it, it is not yet possible to outline a coherent model of a developmental matrix, but some significant relations do emerge. In the following paragraphs we will examine examples of synchronous functions beginning from the earliest stages of development. The primary developmental task facing a newborn is developing a bond with the main caregiver, the “primary object” in psychoanalytic terminology. During the first few weeks of life most infants seem to be less actively engaged in searching for stimuli, aside from those associated with basic body functions (such as nutrition) or physical closeness to the mother; Mahler, Pine, and Bergman (1975) called this stage, somewhat unfortunately, “autistic”. The term “autistic” is apt to be misleading, considering that the normal infant seeks physical closeness to his mother and shows signs of distress when separated from her. Even at that early stage an infant’s eyes are wide open when he is in the quiet-alert state (the state most conducive to absorbing stimuli), thus providing a wide field of vision and facilitating intake of stimuli. Within a few weeks the infant assumes a more active role in the process of attachment. We have already mentioned the “parental response”; the baby, on his part, is well equipped to facilitate it and to consolidate the attachment. The very immaturity of his organism favours attachment: the dependence on mother’s milk (the bottle and milk formula make life easier on parents but ought not to become tools to diminish physical closeness) and extreme motor immaturity make physical closeness unavoidable. The only mature voluntary motor movements are suckling and gaze following, both essential for developing attachment. An infant’s perceptual system is much more developed than his motor system. For instance, numerous studies have demonstrated that very young infants can discriminate between auditory stimuli (Aslin, Pisoni, Hennessy & Perey, 1981; Bridger, 1961). A newborn’s gaze is initially focused at about 20 centimetres, i.e., the distance from the nipple to the eyes of the nurse, allowing him to absorb the

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features of his mother’s face while nursing (Lichtenberg, 1983; Stern, 1977). To use an “adultomorphic” expression, one could say that the suckling infant is intent on memorizing his nurse’s face. Even a casual observer will notice that most men, when feeding a baby from a bottle, intuitively hold the baby close to their breast (usually to their left breast, although they may not actually know that the sounds of heartbeat have a soothing effect on an infant), i.e., at the same distance from their eyes. A suckling infant, on his part, looks intently into the eyes of the person feeding him. After a few weeks the baby can focus his eyes on more distant objects and begins to organize his perception of the environment. The most conspicuous perceptual ability of the infant is discrimination between familiar and novel stimuli, a precondition for recognition of the primary caregiver and the establishment of the bond (Mahler, Pine & Bergman, 1975). Infants usually respond with positive affect to the appearance of a familiar percept (H. Papousek & M. Papousek, 1983), especially a familiar person (unless the percept has been previously associated with an aversive stimulus, e.g., the white coat of the paediatrician). This response becomes more pronounced as the familiar person, i.e., the caregiver, becomes associated with experiences of being fed, comforted, or played with. The reaching of arms toward the familiar person is a vivid expression of the positive affective response. An infant’s joy at meeting the caregiver is, in turn, a powerful conditioning stimulus, shaping the attachment of the caregiver to the baby. In summary, an infant’s emotional and social development, i.e., his attachment to the primary caregiver and later attachment to “secondary” caregivers, is closely interwoven with the level of his motor and perceptual development. Between the ages of four and six months the infant develops visual–motor coordination, i.e., the ability to move his hands under visual control. It is a momentous event in an infant’s life. Mahler, Pine, and Bergman (1975) called the latter part of the first year “the practicing” stage, a stage that, in Mahler’s terms, leads to the process of “separation-individuation”. The term “separation-individuation” implies that before the occurrence of this process, during the first few months of life, the infant perceives himself and his mother as a “symbiotic” unit. The assumption that during that time the infant has no perception at all, however vague, of himself as a separate entity has been challenged by Stern (1977, 1985), but there is no doubt that

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the emergence of visual–motor coordination is a milestone in the development of the self. One can observe that some infants at this stage seem fascinated by their newly acquired competence and turn their hands in front of their eyes. The pleasure of mastering a task motivates the infant to repeat and practice that specific function (H. Papousek & Bernstein, 1969). In this manner he develops motor and cognitive skills and consolidates his sense of mastery over his body and over the environment. Therefore, on the basis of infant observation, one can conclude that the sense of competence becomes an essential component of normal narcissism in the following way: a. An effective operation of an ego function, such as a successful motor or cognitive act (e.g., solving a problem), is accompanied by pleasure (H. Papousek & Bernstein, 1969). b. The pleasure serves as a reinforcer and motivates the child to repeat the action. c. Ego functions that are repeatedly associated with a pleasurable affect become gradually invested with libido (i.e., narcissistic libido), which means that the subject feels proud of his motor or intellectual ability (D. R. Aleksandrowicz, 2009). d. The libidinally invested motor, perceptual and cognitive functions consolidate into a libidinally invested nucleus of selfrepresentation, corresponding to Freud’s “body ego” (Freud, 1923). The young child soon learns that some tasks can be mastered and some cannot. That is the basis of reality-oriented cognition. He also learns that there is considerable lawfulness and predictability as far as the mastery of his body and the environment are concerned, and the predictability contributes to a sense of security, complementing the sense of security derived from parental care. The expanding range of perceptual, motor and cognitive abilities not only contributes to the consolidation of self-representation, it also becomes entwined with social, i.e., child–caregiver, relationships. Many infants, once they are able to stand leaning on the side of a crib, love a specific game, which they might describe as follows: “You hold a toy outside the crib, drop it, and scream; Mother comes around, picks up the toy and leaves; you drop it again and scream, and the sequence repeats itself.”

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We assume that the games of dropping, like those of throwing objects, also serve to consolidate the mental representation of the body: everything that falls is not “me”; what remains, i.e., the fingers, is “me”. The growing skill of motor coordination is accompanied by increased interest in inanimate objects (Mahler, Pine & Bergman, 1975). The infants examine and manipulate any object presented to them. They develop a kind of “object examination protocol” not unlike a standardized scientific procedure: they try to pick the object up, shake it to produce sounds, and then put it into their mouths. This growing interest in inanimate objects results in a change of the role of the caregiver. She (or he) is no longer solely a person who provides for physiological needs and comforts in distress; now the caregiver is also a teacher. Parents facilitate practicing old skills and acquiring new ones by demonstrating, “shaping” (which means leading the child’s movement), and playing joint games, like rolling a ball back and forth. Children show obvious delight in such games and become attached to the people who play with them. At this time, in many families, the father or an older sibling acquires a major role in the infant’s emotional life. Again, a smooth transition into the changing infant–caregiver relationship, with the parent assuming a more teaching-focused role, depends on the synchronous emergence of motor skills and cognitive spurt. At the same time, the caregiver, in her new role, stimulates further development of motor and cognitive skills, and this means that there is a synergistic influence of cognitive-motor and social development. This is the time for developmental enrichment activities (M. K. Aleksandrowicz, Bason & D. R. Aleksandrowicz, 1997). There is an interesting synchrony at that time: most infants become capable of deliberately putting objects into their mouths at the same time (by four to six months) that they become capable of digesting soft foods, i.e., they are no longer exclusively dependent on milk. Thus, the synchronous emergence of motor coordination and of metabolic maturation may be considered a forerunner of autonomy. The emergence of mobility is another milestone in the infant’s emotional and social development (Mahler, Pine & Bergman, 1975). Once the infant can crawl effectively (some crawling infants move at an amazing speed), he no longer depends on crying or vocalizing as the main means to seek physical closeness; he can attain it

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actively. Some infants seem to enjoy turning the tables on Mother and engage in a “disappearing act” (as long as she is dependably available). Exploring the environment, reaching for distant objects, and, eventually, walking upright are accompanied by obvious delight and a growing sense of self-confidence. Motility provides the infant with opportunities for searching actively for stimuli and enriching his cognition. For instance, Kermoian and Campos (1988) demonstrated that the development of a sense of direction is facilitated by locomotion. Apparently, a child who explores his environment provides himself with visual, kinaesthetic and proprioceptive stimuli that facilitate the mental representation of space. There is a reciprocal relationship between exploration and emotional development: exploring the environment engenders self confidence, but a secure attachment to the primary caregiver is a precondition for vigorous exploratory behaviour (Bowlby, 1982). In other words, exploring space increases a sense of security, but an insecure toddler clings to his caregivers and has fewer opportunities to consolidate his orientation in space. During the second year of life the toddler enters into the “oppositional” stage: he asserts his autonomy as a separate human being by sizing up his will against that of his caregivers (Mahler, Pine & Bergman, 1975). The progress in motor development facilitates a more effective organization of the expression of aggression. We assume that the infant experiences rage as intensely as a toddler (perhaps even more so), but his ability to express it is much more limited. A toddler, in contrast, can throw objects, bite, kick, or throw a temper tantrum. The emergence of a more organized discharge of aggressive drive facilitates negativistic or defiant behaviour, which is an important component of “separation-individuation”, as Mahler called it (McDevitt, 1983). The negativistic behaviour of the toddler is not only a way of distancing himself from the caregiver but also a way of asserting his autonomy and enhancing his self esteem. He can perceive clearly his limitations in comparison to what the adults or older siblings can do. He cannot drive the family car (though he may love to sit on Father’s lap and turn the wheel when the car is parked) nor draw like Sister, but he can say “No!” to whatever is suggested. In other words, negativism is a way of coping with narcissistic injuries imposed by reality, and it serves to protect self-esteem.

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The acquisition of individuality implies the formation of a selfrepresentation, even a rudimentary one. In preverbal infants one cannot obtain direct evidence of self-representation, but one can deduce its appearance from behaviour. For instance, Stechler (1982) observed that infants become capable of organizing a goal-directed plan of action during the latter part of the first year of life and the beginning of the second. The infant may delay or modify such a plan of action during its implementation if the circumstances demand it. The observer, nevertheless, gets a clear impression that no matter what bypasses the child must implement, he knows very well what he wants, and he pursues the goal in a stepwise fashion. Stechler suggested that the mental representations of a wish and of a goaldirected, organized plan of action constitute the very beginning of self-awareness, the beginning of meta-cognition. The mental representation of a wish also facilitates the oppositional-defiant behaviour: not only “I don’t want”, but now: “I don’t want even though Mother does”. We have observed that the emergence of language toward the end of the second year seems to facilitate a more favourable resolution of conflicts and to reduce the intensity of the “battle of wills”. On one hand, toddlers respond more positively to attempts at persuasion (since it implies respect for the child as an individual), even when they do not quite understand the reasoning, than to forceful imposition of limits. Parents, on the other hand, are more inclined to attempt persuasion of a child who understands language. At the same time, the child’s ability to communicate his wishes reduces the number and the intensity of frustrations and leaves room for “negotiating”, i.e., allowing some gratification of the unacceptable wish and yet remaining within limits of permissible behaviour. The importance of language can be appreciated when one observes, as we have done, toddlers with slow development of language, especially of expressive language, who are particularly prone to outbursts of rage at that stage. During the second part of the second year (i.e., age 18–24 months) there is a leap in perceptual development: toddlers at that age, like adults, prefer viewing objects in the so-called planar view, that is from the top, side or bottom (Pereira & Smith, 2009), rather than viewing them at random as younger toddlers do, and they recognize and name objects much better than before. At the same time, they

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begin to engage in “pretend” play; that is, they begin to be capable of symbolic thinking. It seems probable that the advance in perception and recognition prepares them for the task of organizing in their minds the family structure: the differentiation between adults and children and between male and female. This step implies the emergence of category recognition. Children aged three to four develop the ability to recognize so-called “natural” categories such as classes of animals (Gelman & Markman, 1986). At approximately the same time, i.e., toward the end of the second year of life and the beginning of the third, there is a rapid development of cognitive skills, language, and gross as well as fine motor skills. These are the years of the Oedipal stage, according to the psychoanalytic theory of psychosexual development. The child’s relationship with his family members, i.e., parents and siblings, changes drastically. They are no longer perceived as merely gratifying or frustrating. The child now tries to form alliances with one parent against the other, perceiving one parent as the beloved one and the other (more often the one of the same sex) as the competitor. Some such alliances are relatively stable, especially if reinforced by a parent’s attitude; more often than not, however, they are opportunistic, i.e., depend on which parent is more responsive to the child’s wish of the moment. The child often also identifies in a competitive way with older siblings, especially those of the same sex. The spurt in motor skills facilitates identification and competition: an agile five-year-old, for example, can engage in some activities, such as climbing a ladder, as well as or better than his overweight parent. Talented four- or five-year-olds can play music at a concert level. In other words, the rule that “whatever the child does, the grown-up can do better” no longer applies in such an absolute way. This fact constitutes a strong incentive for the competitive identifications typical of the Oedipal stage.

Conclusions In conclusion, we suggest that the development in each of the areas—neural, motor, perceptual, cognitive, and social-emotional— is not merely an unfolding of separate pre-existent developmental sequences, facilitated or inhibited by environment. It is a complex interaction, a matrix, of the various developmental lines. A comprehensive model of human development should integrate all these

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development lines. Such a model ought to express the complex reciprocal relationships among the various developmental sequences at each stage. Moreover, it ought to present all the developmental sequences and their synchronization from an ethological perspective, i.e., it should investigate their adaptive and survival values. Today, such an integrated model of human development seems an unreachable goal, even though more and more clinicians and experimental investigators attempt to formulate their ideas in ways that cross inter-disciplinary boundaries. At the same time, the revolutionary progress of neurobiology holds the promise of an additional dimension of the developmental matrix, shedding light on relationships between brain maturation and the unfolding of behavioural and emotional development. Moreover, one may hope that the study of brain networks will buttress the insights gained from child observation regarding the interdependence of emotional, cognitive, and motor development.

CHAPTER THREE

Clinical manifestations of developmental deviations

D

evelopmental deviation, in the context of this chapter, refers to a variety of patterns of idiosyncratic development, including temperamental variability, developmental lags, circumscribed functional impairments, and relatively minor cases of discrete clinical syndromes such as Attention Deficit Hyperactivity Disorder (ADHD). We do not refer to gross pathological conditions such as Autistic Spectrum Disorders or mental retardation. Rather, we discuss relatively subtle deviations that allow a person to develop and function within a seemingly normal range yet may have a profound effect on emotional development and personality. The common element in the conditions we discuss is the presence of a demonstrated or presumed biological factor resulting in emotional or behavioural maladaptation. The nature of such a biological factor is not always easy to establish, but we know that genetic factors, the intrauterine environment (such as maternal stress or nutrition), and the early physiological and social environment all influence brain development and hence later emotional and interpersonal development. In many cases it appears probable that multiple factors operate in synergy to disrupt optimal development. The case of Uri (Chapter One) illustrates the need to take such biologically 33

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influenced idiosyncrasies into consideration when dealing with patients whose development has been irregular or impaired. Idiosyncratic development is common. The prevalence in the United States of just one syndrome, ADHD, has been estimated at 8.7% in children (Froehlich et al., 2007), and prevalence of the adult form of the disorder has been estimated at 4.4% (Kessler et al., 2006). Another study suggests that 90% of subjects affected by ADHD in the US remain undiagnosed (Babcock & Ornstein, 2009). These estimates are probably conservative. Advances in reproductive medicine, such as in vitro fertilization, cryopreservation and artificial prolongation of fertility age, all carry a substantial risk of long-term unfavourable developmental outcomes as a result of less-than-optimal brain development. So does the survival of pre-term infants with very low birth weight (McCormick et al., 2006). We have no reason to assume that subjects affected by idiosyncratic development are less susceptible to psychoneurotic disorders than the general population. Quite the contrary, early difficulties seem to predispose subjects to a disruption of emotional development and hence to neurosis or personality disorder. Therefore, one is justified in assuming that a considerable percentage of patients referred to psychotherapy or psychoanalysis will, on closer examination, also be found to be affected by some form of developmental difficulty; this has indeed been our experience in our practice. Biological factors do not operate in isolation: they interact with environmental influences, i.e., parental attitudes and life events, and fuse into personality structures. The latter are “slow change processes” (Rapaport, 1967), i.e., relatively enduring, though not immutable formations. We use the broad term “deviation” intentionally because we refer to a wide range of innate variables that may affect development. Such deviations can belong to one of two categories. The first category of developmental deviations consists of unusually pronounced manifestations of “normative” temperamental traits such as vigour or sensitivity. Temperamental traits refer to how people act and think, e.g., slowly or rapidly, rather than what they do. The second category of deviations consists of developmental lags or mild impairments. In practice it is often difficult to distinguish between the two types of deviations, since clinical manifestations often include both. Developmental delays may also be difficult to separate from impairments; for example, a child with slowly developing motor coordination is

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likely to remain clumsy in the years to follow. Some developmental idiosyncrasies, such as excessive sensitivity, are apparent from the earliest stages of life; others, like poor gross motor development, become apparent only with the emergence of a particular function. In the discussion that follows we will refer to each category of developmental deviation.

Temperamental idiosyncrasies We have mentioned previously the difficulties encountered in studies of temperamental individuality (Chapter Two). Systematic studies of innate temperamental characteristics began only after the middle of the last century with the pioneering studies of Escalona (1969), Korner (1964, 1971), Thomas and Chess (1977), and Weil (1978), which brought the subject of temperamental variability into focus. Innate temperamental characteristics determine how an infant experiences the world and reacts to it, as well as how the caregivers respond. A large body of knowledge about varieties and stability of temperamental traits has accumulated over the past few decades. The bulk of publications concerning innate temperamental variability deal with theoretical aspects, whereas clinical case descriptions and therapeutic implications are rare, to say the least. This bias is particularly pronounced in psychoanalytic literature. Emde (1988) wrote an extensive review of psychoanalytic literature regarding innate factors in personality development. Most of such literature refers to the “complementary series” model, which assumes that the more pronounced the impact of innate factors, the less critical will be the effect of environment, and vice versa, the more powerful the impact of the environment, the less will be the role of innate characteristics. This model has some merit, but it does not take into account the complex inter-relation of innate and environmental factors (and, in particular, the effect of innate variables on the environment) or the mutual relationships of the innate characteristics, the “matrix” described in Chapter Two. Some of the psychoanalytic literature, such as Freud’s Analysis Terminable and Interminable (1937), refers to innate characteristics primarily as factors limiting the effectiveness of psychoanalytic treatment, rather than as clinical determinants that, if integrated into the therapeutic process, might actually

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facilitate its progress. Lichtenberg (1983), in his exhaustive review of infant research and psychoanalysis, did not discuss developmental individuality, nor did Shuttleworth (1989). A few psychoanalytically oriented case studies have been published: Fries and Woolf (1953) presented cases illustrating the effects of “congenital activity type” on the development of personality and formation of symptoms, and M. K. Aleksandrowicz (1975a) described the treatment in a case of temperamental “mismatch” between mother and child. This patient, a vibrant, restless child, has since become a gifted dancer and choreographer, a vocation that expresses well her true nature (M. K. Aleksandrowicz, unpublished). Temperamental idiosyncrasies, such as an excessive degree of a “normative” temperamental trait (e.g., vigour or sensitivity), cannot be classified as clinical syndromes and are therefore not represented in standard diagnostic classifications. Their impact on personality formation and adaptive or maladaptive functioning in later life, however, is potentially considerable and depends on the degree of compatibility with the temperament of the caregiver. In one of our infant–mother groups we had two infants with diametrically contrasting temperaments: Tommy was a happy-go-lucky, vivacious child, always on the move, crawling around vigorously. His mother played with him most of the time, holding him high up, often upside-down, and he apparently enjoyed those rough games immensely, earning the nickname of “the General” from us. Across the room was Lucy, a plump girl of the same age, sitting most of the time on her plump mother’s lap, immobile but visibly interested in what was going on, fixing her gaze on people as they spoke. We discussed those striking differences in temperament, and Tommy’s mother, who was a former athlete and high school physical education coach, commented: “If I had a baby like Lucy I would be going bonkers.” We will present some examples of extreme variations of innate temperamental characteristics, and in the following chapters we will discuss their emotional implications.

a. Sensitivity Strong stimuli, such as sudden loud noises, usually evoke negative responses, whereas mild stimuli are more apt to evoke interest, often mixed with a touch of anxiety. A hypersensitive infant will over-react

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to intensive stimuli such as loud noises or to novel stimuli such as the touch of sand or grass, and he experiences even moderate stimuli as distressful. Such infants cry more often than other infants, may be more difficult to console, and demand much more attention. Extreme hypersensitivity may lead to severe psychopathology (Bergman & Escalona, 1949). Hypersensitive infants appear fearful and are probably more at risk to develop a so-called insecure attachment pattern, though the subject does not seem to have received the attention of investigators. Those infants fare better in an environment with a limited range of stimuli; they often prefer to be swaddled or relax in a bath. This trait tends to persist: when they grow older such children are criticized or ridiculed by their peers, called “sissies” or considered “spoiled”. Therapists attribute over-sensitivity to maternal over-protection, an assumption that may be justified in some cases but ignores the possibility of an innate factor. It also ignores the fact that a mother of an over-sensitive infant or child becomes over-protective, trying to spare the child from distress.

b. Habituation Many hypersensitive infants also have a diminished ability to habituate. Habituation means a progressively diminishing response to a repeated stimulus. A striking example is the ability of a cat to doze in a living room while children are playing noisily, the TV is blaring, and trucks are rumbling outside. Yet the cat’s senses are not shut off: if one scratches a table the cat’s ears will rise; it will open its eyes and turn its head toward the sound (so-called alerting response) searching for the mouse. If we repeat the scratching sound several times, the cat will only raise its ears without opening its eyes and will finally cease to respond altogether. The biological aim of habituation is to protect the organism from being “overloaded” by an excess of stimuli and wasting energy on repetitive response to stimuli that are no longer relevant. An infant cannot remove himself from a continuous or aversive stimulus, nor can he control the source of it. Therefore, habituation is his only means of protection from unnecessary or unpleasant stimuli. Infants differ considerably from one another in their capacity to habituate, but each individual infant shows a fairly consistent capacity to habituate to stimuli of diverse types (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1976). An infant whose capacity to habituate is impaired, for instance due to barbiturates or opiates administered

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during delivery (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1974; Brackbill, 1979), is at risk of becoming over-stimulated, excitable, and exhausted, unless his caregivers protect him from excessive stimulation.

c. “Cuddliness” Most infants tend to cling to the caregiver’s body when held close to her chest; they seem to seek a maximum area of physical contact. Some newborns, around 15%, bend backwards and struggle against being held close (Brazelton, personal communication). Such infants like best to sit on a caregiver’s lap, leaning on her but maintaining a wide field of vision and freedom to move their arms. An inexperienced, insecure mother might easily become frustrated and feel “rejected” by a non-cuddly baby. In Chapter Fourteen, we describe such an infant. d. Activity level Unusually active, vigorous infants demand a great deal of attention; they signal their discomfort and frustration loudly and persistently. Whether this will have a favourable effect on the infant’s development depends mainly on the resources available to the primary caregiver, namely her personality (as described above) and the support of her environment. Very passive, hypoactive infants may easily be under-stimulated in a large family with little external support, where the father is absorbed in making ends meet, and the harassed mother has to parcel out her attention to each of the children. Lack of adequate stimulation in such circumstances may exert an unfavourable effect on the motor and cognitive development of the child. In contrast, a very passive infant who is the first-born child of his parents and also the first grandchild of an affectionate grandmother can survive psychologically quite well, since the attention lavished on him requires very little initiative on his part. A very passive child is also at a greater risk of becoming victimized as the subject of a sibling’s envy, a situation that may lead to traumatic experiences, especially if the sibling is considerably older. e. Adaptability Infants react to novel situations with heightened vigilance, which means interest mixed with some degree of anxiety. Familiar stimuli,

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in contrast, are associated with positive affect (unless the infant has become conditioned by an aversive stimulus) and facilitate relaxation. Most infants fall asleep much more easily in their own bed or cot and will fuss for a while if placed in an unfamiliar environment, but eventually they become accustomed to the new milieu and relax. Some infants, however, are unusually intolerant of a change of environment and will refuse to sleep until utterly exhausted. Such infants do not enjoy family outings, are terrified by the sight of animals, and generally show very low tolerance of novelty. As a result they experience an excessive amount of negative emotion, even if the family provides them with a “good enough” environment. Moreover, their cognitive development may be affected, since novel stimuli are the catalyst of cognitive growth.

f. Tempo People of any age, including very young children, vary in their tempo and rhythm of movements. There is a wide variability in the spontaneous tempo and rhythm of activity in infants, and Kestenberg, Marcus, Robbins, Berlowe, and Buelte (1971) demonstrated the importance of the congruence of spontaneous rhythm between an infant and his caregiver. Some people are quick, others slow, and these attributes, if extreme, may have an unfavourable effect. Children who respond too quickly may reflect too little before responding and therefore are prone to errors of judgement. Slow children experience endless frustrations, be it in competitive activities with other children or in relation to parents, when the entire family has to conform to the pace of its slowest member. Slowness may be an innate characteristic. Some subjects, however, report that they act slowly in specific situations only. On closer examination it transpires that those subjects suffer from minor impairments, e.g., of attention or fine motor coordination, and slowing down serves as a device to reduce errors. In such cases, therefore, slowness is an adaptive device, and it becomes more prominent under stress, e.g., an examination. Such adaptive slowness is a normal behaviour trait in the aged but may be seen in young subjects with innate impairments as well. It is very common in children with learning disabilities and may aggravate their school difficulties considerably. Finally, slowness may serve emotional needs, namely

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negativism, passive hostility, and the wish to control. Some children, as well as some adults, have developed an exquisite capacity for annoying everybody by simply doing anything that is demanded of them, but doing it slowly. The negativistic aspect of slowness was adopted effectively some years ago by Italian customs officials during the so-called “Italian strike”: they checked each car crossing the border very thoroughly and slowly, causing enormous traffic jams on the highway. Slowness is also an effective way to control. The following fictitious but not uncommon example will illustrate the point: The family is going on a picnic. The family car is loaded with equipment, the older children are waiting inside the car, and even the family dog is sitting in the car. Everyone is waiting impatiently while Junior is tying his shoestrings slowly and methodically, ostensibly conforming to the injunction “make sure your shoestrings are properly tied”. Slowness, then, can be an innate characteristic, an adaptive device, or a drive-motivated character trait. In a given subject slowness may be an expression of any or all of these determinants. In psychoanalysis it is usually possible to tease out the innate, adaptive, and drivemotivated components. In Chapter Eleven, we present a case history illustrating such a combination of factors.

g. Clarity of communication Korner and Grobstein (1967) demonstrated that newborn infants vary in the ability to convey their needs, such as being hungry, cold, or uncomfortable. Therefore, the ability of the caregiver to provide gratification promptly depends not only on her empathy and competence but also, to some degree, on the infant’s ability to communicate needs. If the mother is inexperienced, an infant’s poor ability to express his needs may have serious consequences for the consolidation of a secure attachment. h. Perception of social cues The ability to express one’s emotional or physical needs finds its counterpart, as it were, in the ability to perceive social cues intuitively. This ability appears early in life, long before the so called “theory of mind”, which means the ability to perceive another person as having needs, wishes, or emotional states of his own. Nurses working

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in neonatal units know that if one baby begins to cry, several others will soon join in unison. This intuitive sensitivity to emotional cues seems to be lacking or poorly developed in some children, and it is our impression that this characteristic may persist into adulthood. We have often observed it in older children who present the ADHD syndrome, but not only in them. We do not refer to the deficiency of love seen in the narcissistic personality nor to the psychopath’s callousness (though an inability to perceive social cues may, under unfavourable circumstances, predispose the individual to both; this subject, however, has not been investigated adequately). Subjects with low sensitivity to cues may well be capable of having warm, affectionate relationships, but when they reach middle childhood or adulthood they seem socially inept, as if failing to read interpersonal situations correctly. Investigators who study empathy differentiate between the intuitive, “contagious” type of empathy and “cognitive” empathy, i.e., empathy that involves so-called “theory of mind”. The two kinds of empathy seem to be related to different areas of the brain, namely the inferior frontal gyrus and the ventro-medial prefrontal area, respectively (Shamay-Tsoory, Aharon-Peretz & Perry, 2009). (We write “cognitive” in quotes because even though “theory of mind” involves a cognitive component, conscious or not, every kind of empathy is ultimately an emotional process.) The “contagious” kind of empathy can be observed also in animals—a dog knows when his master is sad or angry—whereas “theory of mind”, i.e., understanding the other person’s state of mind, is apparently a uniquely human quality. In our experience, subjects who seem to lack spontaneous, intuitive sensitivity can compensate by employing cognitive understanding, based on experience and judgement. We have occasionally used such a compensatory ability in therapy (Chapters Ten and Twelve). In the following chapters we will attempt to elucidate the emotional implications of idiosyncratic temperament and discuss the therapeutic issues.

Lags and impairments The second group of deviations consists of developmental lags and circumscribed impairments of perceptual, motor or cognitive functions. In theory one ought to differentiate between

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developmental lags, i.e., delayed appearance of a function, and minor neuropsychological deficits. In clinical practice, however, the separation is often unclear. Frequently, functions that are delayed remain relatively weak, either because the child avoids practicing an activity that is fraught with frustration, or because the delay is a forerunner of a neuropsychological deficit. For this reason it is convenient, as far as our discussion is concerned, to group developmental lags and circumscribed deficits together. Developmental lags and neuropsychological deficits, with the exception of Attention Deficit Disorder (ADD) and motor disabilities, are most often classified as deficiencies of academic skills. This classification tendency reflects current concern and preoccupation with learning disabilities. In clinical practice, however, we find that circumscribed neuropsychological impairment often leads to serious emotional consequences, even when academic performance is satisfactory. This is particularly true in the case of very bright children who may perform below their true potential but still well above the level of their less endowed peers. In these children the presenting symptom is usually emotional or behavioural, and only a painstaking examination will reveal the neuropsychological difficulty. Most classification systems refer to global, complex functions, such as reading or language. They do not attempt to elicit the underlying specific deficit, such as impairment of sequential auditory memory, right-left discrimination, spatial orientation or inter-modal integration (i.e., integration between two separate functions). Emotional development, however, is linked to such specific neuropsychological functions more often than to global areas of functioning.

Discussion of developmental deviations In summary, we take a much broader view of developmental deviations than that reflected in standard nomenclature. The common denominator of such developmental deviations is that they appear early in life, are intrinsic, that is, innate or due to very early environmental influences, and are presumably biological in nature, i.e., generated by genetic, intrauterine or early environmental adverse conditions, such as inadequate nutrition or CNS infection. Clinicians often attribute importance only to more pronounced delays in development, since they might be harbingers of mental

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retardation or other pathology, and they disregard moderate variations because “the child will outgrow them”. This view is unjustified. Many developmental idiosyncrasies, such as hypersensitivity to stimuli, tend to persist even into adulthood. Even a transient impairment, however, may be experienced by the developing child as a source of painful frustrations, especially if the child is cognitively precocious. In such cases there is a gap between the “action plan” in the child’s mind and the performance. A bright boy explained it as follows: “The brain in my head wants to draw a small circle but the brain in my hand draws a large one.” Moreover, the effect of the “developmental matrix”, i.e., the intricate interaction between various lines of development, is such that irregularity or impairment of one developmental line will often interfere with the progress of another. In such a case the effect of a deviation will persist even if the deviation itself is no longer apparent. For instance, we have mentioned before that the spurt in gross motor development around the end of the first year of life facilitates the acquisition of elemental autonomy. Therefore, a delayed and deficient motor development often results in an insecure, dependent personality trait. That trait will persist even after the motor development has matured adequately. In addition, a developmental idiosyncrasy not only may have an impact on the child’s subjective experience but may have a much greater impact on the caregiver, as will be discussed in Chapter Seven. In such a case the resulting unfavourable effect on the personality often becomes irreversible, even if the child “outgrows” the idiosyncrasy. The outcome, in any case, will depend on a number of factors, such as other characteristics of the child (e.g., vigour), the caregivers’ personality and their reaction to that specific difficulty, and the ability of the extended family and the community to provide emotional support to the child and his immediate caregivers. We will not review here the whole range of innate perceptual, motor and cognitive aberrations and deficits, which are the subject matter of child neurology and neuropsychology. We will focus only on some common impairments that result in maladaptive behaviour patterns and may easily be mistaken for conflictdetermined, neurotic symptoms. The differential diagnosis between innate impairments and neurotic symptoms is not always easy or clear-cut, because an innate temperamental trait or impairment may

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become interwoven into intra-psychic conflicts and inter-personal relations. Nevertheless, it is useful to recognize the innate core of a maladaptive behaviour and to separate it from the dynamic overlay. Various perceptual or cognitive disabilities may find direct expression in a patient’s behaviour in an analytic session and be mistaken for resistance or neurotic inhibition. For instance, many children with Attention Deficit Disorder manifest a rigidity of habits that may be taken for negativism. Another example is that of a learningdisabled child who pretends that he refuses to perform a task out of rebelliousness in order to avoid the humiliating admission that he is unable to cope with it. “I would rather be bad than stupid,” the child seems to be saying. An analytically trained therapist may accept the patient’s defensive stance at face value, especially if the child is unquestionably angry and defiant, and overlook the underlying disability. A discussion of neuropsychological impairments that result in maladaptive behaviour patterns follows.

Neuropsychological impairments a. Impulse control and affect modulation Some manifestations of functional impairment appear only when that particular function emerges: such is the case of impulse control and affect modulation. A careful examination of inappropriate reactions and failure of impulse-control is one of the mainstays of psychiatric examination and psychoanalytic treatment. We speak of “acting-out” of unconscious conflicts, of unconscious motivation magnifying the response, and of displacement of affect from another, repressed context. The classic example is Wolf Man’s inexplicably intense grief at the poet’s grave, which Freud interpreted as displacement of the patient’s repressed mourning for his dead sister (Freud, 1918, p. 23). The interpretation revealed the positive, affectionate aspect of Wolf Man’s ambivalent relationship with his sister and became one of the cornerstones of Freud’s analytic reconstruction. Another common example of distorted response is transference. The therapeutic regression reactivates infantile yearnings; consequently, minor events in the therapeutic relationship, such as the analyst’s vacation, acquire symbolic significance and evoke an exaggerated or irrational response.

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It is these irrational emotions, fantasies and actions that alert the analyst to the emergence of transference and provide a lead to unconscious processes. This basic premise, i.e., that an unreasonable, inappropriate response is always an indication of unconscious conflicts, does not apply to patients whose ability to control drives is impaired because of innate factors. Children affected by the syndrome of ADHD manifest impulsive behaviour, irritability, affective lability, and impaired inhibition of drives, i.e., behaviour traits that may easily be confused with symptoms of emotional deprivation or acting-out of unconscious conflicts. Such patients are prone to overreact to emotional stimuli. In such cases the tendency to overreact is more pervasive and less dependent on specific stimuli and situations, compared with dynamically determined overreaction. The latter may appear “out of the blue” in subjects who are otherwise quite composed, as described above in the case of the Wolf Man. Moreover, patients with innate impulse impairment tend to overreact in several affective modalities, i.e., anger, sadness, or elation may all be excessive. In the words of one patient: “My nights are darker, but my days are brighter.” These personality traits of hyperkinetic children often persist after the patients have become adolescents and adults. Hyperactivity usually abates during adolescence, but the behavioural symptoms may persist in the form of so-called Adult ADHD. Mendelson, Johnson, and Stewart (1971) reported that among adolescents who had been previously diagnosed as hyperactive children, 67% were described as irritable, 56% manifested temper tantrums, and 39% complained of “low moods”. When a patient reports that he or she had symptoms of hyperkinetic disorder in childhood, or manifests other signs of neuropsychological impairment, one ought to exercise caution in attributing any disproportionate or impulsive reaction to an unconscious conflict. Only a careful scrutiny of each patient’s personality and of each situation will provide a reliable indication as to the source of the reaction. Impaired inhibition of drives may be manifested in two ways. One is impulsiveness, i.e., a propensity to respond to stimuli without reflection. The other, related but not identical, form of dysinhibition is an inability to delay or forgo the gratification of an instinctual need when the provocation or temptation, as the case may be, is

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intense. The drive may be aggression, genital sexuality or greed. The response may be impulsive, but it may also be deliberately delayed and well planned. The characteristic feature of this behaviour is the subjugation of all the psychic forces, such as ego-ideals, values, and the subject’s affectionate relationships, to one overpowering instinctual need. In particular, such subjects seem unable to consider the full implications of their actions. When confronted with the nature of their action or faced with its consequences, they usually respond with intense anger, which then turns into depression, shame and a loss of self-esteem. Literature is replete with examples of reckless abandon to lust, revenge or greed, and such instances are not rare in clinical practice, either. Ms. Q., a middle-aged married woman, a mother of three, and a respected business executive, was in treatment because of dysphoria, dissatisfaction with herself and obesity. She knew everything there was to know about diet and weight control, yet when gripped by a sudden desire for food, she would devour bread, chocolate or cakes, to the point where she felt nauseated and disgusted. Any discussion of the need to control her food intake or any comment about her weight would enrage her. She knew, however, how to contain and disguise her feelings most of the time, and she felt ashamed of them. The patient also reported uncontrollable shopping sprees of which she was ashamed, too. During one of the sessions the patient said: “You know, I am ashamed to tell you this, but I suddenly realized that when anybody suggests a diet, I feel as if someone were taking the milk bottle away from me; I feel desperate and furious.” The problems of this patient were not limited to impaired inhibition of oral needs, but the above vignette illustrates that aspect. The following brief example also illustrates impulse dysinhibition. (The case is described in full in Chapter Twelve.) Mr. G. was a young adult patient whose detailed diagnostic evaluation, prior to analysis, revealed a previously unrecognized minor cerebral impairment. During analysis Mr. G. described his violent childhood rages. Once, at the age of about eight, he became provoked by another boy who accidentally stepped over Mr. G.’s sand castle.

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Mr. G. began to hit the other child with a belt; the buckle cut the other boy’s face, and he ran away bleeding profusely. Mr. G.’s father, usually a severe and overcritical parent, was left speechless and did not even attempt to punish the son. For Mr. G. himself, the incident remained a painful and frightening memory, a part of his self-image of “a little Hitler”, as his father had once called him. It is important to emphasize that the clinical manifestations we describe here are neither sociopathic personality disorders nor cases of educational neglect. We are referring to individuals with a wellintegrated super-ego. This is not a failure of values or object relationships but of the ego’s ability to contain drives. Control of drives develops gradually throughout early childhood, beginning at infancy, and the infant–caregiver relationship plays a crucial role in it. Therefore, it is not easy to determine in any given case whether the difficulty of controlling drives is due to failure of mothering, to innate, biologically determined factors, or to a combination of both (Fox & Calkins, 2003). It is also not easy to determine whether an imbalance between drives and inhibitions is due to constitutionally excessive drives or to impaired controls. Both possibilities seem plausible in different circumstances. Although there is no method for measuring the intensity of drives, observation of infants demonstrates convincingly that some of them are endowed with vigorous needs and desires, while others are more placid. In such cases we are justified in assuming that the former have an inborn higher intensity of drives. In contrast, in subjects who present the manifestations of so-called “subclinical encephalopathy”, i.e., subtle neuropsychological deficits, the hypothesis of impaired controls seems to be more plausible, because innate as well as acquired neuropsychological impairments, especially if affecting the prefrontal area, commonly result in drive dysinhibition (Elliott, 1982). Some patients may not have excessive difficulty in restraining their behaviour but nevertheless experience overly intense affective responses to emotionally charged situations, a response that we call “affective flooding”. The emotion may be negative (e.g., sadness, anger) or positive (e.g., joy, gratitude); its content may be quite appropriate to the situation, but its intensity is overwhelming. Such “affective flooding” brings to mind the global, undifferentiated

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motor and affective responses of the very young infant and also the emotional lability of brain-injured patients, e.g., patients with prefrontal injury, and also of patients with pseudobulbar paralysis (Wilson, 1923), but at this stage too little is known to venture a hypothesis regarding the source of such responses. We know from clinical experience, however, that such “affective flooding” may lead to a variety of defensive and compensatory devices that become traits of the patient’s personality. Affect dysregulation and drive dysinhibition, as well as oversensitivity and irritability, besides being personality features as described above, are symptoms common to a number of psychiatric childhood and adult syndromes, such as ADHD, Bipolar Disorder (especially the paediatric form), Oppositional Defiant Disorder and Borderline Personality Disorder. There is also evidence of a genetic link between some of these syndromes (ADHD and Bipolar Disorder; Faraone, Glatt & Tsuang, 2003). Therefore, it is quite probable that a common neural mechanism underlies that deficiency.

b. Propensity to anxiety Another significant emotional feature of a developmental deviation is a propensity to anxiety. Weil (1978, 1981) described “panic-rages” in toddlers with perceptual hypersensitivity. These are presumably direct expressions of ego failure. In our experience, excessive anxiety frequently stems from the subject’s dim, or sometimes quite conscious, awareness of his unreliable impulse control and affect modulation. The fear of loss of control experienced by patients with neuropsychological deficiencies is excessive but not entirely irrational. It is a result of repeated frightening experiences of being overwhelmed by ego-alien (i.e., unacceptable to a subject’s self-image) affects or impulses. The following case illustrates the point: Ms. J. was in treatment because of severe and disabling spells of anxiety. Analysis revealed ego deficiencies, especially in the area of impulse and affect control. In one of her sessions the patient described a visit to comfort a friend who had been experiencing a very unhappy life situation. As Ms. J. was listening to the account of her friend’s misery, she was overcome by a feeling of sadness so intense that she had to excuse herself and leave precipitously. This was one of many such incidents. Ms. J. enjoyed her work, but when it reached a certain intensity she would go into what she

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called “a high”, a state of excitement, irritability and talkativeness, over which she had little control, and which made her fear for her sanity. Thus both painful and pleasurable affects tended to flood her and produce anxiety.

c. Rigidity The last direct manifestation of neuropsychological impairment that we discuss is rigidity. Loss of flexibility is one of the cardinal signs of brain injury (Johnstone, Hexum & Ashkanazi, 1995; Luria, 1963); in subjects with subtle neuropsychological impairment it is much less conspicuous, but nevertheless can often be observed. Perseveration or “stickiness” (“Klebrigkeit” in German) may be seen in psychological tests, such as Rorschach, Bender-Gestalt and the Wechsler Adult Intelligence Scale (WAIS). The behavioural manifestations of this condition include an inability to shift focus and “thinking in loops”. The inability to shift focus was described by one patient who could not follow the changing topics of a social conversation. Another patient complained that she could not sustain affectionate physical contact with a child and conduct a serious, adult conversation at the same time. Some children are in the habit of making comments about a topic after the teacher has already started a new one. Another, very bright patient, described her desperate helplessness when dealing with relatively simple mathematical problems that involved inverse proportions, e.g., a pipe that fills a reservoir in fewer hours will fill up a larger part of it in one hour. Eddie was a friendly four-year-old boy, vivacious, restless, and inattentive. His parents complained that he was in the habit of not locking the car door when getting out; in those days cars were not equipped with a central locking system, so that after dropping Eddie off at school the driver of the car had to stretch all the way back in order to lock the door before driving on, a fairly annoying situation. Finally, Eddie seemed to have absorbed the parental requests; after all he wished to be a good boy. One day his mother asked him to drop a letter into a roadside mail box. He got out eagerly, locking the door behind him so that his mother had to repeat the stretching act in order to let Eddie back into the car. “Thinking in loops” is a term coined by a patient to describe her inability to detach herself from a train of emotionally charged thoughts,

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in spite of her better judgement and her wish to be done with the subject. Instead of feeling relieved after expressing her anger or anxiety, she would return to the topic again and again, each time with a greater intensity of affect, like a self-amplifying electric circuit, until the built-up tension became unbearable. This kind of perseveration might be mistaken for an obsessive symptom. The difference lies in the intense, self-augmenting affect, absence of doubt (whereas doubt is highly typical of obsession), and no indication of ambivalence. There is also no repressed content to explain the symptom; it is simply an inability to deal flexibly with an emotionally charged situation. It is quite probable, therefore, that in some cases where psychoanalysis fails to resolve obsessive thinking, the reason for such failure is that the symptom is due to a neuropsychological impairment rather than to unconscious conflict. The perceptual or cognitive disabilities described above may manifest themselves in a patient’s behaviour or in an analytic session and be mistaken for resistance or neurotic inhibition. The problem of differential diagnosis between conflict-determined and innate impairment of a function is illustrated by the following vignette: Mr. Y. was referred to analytically oriented psychotherapy during a stormy and painful process of divorce. It soon became apparent that Mr. Y.’s disastrous masochistic marriage was part of his self-defeating lifestyle and a continuation of a life-long submissive, masochistic attachment to his mother. A similar pattern of masochistic, passive-aggressive relationship began to emerge in transference. The effects of interpreting the neurotic character traits were very slow. The therapist became aware of a characteristic discontinuity in the treatment process, as if progress achieved in one session would be partly lost by the time of the following meeting. The patient complained that his memory was poor and attributed his forgetting of previous sessions to that. Mr. Y.’s Bender-Gestalt test showed superior visual memory, namely, an exact recall of all nine figures. Moreover, the patient graduated with honours from a highly respected and very demanding program, and it seemed improbable that a person with such a serious memory problem could have accomplished this. Therefore, the therapist initially interpreted Mr. Y.’s forgetting as part of his passive-aggressive

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resistance. The interpretation seemed to have little effect and Mr. Y. himself provided the clue to his “repression”. While in college he had developed a habit of jotting down every important lecture. He would then study by memorizing visually the content of his notes. He could recall visually each page, while his memory of the spoken content was hopelessly inadequate. In other words, Mr. Y. suffered from impaired sequential auditory memory, while his visual memory was excellent. Impairment of sequential auditory memory is, in fact, a fairly common cause of learning disability. Thus, the differential diagnosis between innate impairments and neurotic symptoms is not always straightforward, as the two often become interwoven. Nevertheless, as suggested in the following example, it is useful to take into account the possibility of an innate core of a maladaptive behaviour and to address this impairment separately from the dynamic superstructure. Ms. J. (whose analysis has been mentioned above) was suffering from phobias, particularly from an intense fear of situations in which she felt an irresistible impulse to commit suicide. This phobia expressed identification with her depressed mother, who had often threatened suicide and once, when the patient was 12 years old, made a serious suicide attempt. The symptom also expressed guilt caused by the patient’s deeply repressed death wishes against her egocentric, un-empathetic mother. In the patient’s unconscious, any striving to become independent became immediately identified with the wish for her mother’s death. At the same time the symptom was related to Ms. J.’s neuropsychological dysfunction. She was painfully aware of and bewildered by her cognitive difficulties, i.e., momentary confusion due to attention deficit or occasional failure to deal with an intellectual problem that required “shifting” from one conceptual set to another. She was also threatened by her impulsive behaviour and inability to contain affects. Her self-perception as an erratic, unpredictable “freak” made her unable to deal with the intra-psychic conflict, except by paralysing anxiety or avoidance. Only when the cognitive and integrative ego difficulties were explored and the patient’s self-representation consolidated in a more positive

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way was she able to confront and deal with the issue of her deeply repressed hatred toward the mother (Chapter Nine).

Discussion and conclusions We have mentioned before that some developmental idiosyncrasies persist whereas others fade away with time, though their impact on the process of development may persist. Innate or acquired neuropsychological impairment is bound to have an effect on the adaptive and regulatory functions of the central nervous system, i.e., the ego. Indeed, the impairment of the regulatory functions that we have described above, i.e., failure of drive control, inadequate affect modulation and propensity to anxiety, are common symptoms of borderline personality disorders (BPD). Not surprisingly, some investigators have found evidence of subtle impairments such as learning disability in the history of patients diagnosed with borderline personality (Andrulonis, Glueck, Stroebel & Vogel, 1982; Murray, 1979). P. Kernberg, Weiner, and Bardenstein (2000, pp. 155–156) reviewed the subject of biological factors in the development of borderline personality, and Judd (2005) analysed the possible role of neuro-cognitive impairments in the failure of regulatory functions leading to BPD. Recent methods of investigating brain function have provided more data about the role of developmental factors in the formation of borderline personality. Resnick, Goodman, New, and Siever (2005) reviewed the research dealing with biological factors in BPD, and Schmahl and Bremner (2006) reviewed neuroimaging studies in BPD. Borderline personality disorder has also been attributed to emotional deprivation or to early traumatization, especially child abuse (Herman, Perry & van der Kolk, 1989). Therefore, at the present state of knowledge we may conclude that the BPD syndrome is probably a heterogeneous group of disorders characterized by a cluster of symptoms reflecting inadequate or unstable operation of integrative and adaptive functions. That inadequacy presumably reflects persistent brain malfunctioning either caused by innate deficiency or induced by severe environmental traumatization at an early age. In conclusion, there is a wide range of developmental idiosyncrasies, some merely exaggerations of temperamental traits, others

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delays or impairments of a function, some transient, others persistent. All of them may have an effect, often an unfavourable one, on other areas of development and on the infant–caregiver relationship. The infant–caregiver relationship, in turn, is a critical factor in the formation of a healthy, well-balanced personality. Hence, an isolated, seemingly relatively unimportant deficit may set in motion a chain of events with long-lasting unfavourable consequences. This kind of amplified end result is not uncommon in biology. It is exemplified by the metaphor of a butterfly flapping its wings in Florida and causing a hurricane in the Gulf of Mexico. Such “self-amplifying processes” are characteristic of complex systems, or so-called “networks”, and they are a feature of what is called “chaos theory”. Therefore, an examination of the causes of psychopathology will not be adequate if the possibility of innate or acquired biological factors triggering a chain of events is not taken into account. Subtle neuropsychological deficits of cognition, impulse control and other integrative ego functions often bear superficial similarity to neurotic symptoms or signs of resistance. Attempts to resolve such disabilities by interpretation are futile and discouraging for the patient and the therapist alike (Small, 1973), and they undermine the therapeutic alliance.

CHAPTER FOUR

Emotional effects of developmental deviations: the injured self

D

evelopmental deviations do not appear as isolated entities. To the contrary, they affect the emotional and social development of the infant and of the child, and they become incorporated into the structure of personality. We have already mentioned some of the effects of idiosyncratic development on how the infant perceives his environment and reacts to it; the response of the caregivers will be discussed in more detail in Chapter Seven. Here we will discuss the effects of developmental deviations on how the infant (and later the child) perceives himself. Emotional development revolves around the polarities of gratification and frustration. The loving, empathic care of the mother (or an alternate caregiver) assures the prompt satisfaction of physical needs, such as hunger, and of emotional needs, such as the wish for attention or physical closeness. Satisfaction of needs instils in the infant a sense of security, or “basic trust” (Erikson, 1963). Satisfaction of needs, however, is not always possible or prompt, and as a result the infant experiences frustration. If the frustration is neither too distressful nor too prolonged it stimulates growth. The child learns to anticipate satisfaction and delay the satisfaction of his need. For example, a hungry infant who was crying dejectedly a moment 55

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ago may laugh at the sight of his familiar cup even before gulping the cereal it contains. Anticipation occurs when the infant recognizes the signs of approaching satisfaction; hence, anticipation involves a degree of cognitive organization and an ability to relate the present perception to a remembered one and to the gratification experienced in the past. At the same time, the cycle of frustration and satisfaction stimulates cognitive growth and the ability to contain drives. In other words, emotional development and perceptual-cognitive organization depend on each other. Frustrations also motivate the child to find the means to overcome obstacles and satisfy his wishes; in this way frustration, too, stimulates cognitive and motor development. This stimulation occurs, however, only if the child’s efforts lead frequently enough to a successful outcome. If the child’s efforts remain futile too often, the result is a temper tantrum or loss of interest, withdrawal and listlessness. Only the sequence of wish-frustrationeffort-satisfaction-pleasure has a growth-promoting effect. Under favourable circumstances, as a child grows older, his cognitive development allows him to form “action plans” in his mind, while his perceptual and motor skills enable him to implement the “action plans” often enough, and the successful achievement of each goal is a source of gratification. The child perceives the progressive improvement of his skills as a proof of competence, more so if the parents join in admiring his “cleverness”. The young child soon learns that there is considerable lawfulness and predictability as far as the mastery of his body and the environment is concerned. This predictability of gratification and frustration contributes to a sense of stability and security. Parental behaviour is also predictable within certain limits, i.e., the child expects that his basic needs will be satisfied, and that his parents will approve of some behaviours and disapprove of others. All this contributes to a sense of security. In some children the synchrony between cognitive and motor development may not be optimal. If cognition lags behind, the child may have difficulty making realistic judgements. He may set unrealistic “action plans”, thus provoking unnecessary frustrations, or may engage in maladaptive or dangerous behaviour, not being amenable to parental guidance. If motor development is slow in comparison with cognition, the child has to cope with the repeated frustration of not being able to implement the “action plans” he expects of himself,

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like the boy with the “brain in his hand” mentioned in the previous chapter. In our experience, the brighter the child, the more painful the frustration, and thus the greater its impact on the child’s selfregard. This seems to be a general rule: the greater the gap between well-developed and impaired functions, the more the child views himself as inadequate. In a study we conducted, we observed a reverse relationship between the scatter of high and low scores of WISC subtests of learning-disabled children and their self-esteem (D. R. Aleksandrowicz, Davis & M. K. Aleksandrowicz, 1990). In other words, the brighter children appeared to be more affected by their disability than the less bright ones. In presenting this issue to parents we use a metaphor: “It is a lot easier to run on two short legs than on one long leg and one short.” Parental approval of the child’s efforts and accomplishments, i.e., “mirroring” (Kohut, 1971; Pines, 1984; Winnicott, 1967), has a powerful reinforcing effect, but it should be emphasized that successful performance in itself is a source of gratification and a powerful reinforcer. Stechler (1982) (see below) described vividly the triumph of a toddler who finally accomplished a task she had set her mind to. The child then performed a “victory song” all for herself, ignoring her mother and the observer. H. Papousek and M. Papousek (1983) suggested that the pleasure of mastering a task originates in early infancy, and they related this pleasure to effective cognitive processes, such as recognition of a familiar percept, and intentional movements that produce an expected effect. We discuss the concept of mastery and its theoretical aspects in Chapter Fifteen; here we wish to emphasize that the sense of mastery, or competence, becomes an essential component of normal narcissism. The harmful effects of an unpredictable environment, such as inconsistent parental attitudes, are well known and have been amply described. Less appreciated is the fact that unpredictability of one’s own effective functioning is equally detrimental to emotional development, although in a different way. The inability to rely predictably on one’s capacity to achieve or fail to achieve a certain expected result (a subject that will be discussed more in detail later on) has a deep negative impact on the self-representation of the subject. The damaging effect on self-representation is probably the most disruptive and persistent emotional manifestation of a developmental deviation.

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We would like to digress at this point and discuss the elusive but important psychic entity called “the Self”. Volumes have been written about it by philosophers (beginning with Aristotle), psychologists, psychoanalysts, and recently also neuroscientists (Damasio, 1999; Panksepp, 1998, pp. 300–323). We will not attempt the heroic task of reviewing the entire subject, but we will briefly overview those contributions most pertinent to our topic. Freud borrowed the German term “das Ich” (“the I”) from his teacher Theodor Meynert, who intended it to denote a person’s individuality as manifested by the unique set of connections among his brain cells (Meynert, 1868, 1890). Freud initially used the term “das Ich” to describe the concept of the Self, and it became commonly translated as “the ego”. In his later writings, however (Freud, 1923), and especially in those of A. Freud (1936), the term “ego” became increasingly applied to denote the complex of psychic functions that serve adaptation to the environment (e.g., perception, memory or so-called “higher executive functions”) or internal integration (e.g., mechanisms of defence; see also Chapter Six). There is a close relationship between the two meanings of the term “ego”, but they are by no means synonymous. Today most, though certainly not all, psychoanalysts use the term “ego” in this latter sense and the term Self to denote the “I”. The most prominent psychoanalytic contributors to the psychoanalytic theory of the Self were O. F. Kernberg (1984) and Kohut (1971). The essence of Kernberg’s theory is that the self-representation as well as the object-representations emerge from the coalescence of the infant’s memories of fleeting experiences of himself, of the caregiver, and of positive or negative affect, i.e., gratification or frustration respectively. Kohut likewise emphasized the role of the empathic, soothing caregiver in taming the primitive infantile rage and consolidating a Self invested with a healthy narcissism. Both investigators agree that a favourable balance between pleasurable affect and negative affect, i.e., gratifying versus frustrating experiences, is essential for the consolidation of a healthy Self. From the point of view of developmental psychology, it is useful to separate the concept of “self-experience” from that of “self-representation”. The former has its origin very early in life, probably during intra-uterine existence. The foetal brain receives bodily sensory stimuli: tactile stimuli from the skin, stimuli arising

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from the internal organs, and proprioceptive stimuli from foetal movements. These stimuli register in the brain, and their traces form the rudimental nucleus of what later becomes self-awareness. Some investigators call this early stage a proto-self (Damasio, 1999). Self-representation requires a much higher level of perceptual and cognitive organization. It implies a perception of oneself as a distinct entity, corresponding to what Mahler called “individuation” (Mahler, Pine & Bergman, 1975). This presumably consolidates gradually during the second part of the first year or toward the end of it. At the same time, the maturation of the motor system contributes to the formation of the Self as “agency”, i.e., the perception of “I do” or “I want to do”, in addition to the perceptual and proprioceptive input of the central nervous system (i.e., “I feel”). A milestone in the development of self-representation is the ability to maintain an “action plan” and perform an intentional, goal-directed act, even when the circumstances require its delay (Stechler, 1982). The life experience of a child with developmental lags or impairments is characterized by a relative predominance of frustration over mastery, i.e., negative over positive affect. The frustration becomes more painful when the scatter between functions is wide. We have observed, for instance, that cognitively well-developed toddlers with poor motor development tend to become over-dependent and insecure, expecting parental help or retreating at the slightest difficulty, and over-reacting to frustration and disapproval. The life of a developmentally deviant child is not only fraught with frustrations, it is also less predictable as far as success and failure are concerned. As the child grows older and the demands more complex, he becomes increasingly bewildered by doing some tasks well and failing others. This uneven performance may be reflected in a seemingly inexplicable scatter of school grades (often mistakenly attributed to emotional factors) and is also well demonstrated in intelligence test profiles. The result of such unpredictable performance is confusion, uncertainty, and a loss of sense of competence, as described in the following case: Mr. E. was an intelligent and skilful mental health practitioner. During a discussion of learning disabilities he brought up a childhood memory: “I could never tell beforehand what kind of reaction I would get from my teacher. Sometimes the teacher would

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praise my answer, saying, ‘That’s a smart boy,’ or something of the kind. Sometimes he would look at me with bewilderment while all the kids laughed. Obviously I must have said something very silly, but I couldn’t tell what. At times I wished I were dumb; that would have been easier. Finally, I stopped raising my hand altogether.” Let us return now to the subject of self-representation. Selfrepresentation is not a static psychic structure; to the contrary, it is subject to constant changes as a result of feedback and experience that merge gradually into it and modify it. Momentary experiences of body-perception, of wish or action plan (“agency”), feedback of action performed, and social feedback: all these merge into the Self as an object, which means, a distinct entity endowed with its unique qualities and having continuity in time. The Self, then, is both the perceiver and the percept. Each such momentary experience out of which the Self emerges has a valence, i.e., it is accompanied by positive or negative affect, pleasure or unpleasure, pride or mortification. A developmental deviation that results in an excess of negative self-experiences will inevitably interfere with the formation of a balanced, well-adapted self-representation. An impairment of basic functions such as gross or fine motor coordination, memory, or attention will usually generate a sense of incompetence: “I am an idiot”, “I have two left hands”, or “My head is full of junk.” This self-perception is usually reinforced by the environment, by the parents’ disappointment in the child’s poor grades, or by the misguided, but common, comment of the teacher: “You could do better, you should try harder,” as if the child has not tried hard enough. Poor self-esteem is very common among children with learning disabilities and is a familiar experience of educators and psychologists. Few professionals, however, appreciate the fact that most learning-disabled children develop a sense of incompetence long before they enter formal education and begin to fail. Most children with inadequate adaptive functions have at least a vague perception, long before their teachers tell them so, that there is something very wrong with the way they function. Ms. C. (whose case is presented in Chapter Eleven), a very bright research scientist, experienced frequent moods of paralysing

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anxiety and helplessness. During analysis it became apparent that her neurotic inhibitions were reinforced by minor cognitive difficulties of which she had been only dimly aware. She could deal effectively with complex and abstract problems, provided they could be put into a framework or that she could find at least a mental “foothold” from which to begin analysing the problem. An unstructured array of data and correlations could throw her into a panic. This was related to her inability to attend to more than one stimulus. Though a gifted amateur musician, she could not, for instance, sing a piece of music and play a harmony simultaneously. The patient was deeply troubled by her erratic functioning (in spite of her superior intelligence), and it engendered a sense of incompetence and self-contempt, reinforcing the masochistic traits of her personality. Insight into her difficulties led to a considerable decrease in anxiety and an improvement in the patient’s self-confidence and effectiveness at work. Eventually it also facilitated the analysis of the dynamic structure of her neurotic personality traits. The effect of developmental impairments on self-esteem has been observed by other investigators, as well. Coopersmith (1967) found a correlation between low self-esteem and a history of delayed walking but did not elaborate that finding further. Weiss, Hechtman, and Perlman (1978), in their follow-up studies of hyperkinetic children into young adulthood, found that subjects’ vocational adjustment and rating by employers were not lower than those of controls, but the subjects rated themselves negatively on such items as conventional ideals of social interaction and competence. Hence, the low self-esteem of subjects at that stage of development apparently was no longer related to the objective situation but to negative self-representation, a finding consistent with our observations in clinical practice. Impairments of higher executive functions, such as reality judgement or planning, or of integrative functions, such as impulse inhibition and affect modulation, usually have a different and sometimes more devastating impact on self-representation. Individuals with such impairments tend to perceive themselves as “unbalanced” or “crazy”; they often harbour fears of becoming insane and are prone to bouts of intense anxiety. They may experience phobic anxiety, but

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typically their anxiety is of a different kind: it is not the fear of an unconscious, forbidden wish (as is the case of phobias) but anxiety engendered by a sense of gross deficiency at the very core of the ego and a fear of the total disintegration of the ego. Ego-deficiency anxiety is related less to the specific content of the impulse and more to its intensity. The impulse, though ego-alien, is not necessarily unconscious, and the anxiety-inducing stimulus need not have any specific, symbolic meaning. A wide range of emotionally charged situations that stimulate erotic or aggressive impulses may induce anxiety in such patients. In terms of psychoanalytic theory, phobic anxiety is primarily due to dynamic factors, i.e., intra-psychic conflict, while ego-deficiency anxiety is related to economic factors, i.e., inability of the ego to maintain internal integration. This kind of anxiety is illustrated by the case of Ms. J. (see Chapter Nine) and also by the following vignette regarding Mr. G. (whose case is described in detail in Chapter Twelve): Mr. G. reported the following symptom: If he became involved in an argument and had the feeling that he had gotten the better of his opponent, he would go into a state of progressive manic excitement leading to a sense of loss of control—“I could rip the world apart,” in his words—usually followed by severe anxiety. The difference between phobic and ego-deficiency anxiety manifests itself clearly during the process of analysis. In purely phobic patients an interpretation touching on the ego-alien wish initially generates intense anxiety and might mobilize resistance and defence mechanisms. Working through the impulse is experienced as a relief. In patients with ego-deficiency, interpretation of content may evoke little resistance and have little therapeutic effect, while a discussion of the patient’s inability to control drives and his fear of madness is initially intensely threatening, but working his fears through becomes very supportive. These two kinds of anxiety may also be related to different neural substrates, as will be discussed in Chapter Seventeen. It would not be an overstatement to say that a reasonably wellintegrated sensory, motor, emotional and cognitive development is an essential condition for the formation of a well-integrated Self, as is a facilitating environment, namely, “good enough” mothering. Some neuroscientists go so far as to attribute most of psychopathology to

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innate or acquired dysregulation of sensory, motor and cognitive functions of the central nervous system (Levitt-BinNun, 2009). Summing up, the low self-esteem of a child with developmental impairments can be traced to a disruption of the sense of competence, which causes profound damage to the self-representation and to the development of a healthy narcissism. Moreover, developmental deviations are apt to have a negative effect on parental mirroring and later on the feedback of a wider environment (Chapter Seven), and that causes further damage to the child’s self-representation. In conclusion, a child’s self-representation is a condensation of parental reflections (mirroring) and of the child’s self-experience, i.e., his effective or ineffectual functioning. If the affect associated with these two sources of self-representation is predominantly positive, the result will be a healthy, well-balanced narcissism and positive self-esteem. If self-experience, parental mirroring, or both are predominantly negative, self-esteem will be impaired. An inconsistent, unpredictable self-experience or parental mirroring will result in a confused, poorly integrated self-representation and in narcissistic vulnerability. These personality traits persist into adulthood, even in those subjects in whom the basic impairment is no longer a significant functional handicap. Another unfavourable effect of ineffective or inconsistent functioning in subjects with developmental impairments is a shift from an internal locus of control to an external locus of control. In other words, the subject feels himself the victim of circumstances rather than an agent. The sense of an external locus of control may be expressed by blaming the environment, e.g., the school or other children, for one’s difficulties. Such projection of blame is usually interpreted as a manipulative disowning of responsibility (which, indeed, is often the case), but it may also stem from the subject’s genuine feelings of helplessness to effect a change. The shift from internal to external locus of control has a profound effect on the personality of the subject, on the way he perceives himself and the world, and on the way he makes the crucial decisions of his life. Dealing with the issue of locus of control is an important element of the therapeutic process, and we will return to this topic in Chapter Nine. Another common emotional symptom in patients with a history of developmental deviation is a tendency to depression. In our experience depression in this group of patients is multidetermined.

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The most prominent factor seems to be a profound sense of estrangement from the primary love objects, going back into preOedipal stages of development, as described in Chapter Seven. We have mentioned before (Chapter Three) that some infants are innately less able than others to make themselves understood, and such a shortcoming may contribute significantly to a breakdown of empathy between the caregiver and the child. We note that a lack of empathy does not preclude love. Although there is, naturally, a close relationship between loving and understanding, they are not identical. Understanding constitutes a powerful reinforcement for love, but love does not rule out failure of understanding. One patient described her experience in these words: “My mother always told me that she loved me; I suppose she did, but she never respected or even understood my feelings. For that matter, neither did I understand hers.” A sense of lack of competence is also a factor in the tendency to depression. The intense rage experienced by the frustrated, impaired child becomes, in many cases, partially internalized and directed against the self, thus also contributing to depression, self-criticism, masochistic character traits, or self-destructive behaviour. Last but not least, there is also a possibility that a deficiency in the integrative central neural mechanisms in itself contributes to depression (Weil, 1981), even though at this stage of our knowledge there is no empirical evidence to support such a hypothesis. In conclusion, a person with a developmental deviation perceives himself, however dimly, to be different, less competent in mastering his environment, less dependable in coping with drives, affects and inner conflicts, and less emotionally consonant with his parents. Such negative perception of one’s ego functions and the resulting narcissistic injury lead to a low self-esteem, negative self-representation, non-adaptive aggression, depressive tendency and a propensity to anxiety.

Comparison of the emotional effects of developmental deviations to those of physical impairments One question that arises is whether the emotional effects of the developmental deviations described here are in any substantial way

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different from the effects of other, physical impairments, such as inborn malformations or motor handicaps (e.g., cerebral palsy). The following case may help to elucidate the issue. Mr. N., a successful real-estate agent in his early thirties, was referred to analysis because of obsessive fears and compulsive rituals aimed at protecting his relatives from being harmed by accident, disease, or some other misadventure. In addition, he suffered from fears of loss of bladder control and a fear that he would feel compelled to pressure his bladder. As a result he became afraid of places in which he could not go to the restroom unobtrusively, without attracting attention, such as theatres or airplanes. He also had obsessive fears that he might have offended God by thinking about Him while urinating, a fear that led to other compulsive rituals. (During the analysis it transpired that the patient’s compulsive frequent trips to the restroom were a regression to a symptom of childhood. During his Oedipal years he suffered from castration anxiety and used to pressure his bladder compulsively to reassure himself that his penis was still functioning.) Mr. N. was born in a Latin American country, the oldest of five children (three sons) in a working-class family. (The patient’s history was reported in part during the diagnostic interview and in part reconstructed during the analysis. It is presented as one narrative for the sake of continuity.) The patient’s father was a skilled worker in a manufacturing plant, and the family was relatively well-off. The father was a simple man with limited education, brusque in his dealings with the children. At the same time, he apparently did care about them, and the patient remembered with gratitude the father’s encouragement to acquire higher education. The father used to brag about his own working skills, especially in front of his drinking companions; he also tried to get into a business of his own, but failed, causing considerable distress to the family. In Mr. N.’s opinion, the father was far too naïve and childishly ambitious to succeed in business. Mr. N.’s mother came from a middle class family and did not conceal her feelings that she had married “below her class”. She often expressed her disappointment with her husband’s lack of social finesse and implied that she hoped her oldest son, i.e., the patient, would compensate her by being an educated, socially

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well-placed man. She was an anxious, hypochondriacal woman, given to spells of “fainting” and “fits”, and Mr. N., as he grew older, felt very protective of her. The maternal grandmother lived with the family and took an active part in caring for the children. The patient remembered vividly her attempts to instil in him the awe of God, threatening him with frightening divine punishment for sins, with particular emphasis on masturbation. The patient’s younger brother was a strong and vivacious boy, prone to get into fights, and jokingly called by the family “cojones” (“big balls”) because of his conspicuous masculinity, a point painfully remembered by Mr. N, in view of his later difficulties. The youngest brother suffered from paralysis from a very early age (apparently cerebral palsy or poliomyelitis) and remained a wheelchair invalid all his life. The family lavished concern and care on him, and he was the subject of both compassion and jealousy on the part of his siblings. Mr. N.’s father was close to and proud of the younger, “macho” son and not very supportive of Mr. N. himself. The patient recalled an incident that had left a painful memory: he was in his teens, becoming quite concerned about his appearance. He and his father were shopping together, and the patient wanted badly a pair of fashionable, but expensive, slacks. The father refused, saying harshly: “Who do you think you are?” Nothing was known of Mr. N.’s perinatal history and early development. He never suffered from enuresis; quite the opposite, his mother had told him proudly how early he became clean and dry. He was considered a handsome child, and he remembered an incident from his very early childhood, in which his young aunts placed him on a table and admired his black locks and large, dark eyes. One of the aunts remarked jokingly that he was “too pretty for a boy” and should have been born a girl, a compliment that the little boy did not cherish at all. Mr. N. suffered a severe illness at the age of ten. He had very high fever for several weeks, complained of unbearable headaches, and was in a delirium most of the time. The family was told that it was typhoid fever, but the diagnosis was not entirely confirmed. (It could have been viral encephalitis, an illness fairly common in that part of the world.) After recovering he had difficulties

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concentrating, and his school grades deteriorated, much to his distress (until then he was an outstanding student and very proud of it). It took the better part of the school year for Mr. N. to recover his previous level of academic performance. With the onset of puberty, Mr. N. noticed that his sex organs were conspicuously less developed than those of other boys. He was mortified but too shy to ask for help from the parents. He refrained from any sexual activity and consoled himself, instead, by excelling in his studies. He did not enter a college, however, feeling that it was his duty to stay close to his mother. The family moved to the US when Mr. N. was eighteen. Mr. N. was seen in a routine medical checkup, and the examining physician told him bluntly that he was “sexually defective” and referred him to an endocrinologist. The experience was deeply traumatic for Mr. N., who until then had tried to overlook the problem. The endocrinologist, in contrast to the physician, was a kindly older man, who explained that the condition, hypogonadism due to gonadotropin deficiency, was treatable and recommended hormone replacement therapy. The result was a gradual restoration of normal sexual appearance and function (contingent on continuing hormone replacement treatment), with the exception of fertility. Mr. N.’s psychiatric symptoms began about a year after the family settled in the US. By then, he and his father found employment in the same manufacturing plant. The father, however, found it difficult to adjust to more modern work practices, while the patient accommodated himself quickly, was promoted to a supervisory position and became the primary breadwinner. He was proud but uneasy about his newly gained status, while the father became grumpy and chronically dissatisfied and began to drink more heavily. One day the father began to complain about an intolerable headache. The patient tried to reassure him by minimizing the complaint (with a hint at disbelief), but the father suddenly lost consciousness. He was hospitalized, diagnosed as having a severe stroke, and died a few days later without having regained consciousness. Mr. N. felt a deep sense of guilt for belittling his father’s complaint and not taking him to the hospital earlier. During the wake he was seized by fears of losing control of his

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bladder and had to use the restroom repeatedly, and from then on his symptoms grew worse and the obsessive concerns expanded. With time, guilt over his hostile impulses toward the father developed into fear of a divine punishment, even though, as Mr. N. emphasized, he was not a religious man and treated with contempt the “ignorant hogwash” of his grandmother. Narcissistic concerns played a major role in Mr. N.’s personality. Masculinity was always a very sensitive issue. At times it seemed that for Mr. N. the sexual act was not so much a matter of desire as a matter of “performing” and satisfying his partner, in order to reassure himself about his masculinity. He felt a constant need to convince the analyst of his business acumen, dressed meticulously according to the latest fashion, and took great pride in his role as an authority for his siblings. At the same time he was a warm, genuinely concerned person, a dedicated husband, and a loving father to his two adopted children. All those details emerged during psychoanalysis, as Mr. N. gradually gained insight into the connections between his envious Oedipal competition with the father (and the younger brother), the threat of Mr. N’s close relationship with the mother, and his castration anxiety. He began to understand the ambivalence of the relationships: his repressed wish for a loving, supportive father (like the endocrinologist), as well as the resentment against the mother for having used him for her own selfish needs. Moreover, he gained insight into the centrality of his phallic narcissistic vulnerability, beginning with the problematic Oedipal competition with the “machos” of his family: the masculine father and the “big balls” brother. That experience was followed by the disastrous sexual deficiency at adolescence and the partial rehabilitation, contingent on continuing hormonal replacement therapy. He also gained insight into the relationship between the recognition of his sexual deficiency and the need to incessantly prove his prowess, sexual or otherwise. The problem of sexual inadequacy, in the case of Mr. N., became enmeshed with an unresolved Oedipal conflict, due largely to the family dynamics. In this case, like in most patients with innate disabilities, the biological and the environmental factors operated together.

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Mr. N.’s case differs from most cases of somatic developmental impairments, insofar as his handicap was known only to himself and it involved a great deal of shame. Therefore, a reaction on the part of the environment played no role in his dealing with it (with the exception of the fact that an expected negative reaction prevented him from sharing his concern). Otherwise, however, the emotional development of Mr. N. and the subsequent symptoms were in many ways fairly typical of people with an early physical handicap. Comparing the emotional problems of patients suffering from inborn somatic disabilities with those of subjects affected by “invisible” developmental impairments, we see that there is a certain commonality. The most conspicuous similarity is the narcissistic injury suffered and the subsequent attempts to cope, whether by avoidance, denial, aggression, or escape into fantasy, or, as in the case of Mr. N., by over-compensation. Such coping mechanisms bring a measure of relief, but they cannot prevent the pronounced narcissistic vulnerability seen in most persons with handicaps, physical or psychological. At the same time there are important differences between the two conditions. Civilized societies relate to physical handicaps with compassion. In welfare states this compassion finds expression in legislated privileges, including financial benefits. Few such concessions are made for people with innate “invisible” handicaps (though in some countries there are special programs and reduced requirements that facilitate education for people affected by learning disabilities). A person affected by a physical disability may also comfort his narcissism by feeling entitled to special consideration or exempt from the demands of the society, by virtue of having been mistreated by fate. (An example of such an attitude is the opening monologue by Richard, the Duke of Gloucester in Shakespeare’s Richard III. In that monologue, the future King Richard justifies his ruthless and perfidious plans, on the grounds of his deformity depriving him of the common delights enjoyed by his peers.) Moreover, society admires disabled people who have been able to overcome their handicap, such as the legendary Captain Douglas Bader, the legless British fighter pilot, who fought in World War II. Even lesser handicaps, when overcome, are treated with admiration. No such

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public acclaim is bestowed on a person who overcomes his motor clumsiness or intractable hypersensitivity. A person whose handicap is behavioural and its cause unrecognized runs the risk of encountering very negative feedback from the environment. A school or a workplace is rarely sympathetic to someone who is hyperactive or socially maladroit. At best, a child’s parents or a spouse can feel empathy for a person struggling with an “invisible” handicap. Even then, however, they rarely comprehend fully the impact of the disability on the emotional and social development. It takes a professional intervention, sometimes an uphill one, to make the environment understand the nature of the problem, empathize, and respond appropriately. Other aspects of the two conditions, namely somatic, “visible” handicaps, as opposed to neuropsychological, “invisible” ones, also differ in important ways. Many handicapped people protect their narcissism by means of a sense of estrangement toward the affected organ or limb, like the young woman, victim of a car accident, who, when asked by the physician what he could do for her, answered: “Find me a new leg.” This sense of estrangement can become a hostile one, as if following the Evangelist’s injunction: “And if thy right eye offend thee, pluck it out, and cast it from thee.” (Matthew 5.29, King James’ Bible). In other words, the subject “expels” the defective organ from his Self; he implies “that limb is mine but it is not me.” That kind of narcissistic protective device cannot be applied to a neuropsychological dysfunction such as hypersensitivity or affect dyscontrol. At most, the wish to get rid of the defect can be expressed metaphorically, as in the case of Mr. G. (Chapter Twelve) who imagined himself expelling “little black devils” from his body. Deprived of such a protective device, the developmentally impaired patient may resort to more primitive and more dysfunctional mechanisms of defence, namely split and denial, or paranoid projection, in order to maintain a Self that is acceptable to him. In conclusion, emotional development in general, and the formation of the Self in particular, is the result of a reciprocal influence of the unfolding of physical development, the maturation of the central nervous system and the influence of the environment. A less than adequate input from any one of these will disrupt the process and may result in a maladaptive personality structure and

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a poorly integrated Self. A “visible” handicap such as a physical malformation is recognized by the environment and, as a rule, responded to appropriately in civilized societies. An “invisible” handicap often requires professional expertise and intervention to help the subject and his environment to deal with it adequately.

CHAPTER FIVE

Effect of deviations on the progression of developmental stages

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here are different ways to describe the stages of emotional development, though most investigators agree on their approximate chronology. Freud referred to them as stages of “psychosexual development”, emphasizing the vicissitudes of the sexual drive (Freud, 1905). Most later psychoanalytic investigators emphasized the infant–mother relationship (e.g., Mahler, Pine & Bergman, 1975; Shuttleworth, 1989; Stern, 1977) or the consolidation of personality (Erikson, 1963, 1979). Most investigators refer to the maturation of a developmental milestone as the ushering in of a new stage. It is useful for our purpose, however, to describe emotional development in terms of the developmental aim of each stage.

The attachment stage The aim of the first stage of infancy is the consolidation of an infant– mother (or infant–caregiver) bond. In the terms of Bowlby and his students, a most favourable outcome of this stage is a secure attachment (Ainsworth, 1982; Ainsworth, Blehar, Waters & Wall, 1978; Bowlby, 1982). 73

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The crucial importance of early attachment for later emotional development cannot be overstated and is amply documented in clinical and in research literature. Bowlby and Ainsworth attributed secure attachment to the availability of an empathic caregiver. It is, however, equally important that the infant’s perceptual, motor and emotional functions be reasonably well integrated so that the child can benefit maximally from such care-giving. Such integration is facilitated by empathic and consistent care-giving, but it also requires adequate innate endowment. Therefore, any innate idiosyncrasy that interferes even slightly with attachment, e.g., hypersensitivity or excessive propensity to anxiety, may have longlasting adverse effects. This, however, need not be taken as a verdict of inevitable fate: infants, as well as parents, have a great capacity to adapt, to respond to feedback and to learn from experience. The effect of innate factors is an increased risk of unfavourable outcome, not an inevitable cause. Having said this, we will examine the possible interference of developmental factors with optimal attainment of attachment. The earliest perceptual function is the discrimination between familiar and novel stimuli. The infant, if presented with a new object such as a set of shining keys, will appear curious and even fascinated, but he will remain suspicious until he has examined the unfamiliar object. Familiar stimuli, in contrast, evoke a positive affect just by virtue of being familiar (H. Papousek & M. Papousek, 1983), and this response is obviously an important component of attachment. (The latter statement, naturally, does not apply to “familiar objects” associated with aversive experiences, such as a paediatrician’s white coat and syringe.) Moreover, the primary caregiver is not only a familiar object but a provider of satisfaction of needs, pleasurable stimuli, and relief from distress. Infants, however, differ in their inclination to experience positive and negative moods and in their capacity to be comforted. Some are happy little fellows, seemingly enjoying life, while others cry and fuss at the slightest discomfort. Naturally the former will more often experience the primary caregiver as a “good object” (to use a psychoanalytic term). O. F. Kernberg (1984, pp. 227–253) assumes that the fleeting experiences of “me and the good object” or “me and the frustrating object” consolidate into selfand primary “good object” and “bad object” representations. Hence, a favourable balance of gratifying and frustrating experiences will

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facilitate not only emotional development but attachment as well, and such a balance depends not only on the care the infant is receiving (that is obvious) but also on his ability to enjoy it. The ability to differentiate between familiar and novel stimuli (primary caregivers versus all others) depends on cognitive organization, while the ability to tolerate frustration and to be comforted or to comfort oneself (i.e., the balance between positive and negative moods) probably depends on the functioning of the central nervous system, especially the affect-modulating complex, i.e., the limbic system and the fronto-orbital cortex. The ability to enjoy the satisfaction of needs depends on the general state, or overall health, of the organism, and on the integrative functioning of the central nervous system, especially the feedback-reward system. In other words, the attainment of a secure attachment depends on the quality of caregiving and on a number of innate biological factors as well.

The autonomy stage The aim of the next stage, which begins in the second half of the first year, is attainment of a psychological separateness, the formation of a self-representation, and the beginning of psychic autonomy. This is facilitated by motor and cognitive maturation, as described in Chapter Two. The upsurge in the gross motor development (crawling and later walking) enables the child to achieve an unprecedented control of his own body and of the surroundings. He can now reach for objects and, more importantly, move toward the caregiver or away from her. By the same token, a deficiency in motor development disrupts this process and may delay the acquisition of autonomy. Jay was referred to a paediatric movement disorder clinic because of a conspicuous delay in gross motor development: at the age of fourteen months he could neither crawl, stand up, nor walk. He had received physiotherapy for four months with scarce benefit, and an additional consultation was requested. Jay was the second child; his prenatal history was unremarkable except for maternal diabetes, which was controlled by medication. He was born by spontaneous delivery at thirty-eight weeks of pregnancy and was described as a “plump” but otherwise

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healthy neonate. No developmental aberrations were observed, apart from the delay in gross motor development. His visual– motor coordination, according to the mother, was age-adequate. His language development was relatively slow but still within normal limits. He could pronounce only one word (“Mama”) but reportedly understood simple requests. Neurological examination revealed moderate hypotonia but no other abnormal findings. On examination Jay was seen to be visibly overweight, anxious in the unfamiliar surroundings, trying to constantly keep his mother in his visual field and ignoring the attempts by the examiner to establish contact. He showed no interest in his surroundings or in the people around him and angrily pushed aside the toys offered him. The examiner, an experienced physiotherapist, placed Jay in a position most conducive to raising himself up, i.e., kneeling on the side of cloth-covered three-level steps. The mother crouched on the other side of the steps, well within Jay’s field of vision. Jay reached toward his mother but he made no attempt to make use of the support offered by the steps and raise himself in order to move toward her. He forcefully resisted the examiner’s attempts to help him; instead, he stretched his arms and his body forward and sat back on his heels, making any attempt to raise himself impossible. All that time he made small whining noises obviously meant to induce the mother to take the initiative to approach him. An attempt by the mother to engage Jay in a “peek-a-boo” game only resulted in an increase of whining. This case illustrates the profoundly disorganizing effect of a major delay in gross motor development upon the emergence of autonomy, expanding range of interests and an ability to assume initiative. Other functions, however, also influence the consolidation of autonomy; for instance we have observed that in some subjects a poorly developed spatial orientation seems to contribute to an increased separation anxiety and hence to an excessive dependence. Mr. Z., a lawyer in his early forties, developed a disabling anxiety accompanied by fears of myocardial infarction, with hypochondriacal preoccupations. He requested repeated medical tests and cardiologic consultations but they achieved, at best, only temporary reassurance and relief. The anxiety was more or

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less continuous, but the patient also experienced acute spells of severe anxiety accompanied by weakness, fear of fainting, and, on a few occasions, paroxysmal tachycardia. Mr. Z.’s condition developed at a time when he was about to leave his father’s law firm, after several years of a very difficult partnership, in order to set up a practice of his own. Mr. Z.’s personality was characterized by pronounced dependence. During his illness he could not separate from his wife for any length of time and insisted that she should stay within reach by telephone. Mr. Z. had already experienced a period of severe anxiety in his early twenties, which required a brief hospitalization in a psychiatric unit of a general hospital. While there, he had insisted on his mother staying at his bedside and holding his hand. In one of the sessions we discussed Mr. Z.’s childhood. It transpired that he had a conspicuously defective sense of orientation. Even though his school had been only half a mile away from his home, he always walked along the same route out of fear of losing his way. During his military service he had attended an officers’ training course. He did well in most of the subjects, except navigation exercises, which were, in his own words, “a nightmare”. Mr. Z. is just one of several patients in whom we have observed excessive dependence and separation anxiety in conjunction with poor spatial orientation. The relationship is probably reciprocal. A toddler whose spatial orientation is poor will be afraid to venture out and will maintain closer physical and emotional contact with his mother. Likewise, a child who is afraid to separate from his mother refrains from exploring the environment and has fewer opportunities to practice and enhance his sense of orientation. In other words, we are dealing with a synergistic effect of a developmental variable (spatial orientation) and an emotional variable (autonomy). The consolidation of a self-representation and an object representation requires, besides motor maturity, a degree of cognitive maturation. Self-experience (Chapter Four) presumably consists of fleeting self-object perceptions (O. F. Kernberg, 1984). The coalescence of such fleeting states into self- and object-representations implies continuity and hence a degree of cognitive maturity to bind the separate memories into a narrative.

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During the second year of life the toddler enters into the “oppositional” stage: he asserts his autonomy as a separate human being by sizing up his will against that of the caregivers. The progress in motor development facilitates a more effective organization of the expression of aggression as mentioned in Chapter Two. We distinguish the following developmental stages of aggressive discharge: a. Global response, i.e., diffuse motor and autonomic discharge (neonate, infant). b. Behavioural response, manifested by intentional motor activity, either diffuse (tantrum) or goal-directed, e.g., kicking an object, biting, hitting or throwing (older infant, toddler, and sometimes an adult). c. Verbal release, i.e., expressing the angry affect or the aggressive wish in words (older child, adult). d. Cognitive-emotional working-through, without motor discharge (i.e., “civilized” behaviour). The form of the discharge of the aggressive drive, therefore, depends on the level of organization of the central nervous system and on the intensity of the emotion. Each form of discharge is characteristic of a developmental stage but not exclusively bound to it. Emotionally highly charged situations can regressively lead to a more primitive, maladaptive expression of rage. Even temper tantrums can occasionally be observed in some adult subjects when frustrated, though admittedly such occurrences are not frequent. Such a regression is more likely to occur in a subject whose central nervous system is not well integrated, as a result of either environmental or innate unfavourable influences. The emergence of a more organized discharge of aggressive drive during the second year of life facilitates negativistic or defiant behaviour, which is an important component of “separationindividuation” as Mahler called it (McDevitt, 1983). The toddler’s negativistic behaviour is not only a way of distancing himself from the caregiver but also a way of asserting his autonomy and enhancing his self-esteem. His cognition by now is well developed, and he can perceive clearly his limitations in comparison to what adults or older siblings can do. In other words, the negativism is also a

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way of coping with narcissistic injuries imposed by reality and of protecting self-esteem. A toddler whose gross motor development is inadequate cannot express his need for independence in action; such toddlers tend to become particularly negativistic, stubborn or passive-aggressive. Personality traits like these often persist, and the child (or the adult) with passive-aggressive personality traits may develop ingenious methods for submitting to the authority of others but making sure that the result will be a failure. The resolution of the oppositional stage is facilitated by the development of language (see Chapter Two). The ability to express wishes and later to verbalize feelings is a milestone of emotional development, and it enhances the modulation of affects and the containing of aggression. Verbalization therefore facilitates the resolution of negativism. Indeed, it is a common observation that some children with good cognitive development but a delayed expressive language are more irritable and negativistic during that stage. We may summarize by saying that a balanced motor, cognitive and language development facilitates a relatively smooth sailing through the stormy “terrible twos”, and the acquisition of an incipient ability to resolve conflicts and clashes of will, as well as the establishment of a self-representation. Any delay, deficiency or idiosyncrasy in one of these functions is apt to have an adverse effect and impede a favourable conclusion.

The Oedipal stage The next stage, the Oedipal stage, marks the development of affectionate object relationships, ambivalence, and the beginning of sexual identity. Children in whom the attachment stage or the autonomy stage has not been successfully resolved will encounter difficulties in establishing affectionate object relationships in the Oedipal stage. To love another person, one has to be able to perceive the object of love, cognitively and emotionally, as a separate person with his or her own feelings and needs. During pre-Oedipal stages of development the caregiver is perceived by the child merely as an all-powerful need-satisfying or need-denying agency, and now the child has to relate to the caregiver as a person. The Oedipal child has also to learn to cope with ambivalence, i.e., love and hate directed at the same person. This requires a clear-cut differentiation

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of feelings, a characteristic that needs to mature. An infant’s emotional states and affects are fluid, nebulous and poorly differentiated (Bridges, 1932), e.g., intense joy may easily turn into distress. In toddlers, affectionate hugging and aggressive “grabbing” are not easily distinguished, neither by the child nor by the observer. The child in the Oedipal stage, however, shows a sharper delineation between affection and anger, and therefore he can be fully aware of his contradictory feelings. If the maturation process, that is, the differentiation of positive and negative feelings, is delayed, there is a blurring rather than a contradiction. Instead of an emotional conflict between love and hate, there is an infusion of aggression into affectionate relationships. In conclusion, one of the main developmental objectives of the Oedipal stage is the establishment of ambivalent relationships, i.e., the ability to tolerate contradictory feelings directed at the same object. The achievement of this objective depends on two prerequisites: (a) there has to be a consolidated object representation, and (b) there has to be a clear-cut differentiation of affectionate and hostile impulses. The pre-Oedipal child envies his parents’ omnipotence, but the Oedipal child goes one step further and attempts to stand up to the parent and to compete. In order to embark on such a fearsome adventure, the small child needs considerable self-assurance as well as trust in the parent’s benevolence. At this point the feelings of competence and sense of body mastery acquired during the second year of life assist the child in rising to the Oedipal challenges. A developmental lag or impairment that interferes with the establishment of a sense of competence will invariably affect the child’s ability to experience and express competitive, hostile wishes during the Oedipal stage. For instance, many children with slow or defective motor development fail to acquire the normal assertiveness of the Oedipal child and tend to regress to a clinging-dependent or passive-aggressive relationship with the parent of the same sex. The next developmental objective of the Oedipal stage is the formation of early sexual identity, a gradual process that will continue throughout adolescence. The primary mechanism for the establishment of sexual identity is identification with the parent (and an older sibling, as the case may be) of the same sex, though other factors, such as perception of one’s body and social reinforcements, also participate in the process.

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The identification with the parent of the same sex may encounter difficulties when there is a significant temperamental incompatibility between the parent and the child. A chronic conflict between the two will not, by itself, impede identification; at most it may result in excessive aggression or guilt, but estrangement may well impede it. This is because the primary incentive for identification is not so much love as admiration, i.e., a narcissistic need. The young child yearns to be powerful like the parent; the conscious, deliberate wish to be like a beloved person comes much later and is a much weaker determinant of identification. Therefore, the child may easily identify with a frustrating parent, though it will be a hostile so-called “identification with the aggressor” (A. Freud, 1936). An estranged parent, in contrast, is a blurred, confusing image to identify with. Temperamental affinity strengthens the normal narcissistic tie between parent and child, i.e., the parent’s perception of the child as an extension of himself. Therefore, temperamental affinity makes it easier for the child to identify with the parent. As an example of such an affinity we may quote the father who said: “I know when my daughter is up to mischief because I would have done the same if I were in her place.” If there is a strong temperamental affinity with the parent of the opposite sex, the result may be ambiguity or conflict in the sexual identification. The greatest obstacle to identification, however, is a temperamental mismatch with the parent of the same sex and the ensuing alienation, expressed by statements like: “Is this my child?” For a child who is such a “biological stranger” (M. K. Aleksandrowicz, 1975a) to his parent, identification with that parent and resolution of the Oedipal situation are arduous and fraught with conflict. Parts of the super-ego and egoideal (i.e., psychological values) are treated unconsciously as internalized “foreign bodies”, imposed forcibly, alien and hostile. In conclusion, the favourable outcome of the Oedipal stage is facilitated by the following: (a) firm object representations at which to direct affectionate and hostile feelings; (b) a differentiation of affectionate and hostile feelings in order to experience emotional conflict and ambivalence; (c) a sense of competence to dare to compete with the parents; and (d) enough temperamental affinity with the parent of the same sex to form ego-syntonic identification and to lay the foundations for sexual identity and integrated ego-ideals. The direct effects of developmental deviations on the progression of developmental stages decrease in the stages that follow, i.e., the

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school age, adolescence and adulthood. The social and physical world of the child expands, and environmental factors, as well as life events, play an increasing role in shaping the personality. Some developmental deficits or temperamental idiosyncrasies may persist, however. More importantly, the emotional hurt, and especially the deleterious effects on the formation of the Self (as described in the previous chapter), persist in most cases and may interfere seriously with emotional maturation. Moreover, the effects of a failure to achieve a satisfactory resolution of an earlier developmental stage, e.g., attachment, may have a profound effect on the structure of personality and may result in maladjustment or vulnerability.

Middle childhood Middle childhood—school age, or the “sexual latency” stage (Freud, 1905)—is characterized by a spurt in cognitive abilities, especially reality-oriented, so-called “secondary” thinking processes, and by an expansion of the social sphere, especially peer relationships. Developmental impairment may imperil both. The subject of “primary” and “secondary” thought processes, terms coined by Freud (1900, pp. 587–609), requires some explanation. During intrauterine existence the foetus finds himself in what may be called a “primary state”: a condition of only minimal deviations from the optimal balance of vital needs, with gentle (most of the time) and continuous auditory, tactile, and proprioceptive stimulation, which assures the development and maturation of the central nervous system functions. Extrauterine existence allows only limited opportunities for such a “primary state”, and the infant needs to supplement the mother’s ministrations by self-consolatory measures, i.e., by “primary” cognition, aimed at restoring, as much as possible, a condition approaching the “primary state”. At first, “primary” cognition consists, as far as we can infer, of hallucinatory gratification. Later on, when cognitive processes become more structured, hallucinations are replaced by fantasies, daydreams and wishful thinking. “Secondary”, reality-oriented cognition develops slowly as the young child becomes familiar with his environment and learns to recognize its lawful properties. This form of cognition gradually

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assumes a larger role in directing behaviour, though it never replaces “primary” cognition entirely (Brakel, 2007; Noy, 1969). Realityoriented, “secondary” cognition develops in parallel to “primary” cognition, and its control over behaviour shows a steep rise when the child moves from the Oedipal stage into latency. The growth of a young child’s interest in reality and the gradual relinquishing of fantasy are due to the maturation of cognitive skills, but they require reinforcements. The rewards that consolidate reality-oriented thinking and behaviour consist of real gratification of (socially acceptable) wishes, social reinforcements (i.e., praise or status), and last but not least, gratification of the need for mastery (see Chapter Fifteen). Fantasy offers a wide choice of narcissistic gratifications; none of them, however, can compete with a real accomplishment. Growing up, we trade the omnipotence of fantasy for the fulfilment granted by mastery. A child with a learning disability, impaired motor- or visual– motor coordination, or any other neuropsychological impairment, grows up with an insecure competence. Once he reaches latency he runs the risk of further damage to his competence because of difficulties encountered in school or in extracurricular activities. The temptation is great then to withdraw into either private fantasies, i.e., daydreams, or “manufactured” fantasies, such as video or computer games. The content of the daydreams and fantasies of such children is almost invariably grandiose and aggressive, indicating their source: narcissistic injury, feelings of powerlessness, and impotent rage. The withdrawal into fantasies detracts from the incentive to practice reality testing and social competence. The child tends to remain immature, self-centred, and susceptible to instinctual needs, such as excessive eating. Peer relationships of the child who has developmental deviations may also be affected negatively by his poor academic or athletic achievements. Moreover, personality traits common in children with ADD constitute a social handicap: short attention span, impulsivity, and irritability; low frustration tolerance; and, in some children, unexpected lapses of social judgement, like saying the right thing at the wrong time. The child’s low self-esteem causes social timidity or clumsy compensatory efforts, which also do not help his peer relationships.

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In conclusion, the main developmental objectives of middle childhood, i.e., emotional investment in learning, consolidation of reality-oriented thinking and behaviour, and expansion of social interactions, are apt to be delayed or distorted by developmental deficiencies. The result may be inadequate social skills and a fixation of emotional investment on need-gratifying fantasy.

Adolescence The main developmental objectives of adolescence are as follows: a. To contain the rising tide of libidinal and aggressive drives and to direct them into adaptive and socially acceptable channels of discharge. b. To relinquish the original Oedipal love objects and to direct libido to peers. c. To consolidate sexual identity. d. To cope with the growing demands and responsibilities assigned by society, i.e., to “come of age”. Developmental deviations can interfere with each one of these objectives, as follows: a. Containing and channelling drives may become a very difficult task for children whose developmental deviations involve impairment of impulse control, for instance, most hyperkinetic children. Adolescence for such children and their parents can be a trying and turbulent time, often characterized by sexual promiscuity, running away, juvenile delinquency, or other forms of social maladjustment. It is important to determine whether a child’s maladaptive behaviour is an expression of a deep-seated personality disorder, a result of social factors, or a result of developmentally determined impulsivity and poor judgement. The latter condition presents a more optimistic outlook, provided the environment can act with firmness, understanding and patience. b. Relinquishing the tie to parents involves overcoming dependence. Children whose developmental deviation resulted in excessive dependence, e.g., some of the children with delayed motor development or impaired spatial orientation, will experience more than the usual difficulty in separating from their infantile love objects.

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c. The formation of sexual identity during adolescence has its roots in the Oedipal stage. If the latter was less than successful, the process of consolidation during adolescence may also encounter difficulties. d. Coping with demands and assuming responsibilities require a solid basis of reality-oriented, secondary thought processes and effective social skills. We have mentioned before (Chapter Three) that some children with developmental impairments lack the spontaneous intuitive perception of social cues. That impediment becomes even more significant during adolescence, when peerrelations become a prominent developmental objective. A youth who failed to acquire adequate cognitive and social resources during latency will find the demands of adolescence difficult to cope with. He may withdraw even more into the world of needgratifying fantasy or attempt desperately to gain acceptance and respect of the peer group by engaging in ill-conceived, impulse-ridden sexual or aggressive behaviour and becoming “a rebel without a cause”, like the hero of James Dean’s classic film. In conclusion, the adolescence of children who have developmental deviations can be a stormy, difficult and even dangerous time. It is important, however, to keep in mind that developmental deviations alone do not determine the form or severity of the problems. A great deal depends on environmental factors, namely, home situation, educational setting, peer group, sublimatory outlets, and supports available in the community. Therefore, understanding the nature of a developmental deviation is not enough in order to confidently predict adolescent adaptation or lack thereof.

Cognitive and emotional inflexibility In addition to the difficulties and distortions that affect each developmental stage in children with developmental deviations, there seems to be a non-specific factor that may interfere with the progression of all developmental stages. We refer to a certain rigidity of cognitive, emotional and behavioural patterns, which one often observes in subjects with subtle neuropsychological impairments. Different investigators describe children with ADHD as “not amenable to educational methods”, “unable to learn from experience”,

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or “non-responsive to reinforcements”. In our opinion, it would be more appropriate to refer to this quality as a lack of flexibility, or inertia of established cognitive and emotional patterns. Freud, in his reference to an “adhesiveness of the libido” and to a “depletion of plasticity” (Freud, 1937, pp. 241–242), was probably referring to the same phenomenon. Compared with children who are not developmentally impaired, a child with a deviation requires more time and more energy to transition from each developmental stage into the next; therefore, he also needs more help and more patience on the part of the caregivers.

Summary In summary, for each developmental stage, the simultaneous maturation of specific perceptual, motor and cognitive functions is required in order to usher in, develop, and terminate that stage successfully (see Chapter Two). Some functions compel the child to enter a particular stage, e.g., perceptual and cognitive maturation make the separation of self and non-self unavoidable. Other functions provide the means and the gratifications needed to work through the processes involved. For instance, motor maturation provides the means to struggle through the process of separation and the opportunity to release aggression, which is also a critical component of “separationindividuation” (McDevitt, 1983). Termination of a stage is also facilitated by maturation, e.g., the blossoming of physical and cognitive faculties that occurs at the beginning of latency promotes the termination of the Oedipal stage and a shift of libidal investment onto the exciting wide world of middle childhood. Last but not least, the transition from one developmental stage into the next requires a measure of flexibility of emotional and behavioural patterns. Hence, a rich spectrum of individual innate characteristics and the variability of the maturational timetable interact with environmental factors to determine the progression of developmental stages.

CHAPTER SIX

Coping with maladaptive development

B

oth children and adults whose development was less than optimal adopt different defensive manoeuvres to minimize the resulting distress and to maintain reasonably gratifying social relationships. There is considerable overlap between those manoeuvres and what we call “defence mechanisms”, but there is also a basic difference. “Defence mechanism” is a term coined by Freud and elaborated by Anna Freud (A. Freud, 1936). It refers to psychic functions (and more specifically unconscious ego functions) whose ultimate goal is to prevent the subject from acting upon “forbidden” impulses, i.e., impulses (most often sexual or aggressive) contrary to the subject’s own moral values and to his self-image (or his ideal self-image, i.e., how he wants to be). Those inhibitory devices arise originally from internalization of parental injunctions and parental values and reflect the society’s moral code. The feature common to all mechanisms of defence is that they achieve their aim by keeping forbidden wishes out of consciousness, by repressing them. The defences employed to cope with maladaptive development also rely often on repression, i.e., keeping ideas out of consciousness. Some of these defences are the same “defence mechanisms” 87

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described by Anna Freud (1936). Others, however, do not repress wishes but perceptions of painful reality. In most instances they do not prevent action but serve to reduce distress. There is another difference between neurotic defence mechanisms and the coping devices we refer to here. It is well known that in the process of analysis, as defences are being interpreted, there is an increase of anxiety, which abates when the underlying unacceptable impulses are worked through. When the narcissistic protective devices are confronted too rashly, the patient is confronted with the unmitigated impact of his negative, despised self-representation, and this may lead to depression more often than to anxiety. This can be a deeply distressing experience, which may tax the therapist’s skill and empathy. Understanding the roots of negative self-representation, both innate and environmental, may be of crucial importance in overcoming the crisis. The methods of coping with maladaptive development can be divided into three broad categories as follows: (a) devices to minimize the functional impairment; (b) defences against impulse dyscontrol, aggression, anxiety, and other emotional difficulties resulting from the developmental deviation; and (c) means for coping with the narcissistic injury and negative self-representation.

Minimizing functional impairment The most natural reaction of a child to recurrent frustration is to avoid the task that he or she is not competent to perform. We often hear about a child who “does not like to draw” or the youngster who is “just not interested in athletics and prefers to browse in the library”. Such statements should not be taken at face value. We have yet to meet a small child who does not like to draw if he can, or an agile youngster who does not delight in physical activity. A declared “lack of interest” is a disguise for avoidance, shielding the child from experiencing incompetence. Once a subject has overcome the tendency to avoidance, he finds means, sometimes very ingenious ones, to overcome or bypass the impairment. We have mentioned the student (Chapter Three) who memorized visually his notes because he could not remember the lecture. Another subject, a bright high school student, suffered from partial anomia, i.e., he could not recall many words (although he recognized their meanings when they were presented to him)

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and consequently had great difficulty in constructing sentences. This youngster taught himself to memorize entire sentences from textbooks and to use them as “building blocks” to express himself. His grades were excellent, and the examiner expressed some disparaging comment about teachers who do not recognize such replicated texts, but the boy explained: “Oh, no, the sentences were duplicated but the ideas were all mine.” This kind of juggling of verbal content admittedly requires a superior intelligence, which that youngster had indeed. Some exceptionally intelligent people, endowed with imagination and determination, turn their disabilities into assets. Unable to use conventional strategies to cope with cognitive tasks, such as mathematical problems, and unable to rely on guidance by teachers, they learn to depend on their own ingenuity and become capable of unconventional, creative ways of thinking; Einstein allegedly could not read until the age of nine. Convention is the worst enemy of creativity, and we all know of scholars endowed with superior intelligence whose contributions to science were negligible, because they merely improved on what had been said before and was accepted by consensus. History of science has taught us that great advances in scientific theories were usually accomplished by people who did not dispute their predecessors’ conclusions but questioned their “conventional wisdom”, that is, their premises. Some other subjects seem to reverse the situation: they invest so much effort into mastering the difficulty that they excel in that area. Demosthenes, the legendary Greek orator, was reported as having suffered from a speech impediment, which he overcame by walking alone along the beach, holding pebbles in his mouth and practicing speech (Bobrick, 1995). Mr. R., a colleague of ours, told us that he had a history of delayed expressive language development. He later became a talkative child (one of his teachers called him “Dauer-redner”, “non-stop talker” in German), but his language tended to be abstract, the logical connections of his thinking were often unclear, and he had some difficulty in retrieving words. Eventually, however, he improved his expressive language to the point that his writing became remarkable for a careful choice of words and clear reasoning. This made him a popular public speaker and a prolific writer in his field.

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In such cases the developmental handicap develops into an asset; unfortunately, such a positive outcome does not seem to occur in the majority of cases. Cognitive detours and coping devices have clinical significance because they may be misinterpreted as neurotic behaviour traits. For instance, some subjects, prone to becoming confused or disoriented because of impaired attention span or poor retention memory, compensate by becoming “conservative”, pedantic, over-concerned with order and sameness, and anxious when forced to deal with change. Such character traits may easily be misdiagnosed as compulsive symptoms. They are not apt to change, however, unless the underlying cognitive impairment is recognized and the anxiety caused by episodic disorientation reduced.

Coping with affect or impulse dyscontrol A child with a functional handicap is a frustrated child and therefore an angry one. Aggression is the natural response of a living creature to frustration. It is also an adaptive response: in nature, attack is often the most effective means of overcoming an obstacle that stands in the way of satisfaction of the organism’s needs. For a child with developmental difficulty, however, being chronically angry does not relieve the problem; it only compounds it. Most such children tend to initially direct their anger at their parents, like an infant directing his rage at the caregiver. One of us (M.K.A.) used to say: “They are too young to blame the government.” The overt or unconscious anger of many patients at one or both parents does not automatically prove that the parenting was inadequate, as most therapists tend to assume. Such may well be the case, but it is also possible that the child was frustrated because of developmental dysfunction, or that both factors were involved. Automatically attributing all the responsibility for an excess of anger (or any other unfavourable developmental outcome) to the parents is an unnecessarily hasty conclusion that may conceal a vestige of the therapist’s own infantile fantasies of parental omnipotence, fantasies that unfortunately seem to permeate the writings of some psychoanalytic theorists. Subjects coping with an excess of anger develop a variety of defences, similar to the defence mechanisms employed by patients with neurosis or personality disorders. These defences include denial,

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displacement, rationalization, and reaction-formation. Such defences rarely exist in isolation: in most patients with a history of developmental deviation the analysis of a symptom reveals two determinants, (a) a dynamic one, i.e., unconscious guilt resulting from a repressed wish, originating from early object relations, and (b) a structural one, i.e., non-specific anxiety due to the ego’s inability to deal with the excessive anger. The neurotic mechanisms adopted by some patients with innate ego-weakness are apt to become excessively rigid, resulting in “difficult” patients or “unanalysable” personalities. In other patients the defence mechanisms are frail and prone to failure when the subject is faced with stress, a situation commonly seen in borderline personality structure. In each case, however, understanding of the innate features of personality and exploration of the neurobiological dysfunction are essential for the treatment to be effective. The problem of aggression is further compounded in those patients in whom a neuropsychological disability involves an impairment of impulse control, e.g., in most hyperkinetic children. The excessive anger of the child with deviant development and the difficulty in coping with this anger in an adaptive way persist into adulthood. The direct expression of such senseless rage can be seen in the so-called Episodic Dyscontrol Syndrome (Elliott, 1982), now more commonly referred to as Intermittent Explosive Disorder (American Psychiatric Association, 2000, pp. 609–610). The problem, however, may lead to a massive compensatory reaction and manifest itself in a rigid, overly controlled personality (Weil, 1978) with excessive isolation of affect, or in an emotionally impoverished, “wooden”, over-intellectual personality. Exploration of such character traits usually reveals defence against uncontrollable rage, and a developmental deficit may be discovered as one of the factors leading to it. Some subjects cope with an excess of aggression by turning it on themselves in a self-derogatory, sneering attitude. This allows them to retain some degree of internal locus of control and to protect their narcissism. (“You are not going to humiliate me; I will do it myself.”) Other patients express their excessive anger by a contemptuous devaluation of everybody else or by a petulant, querulous personality trait. In other subjects the self-directed aggression leads to depression as described in Chapter Four. Another affective difficulty in subjects with developmental impairment is a susceptibility to excessive anxiety. We have already

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mentioned that the cause for such anxiety is the subject’s perception of ego weakness; it may often co-exist with anxiety due to dynamic factors, i.e., unresolved unconscious conflicts. An example of such an intertwining of factors can be seen in the case of Ms. J., mentioned in Chapter Three and described in Chapter Nine. The most common defence of a person affected by anxiety is avoidance of situations that may provoke such anxiety. This is equally true with regard to subjects suffering from neurotic anxiety and those affected by neuropsychological deficiency. Avoidance can be effective in preventing or reducing anxiety, but the price a person pays in quality of life may be high. Ms. J. was, at the time of her referral, practically an invalid. Unable to work away from home she became financially dependent on her husband, who was supportive but intellectually much inferior to her, as well as on her extended family. She had to be accompanied to sessions during the first months of therapy. As her anxiety gradually subsided, I came to recognize the impressive potential of that seemingly helpless invalid. A very bright woman, she subsequently became a successful junior executive, a competent amateur painter, and a story-writer. Some subjects cope with anxiety by engaging in so-called counterphobic (or “manic”) defence: they seek situations that provoke anxiety in order to prove to themselves that they can overcome it. (D.R.A. once treated a paratrooper who suffered from acrophobia.) This may be a more adaptive defence, but few succeed in it. A more common reaction is defeatism, an “I give up” style of personality, like the student who turns in a blank page on an examination, though he knows well that the worst solution he might write will still earn him a better grade than will an empty page. In our experience, this kind of personality trait, once established, tends to be firmly rooted and can have devastating consequences on the subject’s life. It is an important but a difficult therapeutic challenge, and insight into the developmental difficulty may be of great help. A particularly harmful form of avoidance is an aggressive response masking fear of failure. We have mentioned already in Chapter Three that a child with learning difficulty will often choose to appear negativistic, i.e., “bad”, rather than incompetent, i.e., “stupid”. Being aggressive is less of an injury to a child’s self-esteem, and it restores,

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to some extent, the sense of internal locus of control, i.e., the feeling that “I am the one who chooses to be mean.” Dror was seen in consultation, after being referred to a child psychiatry clinic. He was brought by his parents at the request of the school, which could no longer cope with him and described him as a menace to himself and others. Dror was eleven years old at the time of the examination, the younger of two children. His family had lived inside the Gaza Strip in a tiny village that was evacuated, and they moved to a city not far from the border. During the Gaza operation, as their city came under repeated rocket attacks, Dror became very anxious, refused to leave the shelter, and demanded that his father sleep in the same room with him. When the military activity wound down, Dror’s fears abated, but his school problems persisted. His adjustment at school deteriorated progressively, and by the time of the referral Dror no longer participated in school activity. He took part only if the subject interested him, which occurred infrequently. Otherwise he ignored the teacher and worked at solving riddles from a book. When the teacher took the book away, Dror would disrupt the lesson by making noise or provoking other boys into a fight. Quite often he would run away from school or fail to go altogether, sometimes telling his parents that he had been “suspended”. On one occasion he climbed a tree inside the school compound and the school staff thought that he had tried to run away, although it remained unclear how he could do it that way. In any case, the school staff perceived Dror as dangerous to himself and others and demanded urgent intervention. Dror was born at term, and the pregnancy and delivery were uneventful, but he developed neonatal jaundice, and his gross motor and language developments were moderately delayed. While in kindergarten he was evaluated because of attention difficulty and restlessness. He was seen by a neurologist who found hypotonia and dysgraphia and diagnosed the child as suffering from an Attention Deficit Hyperactivity Disorder and as having signs of Tourette’s Syndrome as well, manifested mainly by vocal tics, i.e., emitting various sounds impulsively. He was given a TOVA test to assess the therapeutic effect of a stimulant (methylphenidate (Ritalin)) and the result was improvement in

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attention but an increase in impulsivity. A trial of Ritalin resulted in a worsening of tics and had to be abandoned. An attempt to maintain regular contact between the school and the parents did not succeed, as the homeroom teacher claimed that she had several problem children in her class and could not cope with the load. Instead, the school called the father to come each time Dror’s behaviour became too much for staff to handle. Naturally, the parents resented this and blamed the school for making Dror the scapegoat rather than helping him. According to the parents, discipline problems at home were minor, and they could deal with them effectively. Dror had been referred to group therapy at a Post-Traumatic Stress Disorder Centre with some effect on his fears but no visible improvement in his school behaviour, and therefore the school requested an additional consultation. Dror was a relatively small boy, vivacious, attractive looking, with large, dark eyes and an engaging smile, quite different from the menace described in the letter written by the school. Initially he appeared inhibited and diffident, but he established a good rapport quickly. He readily admitted to not being happy at school and blamed it on the poor quality of the teachers. He slumped in his chair and became visibly sad when the examiner tried to go into details of his problems at school. Nevertheless he was willing to tell us that he was socially isolated, fought with some boys in his class and got along only with some younger children. His mood perked up visibly when his hobbies and interests, such as building airplane models from Lego blocks, were brought up. He explained that he did not use prepared sets of Lego blocks but used his own imagination to create various items, such as different models of airplanes. His range of interests appeared quite broad, ranging from dinosaurs to sports, in contrast to his gross under-achievement at school. No tics were seen during the interview; Dror was restless, fidgeting in his chair and touching parts of his body, but he was not grossly hyperactive and willingly engaged in play with toy animals during the interview with the parents. He was obviously a bright child capable of adequate academic achievement but in need of a considerable amount of help.

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The team agreed on the following in.tervention plan: 1. Individual psychotherapy, to deal with his frustration, anger and alienation from school and other children. 2. A trial of pharmacotherapy (clonidine) as an adjunct. 3. Remedial education, as indicated by the psychological test. 4. Counselling with parents and the school in order to cooperatively set up a program of behaviour modification, congruent with the child’s ability to control impulses. This program should be aimed at restoring a sense of internal locus of control, i.e., an understanding that getting or not getting a reward is within his power to decide. Such an aggressive type of avoidance may be compounded by irritability, which is seen in many children with developmental impairment, and by failure of impulse control, and it is often misdiagnosed as conduct disorder. In the absence of adequate therapy, a proper educational setting and family support, these children easily drop out of school and become at risk of antisocial behaviour. The juvenile gang satisfies the need to be accepted as an equal and not as the “village idiot”. The narcissistic injury of feeling incompetent may now be compensated for by the admiration shown by fellow gang members for the subject’s daring. In this manner, the initially inappropriate diagnosis of antisocial personality becomes a self-fulfilling prophesy. Such children easily become a part of the statistic of juvenile delinquency because of their impulsivity and poor judgement. Consequently, they not only commit antisocial acts, they are also easily caught.

Coping with narcissistic injury Coping with narcissistic injury may take very different directions. A very common feature of narcissistic vulnerability, especially in younger children, is overcompensation by bragging over real, or more often imaginary, capabilities and accomplishments. We encountered the tendency to boost the self-esteem by bragging when we tried to compare the self-esteem of developmentally impaired and normally developed pre-school children by means of a suitable questionnaire (“I am like …”). The results were confusing because the developmentally impaired children appeared at both

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ends of the scale: either over-critical of themselves or seemingly over-confident. In Chapter Ten, we describe the treatment of a girl who demonstrated such defensive bragging. In older children and adolescents, the need to overcompensate for a narcissistic injury may drive subjects to risky behaviour or to bullying weaker schoolmates. Many risky behaviours of adults, such as “extreme” sports, are frequently narcissistically motivated, and some such behaviours may also serve as compensation for narcissistic frustrations caused by developmental handicap. The tendency to overcompensate for the narcissistic injury may become an ingrained personality trait. Some such subjects become what we call “social fools”: egocentric, self-aggrandizing individuals, overly concerned with ambition and public image, intolerant of criticism, and often insensitive to the nuances of interpersonal situations. These subjects manifest many features of narcissistic personality. Some of them, indeed, should be so classified, but others only appear to be narcissistic personalities. Closer scrutiny shows that those “pseudo-narcissistic” personalities are capable of true loving relationships when the object does not constitute a threat; for example, they may be warm and considerate toward children and become deeply attached to them. Therefore, the difference between narcissistic personality disorder and narcissistic over-concern or over-sensitivity, which are reactions to severe or prolonged narcissistic injury, is to be found in the quality of object relationships. Another common mode of overcoming the narcissistic injury of feeling incompetent is to escape into fantasy. Children’s fantasies usually consist of imaginary power, and writers of children’s stories such as Harry Potter (Rowling, 1997) know well how to appeal to their audiences. The power of fantasy is limitless; it heals the narcissistic injury and restores the locus of control to the self. This coping device is, naturally, not confined to people who have developmental handicaps. Quite to the contrary, it is a universal way of dealing with life’s hardships. It is, however, often very pronounced in children whose lives have been marked by repeated frustrations. Children with learning disability and especially those affected by attention deficit (without hyperactivity) are particularly prone to let their attention wander and to daydream when they can no longer follow their lessons. Such behaviour leads to a host of interpretations, ignoring the simple fact that a child who cannot attend to the

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lesson and does not wish to attract attention by misbehaving has nothing better to do than daydream. Escape into fantasy is a double-edged sword: it helps to alleviate frustration and to contain anger, but it often does so at the price of reducing whatever motivation there might be to overcome the difficulty. Moreover, it may seriously impair a child’s social ties. Such a negative resolution of “Hamlet’s dilemma”, of the issue of whether to tackle a problem or to escape into passivity, may well predispose a child to seek later other forms of escape, such as alcohol or drugs, but to our knowledge the question has not been investigated. There is, however, an important positive aspect to the inclination to use compensatory fantasy: gifted people whose frustrations in real life induce them to create an imaginary realm may become creative artists who share their imagination with others. The painter Toulouse Lautrec, whose body was badly deformed, was just one example of such an outcome. One does not need knowledge of depth-psychology to understand Toulouse Lautrec’s fascination with cabaret dancers, since dance is the epitome of the beauty of the human body and its graceful movement, and constitutes a defiance of gravity. Other coping devices are less adaptive. Some narcissistically vulnerable children seek comfort in the company of much younger children whom they can dominate. A child may also bolster his sense of mastery by becoming absorbed in gadgets and particularly such activities as remotely controlled toys, video games and computers. These are fascinating to most children, but they acquire a special meaning for the child who feels lacking in competence. For such a child social contacts are apt to be threatening because one can neither predict with confidence nor control the responses of the people with whom one has social interactions. Gadgets, however, are both controllable and entirely predictable if one applies the correct rules, and therefore gadgets enhance the child’s sense of skill and mastery, restore his internal sense of control, and nurture his narcissism. Manufacturers of gadgets seem to be well aware of this, since the content of the games emphasizes both power and skill. Some children with narcissistic vulnerability find other means to create a world of their own: they develop special interests or engage in hobbies, like Dror’s Lego airplanes, mentioned above, which offer opportunities to feel competent or in control. Such activities may enrich the child intellectually, but they are apt to deepen his social

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isolation, unless the hobby involves contact with other children interested in the topic. Other individuals do not attempt to compensate for the narcissistic injury generated by deviant development. Their negative self-representation is ego-syntonic, and they develop insecure, passive, dependent personalities, sometimes with masochistic or self-derogatory character traits. In conclusion, a person with a developmental deviation perceives himself, however dimly, to be different, less competent in mastering his environment, less dependable in coping with drives, affects and inner conflicts, and less emotionally consonant with his parents or other significant persons. Such negative perception of one’s ego functions and the resulting narcissistic injury lead to a low self-esteem, negative self-representation, non-adaptive aggression, depressive tendency, and a propensity to anxiety. Children affected by developmental handicaps develop a variety of coping manoeuvres, some identical to the defence mechanisms described in psychoanalytic literature, others more characteristic of narcissistic protective devices. Those devices may be adaptive and in some, relatively rare, cases even beneficial, but most often they impair a subject’s functioning and have a negative impact on interpersonal relations, both in the family and in the social sphere.

CHAPTER SEVEN

Raising a child with idiosyncratic development: a mission barely possible

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e refer in this chapter to parents rather than caregivers in general, as we did in previous chapters, because parents have an emotional investment in their child different from and more complex than that of any other caregiver, no matter how strong another caregiver’s attachment to the child might be. Parents, as a rule, perceive their offspring, to some extent, as extensions of their “Selves”. That perception may be very dominant or slight, conscious or not, but it is hardly ever absent. As a result, some of the narcissistic investment directed toward the Self binds to the person of the child. Therefore, a parent projects his or her narcissistic aspirations on the child, often hoping the child will succeed where the parent has failed. Another, not unusual, narcissistic need of the parents is for the child to serve as “proof” that the parents are “good” and competent in their roles, consonant with their perception of “good” parenting and with the expectations of the society. The criteria for “good” parenting vary across cultures. For instance, in European societies of the nineteenth century, the child, in order to demonstrate parental competence, had to be healthy and well fed, preferably plump (in Yiddish the word for “healthy” also means “fat”), and well behaved when older. Today, a fat child is more often 99

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than not a sign of parental disregard for a healthy diet. With the advent of child development studies in the last century, the child of competent parents is supposed to be intelligent and, in some circles, happy most of the time. The school system still mostly wants well-behaved children (the schools call it “motivated”), and not all teachers value critical inquisitiveness or vivaciousness. All this taken together imposes rather arduous demands on any parent, and it becomes a mission almost impossible when the innate abilities of the child simply do not fit such goals. In summary, parenting a child with idiosyncratic development is a challenging, and often a discouraging, task. The problems of parenting an “exceptional” child manifest themselves in different ways, as we discuss below.

Emotional resonance In previous chapters we described the reciprocity of the infant– caregiver relationship and emphasized the critical importance of emotional “resonance” on the part of the caregiver for optimal psychological development of the infant. H. Papousek and M. Papousek (1983) and M. Papousek (2007) described the biological basis of that interaction. An optimal development of such an emotional resonance, or attunement, requires both maternal capacity for empathy and an infant’s ability to signal his needs with reasonable clarity (Korner & Grobstein, 1967; see Chapter Three). Infants who are particularly difficult to understand and do not respond to persistent efforts to comfort them drive the caregiver to despair. Her whole body is primed to comfort the little creature, and the failure to evoke positive feedback wreaks havoc on her emotional state. The child whose emotional needs are unmet feels unloved, even though, strictly speaking, not being understood and not being loved are not quite identical. Yet, even under the best circumstances, a difficulty in emotional attunement may lead to a profound sense of estrangement, which M. K. Aleksandrowicz described as being “biological strangers” (1975a). A mother of three described her feelings in the following way: “My other kids often made me mad, but I knew why they acted like that. With Johnny it was different: I could never figure him out.”

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The issue of empathy becomes more difficult if the child exhibits “atypical” characteristics such as idiosyncratic temperamental traits or minor central nervous system impairment. Naturally, a caregiver’s ability to empathize with an “atypical” infant depends on her sensitivity and care-giving experience, and therefore a child with idiosyncratic temperament born to a young, inexperienced, and insecure mother is at a more serious risk of impaired emotional development. Psychological theories that put all the responsibility for early difficulties on the mother and ignore the temperamental variability among infants do not make the problem any better. Such a one-sided view undermines whatever little self-confidence the mother has to begin with and often becomes an excuse for the other members of the family (especially the spouse or mother-in-law) and the professionals to put the burden on her, rather than provide support. Well-intentioned advice given to the mother, such as: “Try to relax, don’t be so anxious and the baby will be all right,” makes matters worse, by implying that it is the mother’s anxiety that makes the baby difficult to cope with and not the other way around. Even wellintended guidance can be experienced by the mother as criticism. The S.’s were a young couple of our acquaintance. Their first child was normally developed physically, but he was an oversensitive baby who cried for the slightest reason, e.g., whenever people on the television screen were quarrelling. Ms. S. was quite exhausted taking care of him, and her mother-in-law came to stay with the family, to help and to provide guidance for the inexperienced mother. Her presence brought some relief but did not change the baby’s excessive tendency to cry for the slightest reason. Finally, however, the mother-in-law had to return to her home and left. The little one stopped crying on that day, and his development proceeded smoothly from then on. When a mother says that she, like Johnny’s mother, finds it difficult to understand one of her children, the examiner will be well advised not to hastily assume that that mother suffers from a deficiency of empathy. A lack of empathy may well be the case, but it is also possible that the mother’s empathic ability is challenged by a child who is difficult to empathize with, for reasons of his own. One of the patients referred to us for psychoanalysis was a young mother who lived in a village at a considerable distance from our

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clinic. She could not specify any particular symptom that might have led to the referral but told us that she was willing to cope with the problem of travelling for several hours, three or four times a week. The reason for her assent was that her infant son was diagnosed as suffering from autism, and she had been told that “the only hope for a cure depended on her undergoing psychoanalysis”. She added, as an afterthought, that the baby had also been seen by a neurologist who had diagnosed cerebral palsy. Apparently, no one had told this young mother that autistic spectrum symptoms are not unusual in infants affected by cerebral palsy. This was, probably, an exceptionally ill-conceived referral, but instances of overlooking the contribution of a child’s innate characteristics to a difficulty of attunement are not rare.

Comforting Comforting a child in distress has been described by Bion (1962, pp. 89–90, 1970, pp. 95–96) as “containment”. By that we mean that the mother, or other caregiver in close physical contact with the baby, has to experience the child’s anxiety as her own and “contain” it, i.e., attenuate it by virtue of her more mature ego and more effective self-comforting ability. The infant “resonates” emotionally with this process and calms down. If the mother experiences excessive anxiety, as may well happen in the case of a difficult, oversensitive infant, she may find herself unable to contain the child’s distress, and the entire process breaks down. Comforting is one of the critical care-giving skills. Healthy infants can usually be comforted by holding, caressing, gentle rocking, or exposure to stimuli that evoke interest, e.g., by holding the baby propped up against one’s shoulder in order to expose him to a wide visual field, talking to the child, or offering an interesting object to examine. Restless, irritable infants who cannot be soothed by appropriate sensory stimuli may condition the parents to use other means, such as frequent feedings, to cope with the infant’s distress. Such a comforting technique may prove temporarily effective, albeit at the price of interfering with the child’s natural hunger-satiation cycle and perhaps with his sleep cycle as

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well. It also engenders the risk of an excessively strong tie between feeding and comfort. In other words, undesirable child-handling methods may develop as a council of despair, not necessarily as a result of deep-rooted neurotic aberrations in the parents. The following example illustrates a “desperate” comforting technique and its results (M. K. Aleksandrowicz & D. R. Aleksandrowicz, 1975): Carmel was a wanted child. When she was born, her mother, a housewife, was 28, and her father, a semi-skilled warehouse employee, was 35. They had an eight-year-old son. The family’s medical history was unremarkable. Mother’s first pregnancy was followed by a period of infertility and one miscarriage. The pregnancy with Carmel was uneventful, but the delivery was overdue by one month and prolonged. During labour and delivery, Carmel’s mother was heavily medicated by oxytocin, meperidine, scopolamine, and general anaesthesia (nitrous oxide and methoxyflurane; see also M. K. Aleksandrowicz & D. R. Aleksandrowicz (1974)). Delivery was spontaneous without the use of forceps; Carmel weighed 3.7 kg. She was bottle-fed, and her physiological jaundice was mild. Throughout her first year she suffered from recurrent colds, but otherwise her physical development was normal. We administered the Brazelton Neonatal Behavioural Assessment Scale (Brazelton, 1973), as part of a research project, daily during the first five days of life, and then on days 7, 10, and 28. Carmel’s Brazelton scores indicated several developmental risk factors, as follows: States (immediately preceding and after stimulation) From the first day (age 18.5 hours) until the tenth, Carmel was deeply asleep at the beginning of testing. After stimulation, she was either in a drowsy state or screaming; the “Quiet alertness” and “Activity” states, during which the highest level of functioning can be observed, were conspicuously absent. After 10 days, she could be brought up to the “Quiet alert” state for brief moments but then resumed screaming. This pattern of states was considerably different from the mean behaviour of the infants in our sample.

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Neurological examination Neurological ratings on the Brazelton scale range from hypo- through normo- to hyper-responsiveness. Carmel exhibited a persistent pattern of hypo-responsiveness to the following stimulations: Tonic neck reflex, Ankle clonus, Crawling (motility was very low), Moro’s reflex, and Incurvation. Rooting and Sucking were weak only on the first day. At the age of one month, Carmel showed no “Walking response” when placed in a vertical position.

Comparison of Carmel’s individual behaviour patterns and the individuality factors (see Chapter Two) Impressionistic description Consistently, all the examiners described Carmel as very difficult to test because of her irritability and the absence of states of optimal functioning. Moreover, her lack of cuddliness and her “pushing away” behaviour made examiners uncomfortable. “Orientation responsiveness” to visual and auditory stimuli In the first four days Carmel did not fixate her eyes or follow the visual stimuli, and she responded only slightly to the auditory stimuli. On the fifth day, she oriented herself to the stimulation; however, her orientation behaviour decreased on subsequent testing. At the age of one month, she barely fixated her look on the examiner, and then only after the examiner had used considerable coaxing and tried repeatedly to get into Carmel’s field of vision. Her responses to the auditory stimuli were low and were also achieved only after considerable coaxing. Summing up, Carmel’s scores on all items comprising the “Orientation responsiveness” factor were grossly and consistently low. “Habituation” Except on the tenth day, visual and auditory stimuli during sleep were quickly “ignored”; that is, Carmel habituated immediately. In other words, throughout the first month while asleep, Carmel exhibited a hypo-responsiveness to the world around her, compared with the other infants in the group.

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“Excitability” Here Carmel’s behaviour was quite consistent from her first day on: Tactile stimulation, such as turning the child from a prone to supine position, uncovering, undressing, or even just holding her, produced continuous crying and rapid changes in skin colour. Only when wrapped up with a pacifier in her mouth, while being slightly patted on her back, did Carmel quiet down and sink into a deep, motionless sleep. At one month, she actually responded to an examiner’s voice, face, and hugging arms by crying. In her mother’s arms, however, she relaxed slightly and smiled. In summary, Carmel’s scores on items comprising the “Excitability” factor were persistently much higher than the group mean. “Motor organization” Carmel’s motor organization was average or above (except for the absence of “walking” movements mentioned above). On her first day, she could hold her head erect for a few seconds when pulled to sit, although she fluctuated in her ability to do so from day to day. However, her Activity level was persistently low until the age of one month. “Relaxation” Carmel’s ability to utilize inner controls over her excited state when confronted with distressing stimuli was inconsistent. On the first day, she was able to quiet herself by sucking her fist; in addition, she was moderately cuddly but did not smile. On the second day, the patterns reversed: no self-quieting, little fist-sucking, but she did smile twice during the testing session. Gradually Carmel showed less and less cuddliness; she no longer smiled or attempted to quiet herself. (This pattern of smiling compares with the mean smiling scores for the group as a whole: 0.57 on Day 1, 0.50 on Day 2, 0.93 on Day 4, 1.09 on Day 7, and 1.23 on Day 28.)

Family interview at the age of eighteen months In view of the psychologist’s impression about Carmel’s deviant behaviour and excessive anxiety in the office, we decided to see the child in her home. During the visit, we observed, conversed with the parents, and attempted to engage the child in

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play. The Vineland Social Maturity Scale (Doll, 1953) was used as a guideline for estimating Carmel’s development. The following is a description of the family interview as well as an attempt to understand the dynamics of the relations between the child and her parents. When the examiners first entered the living room, Carmel looked at them and immediately began to cry. The mother, seated in an armchair, used her soothing voice but was unable to quiet the child. At that point, the father came to the rescue, holding up his arms to Carmel who fled into them. He talked to her in a very animated voice (it was difficult to understand what he said), hugged her, threw her into the air, tickled her, lay on the floor and let her “ride” him. This stimulating play went on until the telephone rang. When the father went to answer the call, Carmel looked at the examiner and again began to cry. The brother immediately offered his support, but he did not succeed in diverting Carmel’s attention from the examiner. The child continued to cry. At this point, the father abruptly finished the telephone conversation and resumed his active stimulation of the girl, encouraging her to push him. She fell, started to scream, and immediately father consoled her by lifting her into the air and engaging her in play. Every time she fell, almost on purpose, he diverted her attention by physical contact and body stimulation. When Carmel was slightly more relaxed, her mother offered her plastic blocks, and the girl began to play. At that point, the psychiatrist decided to join her in her game and offered her some blocks. Carmel did not reject him; she looked at the smiling stranger squatting beside her with curiosity mixed with apprehension, but did not cry. But then the father intervened. He verbally encouraged Carmel “not to be afraid and to play”, but the effect, predictably, was the opposite. Beginning to cry, she turned to her father, who immediately started with his usual over-stimulating, consoling procedure. This incident seemed typical of the father–daughter relationship. Though ostensibly encouraging her to play with the stranger, the father, by his intrusive and ill-advised intervention, actually disrupted the tenuous rapport with the examiner.

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Throughout this scene, the mother, sitting impassively in her armchair, continued to report details of the child’s history. Carmel had cried throughout the first three months every night. Only the father could quiet her down until she fell asleep and was put in her crib. In the mother’s words: “He has a special way of holding Carmel that apparently relieves her from her gases and she stops crying. Yes, Carmel is Daddy’s daughter!” Throughout the first year, Carmel ate well and gained weight even though she suffered from recurrent colds. The bottle was always the best way to console her. About a month before the meeting, she had switched to the cup. According to the mother, “If Carmel has her cup of milk, the world is okay.” The pacifier was taken away when the girl was four months old. At eighteen months, at the time of the family interview, Carmel could feed herself, take off her clothes without help, and, according to the Vineland scale, had attained at least an average level of development. Carmel’s social interaction was still restricted. She accepted the babysitter with whom she was left once a week while the parents attended services, and even extended her arms to that lady. Carmel could also be left, reluctantly, with the maternal grandmother, but the presence of any other adult caused her intense anxiety. She let older children play with her, but only if the parents were not in the room.

Discussion Carmel’s behaviour from the first day of her life set her apart as an infant with deviant development. She was handicapped in dealing with the external world because of a consistently low level of orientation responsiveness, high irritability, and paucity of states of optimal interaction between the infant and her environment, that is, quiet alertness and activity. Such behaviour also made her difficult to comfort and a demanding baby who created for herself a very different environment from the one a relaxed, alert, and responsive infant would create. With her screaming she kept the whole family constantly tense, anxious, and tired. The mother was relieved when the father assumed control during the hours when he was at home.

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The father was most skilful in quieting Carmel by applying physical stimulation and thus diverting her attention. By doing so, however, he reinforced this crying-demanding pattern. By constantly “protecting” Carmel from others and taking over, he unwittingly magnified the child’s fear of strangers and further lowered her threshold of tolerance. The relation between the two appeared symbiotic, with the father constantly at his daughter’s service while completely controlling her and enhancing her attachment. The only relief in this relationship occurred when the father was absent during working hours and during religious services. Carmel’s differential response to her mother and to the examiner at the age of one month showed that she had the elementary innate capacity for object relationship. Therefore, the fact that at the age of eighteen months she showed a delay in individuation and excessive dependency on the parents was probably due to the parents’ behaviour, which in turn was their way of coping with anxiety produced by a difficult, hyper-irritable child with low frustration tolerance and low ability to reduce tension. The child’s innate characteristics and the parents’ vulnerability to anxiety seem to have produced a snowballing effect. At the time of the interview, the family seemed to have reached a sort of equilibrium. The father counteracted his anxiety by over-protectiveness and constant physical contact with the child. This tense closeness was interrupted only when the father was absent from home. The mother had resigned herself to the role of a “secondary caregiver”, active only when the father was away. The older boy was kept away from Carmel; his attempts at closeness were usually frustrated by both parents. He appeared somewhat sad and subdued but did not create problems for the rest of the family. Carmel continued to be an anxious, hyper-excitable, and over-stimulated girl, and the parents, whom she firmly controlled, supplied her with an incessant flow of emotional stimulation and gratification. Her acceptance of the structure of the baby-sitting situation showed that the child was capable of tolerating more frustration than the family gave her credit for. Although Carmel’s tolerance of a baby-sitter might be considered an encouraging sign, the outlook in her situation is

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not favourable. The family’s state of equilibrium cannot be maintained for long, and the child must eventually cope with demands for which she will be ill-prepared. Carmel’s intense, close dependency on the father as well as crucial lack of support from a strong, limit-setting but reassuring mother, may well lead to difficulties in the Oedipal period. Moreover, the child’s limited ability to establish substitute object relationships with other adults, peers, or siblings can increase her problems. Further difficulties may be expected with the social demands of kindergarten and school. Since the child’s innate equipment, as reflected in the neonatal behaviour test, is not strong, regression could be precipitated by the evolving demands. Moreover, the father, by constantly interposing himself between the child and any environmental frustration, has inhibited Carmel’s ability to cope with social situations and may have delayed the development of adaptive ego functions. In conclusion, Carmel’s seriously impaired social and emotional development seems to have been due to an excessively intense, anxious and exclusive attachment to her father (and to her mother to a lesser extent). This pathological attachment, however, was rooted in the father’s maladroit efforts to cope with an extremely difficult infant, of a type that Thomas refers to as “mother killers” (Thomas, Chess & Birch, 1968). Feeding or prolonged body contact, accompanied by vigorous motion, proved effective in soothing the child, and therefore those methods became firmly established as means of comforting. In other words, the child’s pathological responses shaped inappropriate parental handling techniques by a process of contingent conditioning. Those inappropriate comforting methods, in turn, resulted in, or at least facilitated, an anxious, clinging attachment and a gross impairment of emotional and social development. Parents learn from their baby how to be caregivers; in this case Carmel taught her father and mother how to be pathogenic parents. Carmel’s case illustrates how some parents of atypical children cope, adopting a dubious, but temporarily effective comforting method. Many such families reach the stage where the entire household becomes organized around the needs of the “difficult” infant: subdued noise to avoid waking up the “tyrant”, sleepless nights

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of rocking and walking, and ceaseless concern, at the expense of emotional resources available to older siblings. In conclusion, developmental deviations during early infancy can make “containment” difficult and tend to undermine the positive, mutually gratifying aspect of care-giving. For that reason they can pose a threat to the early parent–child bond and imbue the relationship with negative affects, i.e., with anxiety and rage. Alternatively, they may lead to maladaptive parenting responses that inhibit rather than facilitate emotional and social development.

Parents as “mediators” of competence and the problem of narcissism From the second half of the first year on, the dialogue between the infant and his caregiver extends rapidly beyond taking care of the child’s physical and emotional needs. As the child takes an increasingly active interest in his surroundings and learns to manipulate objects, the caregiver assumes more and more the role of a “mediator” (Feuerstein, 1979) and teacher. Much of the time spent together is focused now on practicing and developing motor and cognitive skills. The caregiver’s “mediation” consists of providing new sources of stimulation, suggesting “games” (e.g., switching a light on and off, rattling a toy), and demonstrating or “shaping” skills (e.g., pushing an object through an opening). Parental mediation also involves promoting the child’s cognitive organization by providing so-called “categorizing criteria”. A caregiver conveys such “categorizing criteria” sometimes intentionally, in order to teach the child, and sometimes spontaneously, by exposing the child to the organized aspects of the adults’ own lives. For instance, the parents teach the child to put all the toys into the toy box and all the pots on the shelf. The parents also associate an object with its picture and its name, e.g., by pointing to a real cat and then a picture of a cat and saying “cat”. Ordering objects into categories is the first level of abstract thinking. The parent also “mirrors” the child’s newly acquired skills by showing pleasure and approval when the child exhibits his accomplishments. Thus the parent becomes an active associate in the child’s rapidly growing mastery and his “love affair with the world” (Greenacre quoted by Mahler, Pine & Bergman (1975)). This shared sense of growth and accomplishment is an emotionally rich experience and

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has a profound influence on the parent–child relationship. It shapes the parent’s narcissistic investment in the child and contributes significantly to the consolidation of a child’s healthy narcissism. Parents assume the role of a mediator intuitively in response to the natural curiosity of the infant. It seems that we all are biologically “pre-programmed” to act as teachers of infants and children; Koester (personal communication, 1988) suggested that adults (and older children as well) have an innate need to impart skills, just as children have an innate need to acquire them. (In other words, the urge to teach may have a deeper root than an identification with the adults.) At the same time, more and more parents nowadays also make a deliberate effort to enrich their child and to stimulate cognitive growth. In Chapter Two, we suggested that the positive affect associated with acquiring and exercising skills helps to consolidate the self. Now we suggest that the pleasure the child derives from acquiring cognitive and motor skills, with the mediator’s assistance, helps to consolidate the infant–parent bond. The child not only learns willingly from his parents because he loves them, he also loves his parents because they teach him (Chapter Sixteen). Developmental deviations that interfere with the acquisition of new skills, e.g., delay of speech, attention deficit, poor motor coordination, or behavioural rigidity (Chapter Three), inevitably interfere with the emotional bond generated by teaching. The parent becomes just as frustrated by the child’s ineffectual performance as the child is, and the parent experiences a similar narcissistic injury.

Narcissistic needs We have mentioned before that parents have considerable narcissistic investment in their offspring. This is neither abnormal nor harmful, provided two conditions are met: a. The parental narcissism is balanced by love, that is, by an empathic understanding of, and respect for, the child’s needs, wishes and aspirations. b. The parental expectations, dictated by projection of their own (often unfulfilled) aspirations and by social pressures, are commensurate with the child’s abilities and inclinations.

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The pride that parents take in their child’s abilities and achievements is not only unavoidable, it is also beneficial. An infant glows with pleasure when his mother showers him with both admiration and love, and parents’ pride is a stimulus for an older child to undertake challenging tasks and develop skills. Parental approval is a powerful boost to the child’s self esteem. Only when a parent’s narcissistic needs grossly disregard the child’s feelings will the result be deleterious. In Susan Hayworth’s film “I Will Cry Tomorrow” (1955; directed by Daniel Mann and based on the life of the alcoholic actress Lillian Roth), the mother, whose hopes to become an actress have failed, takes her little daughter to an audition, hoping the child will fulfil her ambition. They hurry and the little girl falls and begins to cry. The mother, horrified that the elaborate make-up will be ruined, begs her child: “Don’t cry, you will cry tomorrow as much as you wish, but don’t cry now”. Parents of a child whose performance does not meet the expectations face a dilemma. They usually are aware that expressing their disappointment will only increase the child’s frustration and hurt his self-esteem. Yet, praising an inadequate performance may be counter-productive, because the child knows well that the result falls short of what his “action plan” was, and unrealistic parental praise is received with incredulity. Parents of a six-year-old girl with very poor visual–motor coordination praised her clumsy scribble: “Look what a pretty butterfly!” The little one replied sheepishly: “I really wanted to draw an airplane”. Such attempts to artificially prop up a child’s self-esteem can make the child diffident and doubtful of the parents’ sincerity. We may wish to spare the child’s feelings and avoid expressing our disappointment, but children have their own way of perceiving the parents’ unexpressed and even subconscious attitudes. On the other end of the scale are parents who drive their children ruthlessly and express their disappointment sharply, even brutally. “Being Number One is everything, being Number Two is nothing”, one father said. The parents’ reaction to the narcissistic disappointment depends on their own personality, on the kind of deviation or impairment

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the child has, and on the attitudes of the environment, especially the extended family and society in general. R. was referred for an evaluation because of poor attendance and uncooperative, negativistic behaviour at school. He was the third child in a strictly Orthodox Jewish family. His two older brothers were outstanding students in a religious seminary (“yeshiva”), expected to become respected scholars in the community. R. was seen by a psychologist who found an average level of intelligence and a serious learning disability, manifested by dyslexia and working-memory impairment. It was obvious that R. could never become a prominent religious scholar and would remain an underachiever as long as he attended the traditional Orthodox educational system, which emphasizes reading and memorizing religious texts. R. was an agile youngster, with a real ability to excel in some sports. That, however, could never accord him a status in that particular community, nor compensate his father for not having another scholar in the family. The parental response may be further complicated in those cases in which the child is assigned a special role in the family. Such may be the case of refugees whose social status was downgraded as a result of immigrating (like the Russian aristocrats driving Paris taxicabs, after the October Revolution) and whose children are expected to restore the family’s status. Another example is the children of Holocaust survivors, who are often expected to fill the void left by the loss of the entire extended family. Some parents react passively to the idiosyncratic child’s (and their own) distress and they withdraw emotionally from the child, making him feel rejected. Some withdraw either by denial or by immersing themselves in work. Others may engage vigorously in efforts to “correct” the situation. They set unrealistic goals for the intervention and refer the child to conventional or non-conventional therapies, or employ exotic solutions based on faith more than on evidence. They do all this, however, in order to escape rather than to confront their own pain and the emotional distress of the child. Anxious over-protection is another common reaction to a developmentally affected child. It may take two opposite directions. Some parents take over too much responsibility and leave too little room for the child to make his own decisions and to assume responsibility for such tasks that he is capable of. Other parents are over-indulgent

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and fail to set limits. In both cases the child will not feel rejected, but he is apt to be emotionally immature and over-dependent. In the first case he may also resent the parent’s intrusiveness and later rebel against it, or develop a passive-aggressive style of defence. (“I will comply with your dictates, but I will make sure that the result will be a failure.”) Quite frequently the parental attitudes are split: one parent (more often the mother) is over-anxious and over-protective, while the other (more often the father) is denying or withdrawing. This may lead to friction, with each parent blaming the other (usually with some justification) for not dealing with the situation realistically, or dumping the entire burden onto the other. In rare instances, sharing the challenge of raising a “difficult” child can consolidate a marriage; more often it leads to acrimonious arguments, aggravates previous frictions, and may lead to a breakdown of the marriage. As the child grows older, some developmental lags are overcome, but other difficulties appear, because the child’s world expands and the demands of the society become more complex. The child and the parents now compare his performance to that of his peers, and the narcissistic injury deepens. The child with poor visual–motor coordination writes illegible scribbles and cannot draw; the clumsy one cannot run fast or catch the ball. The restless child cannot sit while the teacher reads a story, the impulsive one gets into trouble, and the child with poor retention memory cannot remember what the teacher just said or fails at an examination, though he studied the subject diligently the evening before and understood it well. The parents have to contain not only their child’s misery and helpless anger, but also the complaints and criticisms by teachers, relatives, and neighbours. Many parents begin now to develop fantasies that the child is “defective”, “retarded”, or “crazy”. Such fears are reinforced by the child’s unpredictable and sometimes incomprehensible behaviour: violent emotional reactions, or misunderstanding of instructions and misinterpreting social situations due to concrete or literal thinking. Nick was a ten-year-old boy seen in consultation because of a learning disability. The physician examined the child’s gross motor coordination and right-left dominance and told him: “That will be all, you may now sit down”. Nick took the suggestion literally

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and sat down on the floor where he was, without returning to his seat. Nick’s mother blushed and apologized with embarrassment for the boy’s maladroit behaviour. Another child, when asked whether he was attending a “small” class (meaning special education) or a “large” one (i.e., regular class), answered: “It has four windows”. Such concrete, literal thinking may sound insane to the uninformed observer, and we have known colleagues who misinterpreted literal, concrete thinking for psychotic thought disorder.

Coping with anger Parents of a child with developmental problems are disappointed, frustrated, and angry, no less than the child himself (see Chapter Four). The way they deal with anger depends primarily on their own personalities. Most parents refrain from venting their anger directly on the child when he is very young, although there are some exceptions. Some emotionally immature parents perceive a difficult, inconsolable infant as a persecutor: “He is doing it to me on purpose”. In such circumstances the infant is at serious risk of physical abuse, and in our experience many abused infants were developmentally “difficult” babies to begin with. Verbal or physical aggression against an infant is rare, but a direct expression of anger at an older child is more common. The son of a prominent psychoanalyst suffered from severe dyslexia. He received remedial education and made some progress, albeit slow. One day, trying to impress his father with the progress, he read aloud a street sign, making a few mistakes. The father reacted angrily: “If you can’t read it right, better not read it at all”. That father was an experienced and highly respected professional. We presuppose that he would never have said anything so insensitive and hurtful to a patient, and one must assume that it was an extreme degree of helpless frustration that made him do so. Parents who cannot control their aggression either reject the child or abuse him physically. These cases require more extensive help. Even in less extreme cases the self-perpetuating cycle of failure to

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cope—anger—guilt—further failure—more anger—more guilt leads to a grossly disturbed parent–child relationship. A common outcome in such cases is a sado-masochistic relationship, in which the child learns to find an outlet for his own anger and guilt by manipulating the parent into more and more hostile attacks, which in the child’s perception may be tinged with erotic excitement. Many parents refrain from blaming the child for his difficulties and displace their anger at substitute targets. Some blame themselves, some blame the other parent. They may attribute the problem to a wrong educational approach or even to “poor genes”. (“Don’t you tell me that your grandfather’s half-brother Jack wasn’t daft.”) Some parents vent their frustration on the therapist. Many others blame the environment, such as: “We live in that cursed neighbourhood and he got involved with the wrong guys”. Many children with developmental impairments, such as attention deficit, manage to cope reasonably well at home (or the parents manage to overlook the problem), and the difficulties surface at school. In such a case it is only to be expected that the parents will blame the educational establishment. Some parents attribute the problem to unfair treatment of an underprivileged ethnic group. One has to admit that such accusations may well have more than a grain of truth in them; nevertheless, overlooking the primary contribution of a developmental impairment makes successful intervention more difficult to achieve. In our experience, even in extreme cases of parents’ persecutory accusations of institutional malevolence, a sympathetic but frank discussion of the child’s own difficulties and of the ways to deal with them will be accepted by the parents. The narcissistic component of a parent’s attitude to a child’s developmental problem acquires a special meaning when the parent had the same problem in his or her childhood. That is not unusual, for instance, in cases of ADHD. In such a case everything depends on the feelings the parent harbours toward that aspect of his own personality. If the parent accepts his idiosyncrasy, he may find it much easier to empathize with the child and cope with the problem. When I discussed the diagnosis of a hyperactive girl with her parents (Giselle, Chapter Ten) her mother commented: “I see what you mean, I was a tomboy and restless myself”. In fact, the mother was more empathic than the father and found Giselle’s behaviour easier to handle than he did.

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The issue becomes more difficult in cases when the parent’s developmental problem is ego-dystonic and, even worse, when it has been disowned by repression or split. In such cases all the anger and contempt that the parent feels toward the disowned part of his Self is projected on the child and may be a source of considerable hostility. Such an inclination, incidentally, is a general psychological rule: we tend to be intolerant toward people who represent what we hate in ourselves.

Adolescence Adolescence can be a particularly trying time for a child with a developmental handicap and for his parents. All the typical aims of the adolescent stage of development, such as the need to strengthen the peer relationship, to redraw the relationship with the parents and free oneself from the childish dependency, and to consolidate the sexual identity, are fraught with difficulties if one is burdened with inadequate adaptive capabilities, suppressed anger, and poor self-esteem. The parents in this situation have to face unexpected and, in most cases, unwelcome changes in the child’s behaviour. Paz was seen for the first time at the age of eleven. He was the third child out of five, a younger brother of Maya, the girl described in Chapter Eight. He had been diagnosed as suffering from multiple developmental impairments, which became apparent after the age of four. His pre-school teacher noticed that Paz was clumsy, very quiet, and “a delicate” child, passive in his relationships with the other children. He was diagnosed as suffering from weakness of the upper extremities and poor visual–motor coordination. Psychological testing revealed above-average intelligence with specific deficits in arithmetic, and emotional immaturity. Paz was attending a regular school at the time of the examination and was receiving remedial education. He was socially isolated, insecure, and unhappy at school. His mother, who was bright but a very anxious person (with a history of a learning disability), became very concerned with his emotional state, hovered over the boy, and blamed the school for not really helping him. The reason for referral was to get help in transferring the child to a different school. At the time of the examination, Paz was a

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very passive, anxious child, clinging to his mother, barely able to participate in the examination. Paz’s mother requested an appointment six years later, when Paz was 17. She was bewildered and helpless. She told us that in the previous two years Paz had changed in a way that she found difficult to comprehend and to cope with. The passive, delicate, dependent child had changed into a morose, irritable, and oppositional teenager, associating with questionable characters, neglecting his school assignments, smoking, and drinking. Summing up, significant developmental deviations in infants and children and the emotional consequences of those deviations place a heavy burden on the parents and pose a challenge to their parenting ability. We all, women and men, have biologically “pre-programmed” capabilities to respond to infants’ and children’s emotional needs, but those built-in responses are often inadequate to meet the needs of an “atypical”, idiosyncratic child. We need to make a digression here and mention a topic rarely given adequate attention in psychoanalytic literature, namely the influence of siblings on the emotional and social development of a child. The common, natural relationship between siblings is ambivalent: a combination of affection and competition, often tinged with envy. Such ambivalence is even more pronounced if one of the two is affected by a developmental difficulty. The “problem” child requires more attention than the other siblings, and that magnifies the issue of competition and envy. The healthy child feels that he is being penalized for being “normal”, for behaving properly and not causing problems at school or at home. Some siblings vent their aggression on the “difficult” brother or sister, compounding the problem and even traumatizing him or her. Others feel sorry and try to help. We have known cases where an older sibling was lying to the parents in order to cover up for a younger’s sibling mischief and protect him from the parents’ anger. Very often there is a mixture of empathy and envy at the same time. Much depends on the parents’ way of coping: they may exclude the “normal” child, thus increasing his feelings of being rejected and his envy, or they might expect him to share the burden, running the risk of making him a “parentized” child, i.e., burdening him with responsibilities beyond his

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developmental level. The most effective way to deal with the issue is to recruit the other sibling to help the parents, without, however, assuming responsibilities that are inappropriate for his or her age. An often neglected aspect of a sibling’s dilemma is being ashamed of having a “freak” for a brother or sister. This is more likely to happen if the developmental problem is very visible, such as pronounced hyperactivity, or when it carries a social stigma such as attending a special education program. Some children go to great lengths in order to conceal from their peers having a “defective” sibling. In conclusion, deviant development of a child turns parenthood into a strenuous, frustrating and often ungrateful task. Not only the parents, but the entire family is apt to be affected, and its stability may be at risk. Raising an “atypical” child is fraught with anxiety, anger, guilt and narcissistic hurt. It often cannot be accomplished without professional help and, more specifically, without help of a “developmentally informed” guidance. Yet children do improve with parents’ efforts and persistence. Overcoming the obstacles and challenges described here may in the long run give parents the deep and well-earned satisfaction of having accomplished what seemed at one time to be a “mission, impossible”.

CHAPTER EIGHT

Diagnosis of developmental deviations

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he diagnosis of a developmental deviation may be obvious, as in the case of a hyperactive child, or it may be subtle, as in impairment of working memory in an adult. The problem may be apparent to the patient, his parents, or even a casual observer, or its identification may require professional expertise and specialized instruments. The age of the subject and his developmental stage determine the diagnostic procedure. In most cases, a detailed history is indispensable; a family history may often be helpful, since genetic factors may play a role, as we have already mentioned. We will examine the diagnostic procedures according to age: infancy and toddlerhood, childhood, and adulthood.

Infancy and toddlerhood We will first discuss the subject of risk factors for developmental irregularity. Such risk factors are the domain of obstetrics and of neonatology and are much too numerous to review here; we will mention only a few common ones, some of which we have encountered ourselves. As a rule, any condition that can adversely influence the pregnancy may represent a risk factor for the development of the 121

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child. Such conditions include maternal diabetes (a very common unfavourable influence on the developing foetus), malnutrition, infections, especially viral infections, exposure to radiation, many prescription drugs, heavy smoking, and most substances of abuse, especially alcohol and opiates. Paternal exposure to alcohol or ionizing radiation is also likely to have an adverse effect (Abel, 2004; Morgan, 2003). Foetal factors comprise anything that can adversely influence the development or maturation of the foetal brain, including inborn errors of metabolism (e.g., hypothyroidism or phenylketonuria), cardiovascular malformations interfering with brain blood supply, neonatal prematurity, a small-for-age neonate, heavy medication during labour, foetal anoxia, and neonatal jaundice. It should be stressed that some risk factors are just that, which means they do not inevitably result in damage to the foetus or the newborn: they merely increase the chances of such an outcome. Conversely, developmental irregularities often occur in infants in the absence of any identifiable risk factor. Parents of an infant, and quite often his grandmother (by virtue of her experience), are usually the first ones to notice that there is something atypical in the child’s behaviour. In many other cases, however, the parents overlook or rationalize defensively the deviation, and, in such cases, it becomes the task of the public health nurse or the paediatrician to assume the initiative. The first step in diagnosis, following a history-taking, is observation, preferably in the infant’s natural environment, both alone (or with toys, in the case of an older infant) and in interaction with the caregiver. This may be followed by one of the specialized tests of infant temperament and development, listed in Chapter Two. In Chapter Three, we described the early signs of idiosyncratic development. Specialized medical procedures, such as neurological assessment or laboratory tests, may be indicated in some cases, but most early irregularities are diagnosed by clinical observation and interview with the caregivers.

Early and middle childhood Developmental deviations that do not become apparent in infancy or toddlerhood do not usually come to the attention of the people taking care of the child, until the child enters an educational setting and becomes exposed to educational expectations and social demands.

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Experienced pre-school teachers rarely miss any developmental lag or unusual aspect of a child’s behaviour and relationship with fellow children. The situation in grade school or junior high school (middle school in some countries) is different: in the latter case the class is much larger and the teacher has less personal contact with each child. Difficulties in visual–motor coordination, for instance, or shyness in peer contacts, may easily be overlooked. The symptoms that do invariably attract the teacher‘s attention are failing grades, lack of compliance with the school’s requirements, truancy, and unruly behaviour. It is, therefore, only to be expected that many children for whom the school situation is stressful resort to misbehaving (like Dror, mentioned in Chapter Six) in order to attract attention to their discomfort. The diagnostic assessment of a school-age child requires the cooperation of the parents. A teacher’s report is helpful, but not sufficient, and one cannot expect the teacher of a trouble-making child to be as objective as she, or he, might wish to be. Therefore, it is essential for the examiner to gain the confidence of the parents, no less than the confidence of the school. Diagnosing a child at the school’s request requires understanding that a consultation is a three-way relationship, involving the client (in this case the child and the parents may not be one, but two or three clients, each one with different expectations), the institution, and the consultant. The risk of over-identifying with one client and neglecting another relationship is always there. In some cases the process of consultation is relatively simple. A clinical interview with the child, combined with information received from the parents and the school, is often sufficient in order to come to a diagnostic conclusion about any developmental idiosyncrasy that might be contributing to the child’s maladjustment. In other cases, however, one needs special instruments in order to obtain a more complete picture. There are questionnaires that allow a quantitative assessment of diagnosis as well as of the effectiveness of a therapeutic process. One of the most popular questionnaires, the Conners Rating Scale, is a standard instrument for the diagnosis of ADHD (Conners, Sitarenios, Parker & Epstein, 1998a, 1998b). The critical component of the diagnostic process is, in many cases, a psychological diagnostic test, especially the assessment of cognitive functions as reflected in intelligence tests. It is an invaluable aid, provided it is properly administered and interpreted.

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The standard intelligence test in many educational and clinical institutions is the Wechsler Children’s Revised Test (WISC-R) (Wechsler, 2003). It has been translated and standardized in several languages besides English. It is a well-tested instrument, not excessively time-consuming, and not overly difficult to administer. It has some pitfalls, however, particularly relevant in the case of children affected by innate impairments. One such pitfall is that several tasks required of the child, such as arithmetic or vocabulary subtests, are very similar or identical to what the child is required to do at school. A child who is frustrated and angry or discouraged at school may easily feel antagonistic toward the test requirements and perform below his true ability. The other pitfall concerns the interpretation of results. It is a common practice in many centres to describe the child’s “overall functioning” by calculating the average of all subtests. This is usually followed by a more detailed description of the verbal score versus the performance score and the various sub-scores. To the uninformed, such “overall functioning” represents the child’s intellectual ability. There may sometimes be a true correlation between the two, especially if there is little scatter between the subtests. In the case of a wide scatter, typical of subjects with innate impairments, such a conclusion is not warranted and is actually misleading. If a subject obtains, for instance, a score of 13 on the Block Design subtest (a measure of non-verbal abstract cognition) but a score of 5 on Digit Span (requiring auditory memory), the average of those two subtests, in theory, will be 9, i.e., a slightly below-average level of intelligence. This is patently wrong because the child has to be bright in order to obtain a high score on abstract cognition, especially if he obtains a similar score on one or two other subtests. In such cases it would be better to omit the “overall functioning” concept altogether. The following case illustrates such pitfalls: One of us was requested by the court to prepare an expert opinion on the case of Z., a fifteen-year-old boy who had been injured in an accident. Z. was the oldest of four in an Orthodox Jewish family, a student in a religious high school at the time of the examination. He was injured at the age of seven, while playing in a playground, suffered a deep cut in his scalp, but no neurological injury. He had

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repeated bleeding from the wound, requiring several visits to the hospital and a brief hospitalization. Following the accident and the treatments, Z. developed a Post-Traumatic Stress Disorder, manifested by fears, excessive worry about being hurt at the site of the original injury, avoidance, and anxiety dreams. According to the family there was also deterioration in his academic achievements and peer relationships. Z.’s mother suffered from diabetes during her pregnancy with Z. Delivery was uneventful, but Z.’s gross motor and language development was slow. (Two of his brothers were also described as “slow”.) Z. suffered from repeated ear infections but no other significant illnesses. He experienced some learning difficulties, which the parents attributed to ear infections, and which allegedly disappeared after treatment and returned after the accident. Two years after the accident, Z. was given a psychological diagnostic assessment that revealed both emotional and cognitive problems. His WISC-R test showed a very wide scatter, with a relative lowering of the verbal subtests. The weighted score of the Picture Arrangement subtest was 3 (!). There was an indication of poor self-esteem and a feeling of lack of support (findings common in children with developmental impairments). The psychologist included the standard statement about “overall functioning” and wrote that Z.’s IQ was 84, i.e., at the limit of borderline retarded. Z. was seen by two child psychiatrists. Dr. Y., a senior child psychiatrist, wrote an expert opinion for the claimant. He saw Z. before the psychological test was administered and apparently had no information about the developmental data. (The parents of Z. were, as a rule, reluctant to provide such information and emphasized that “everything was normal until the accident.”) Dr. Y. ascribed all the difficulties to the accident and made a diagnosis of Post-Traumatic Stress Disorder. Dr. S., a prominent child psychiatrist, presented an opinion on behalf of the defendant, i.e., the insurance company. He saw no relationship between the emotional and social difficulties described by the father, and the accident, accepted at face value the boy’s statement that “he was doing all right”, and concluded that the boy suffered no longer from any ill effects of the

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accident. Dr. S. rejected the psychological test report outright, on the basis of the obvious contradiction between the supposed level of “overall functioning” (IQ of 84) on one hand, and the fair academic achievement and the clinical examination, which revealed an intelligence level of average or better, on the other hand. He did not examine the details of selective impairments and their implication. The judge decided he was unable to bridge between such contradictory conclusions and requested an independent opinion by a court-appointed expert. The conclusion was that Z. was an emotionally vulnerable child due to a developmental impairment, who reacted excessively to a relatively minor traumatic event. The present symptoms, i.e., academic underachievement and social difficulties, reflected his developmental problems, aggravated rather than caused by the accident. This case illustrates the diagnostic confusion and misjudgement resulting from biased developmental data (parental reports) and misinterpretation of the results of psychological testing, including the unfortunate concept of “overall functioning”. Another, newer instrument for cognitive evaluation is the Kaufman Assessment Battery for Children, or K-ABC II (A. S. Kaufman & N. L. Kaufman, 2009). It is somewhat more time-consuming but has a number of advantages. It is free of a cultural bias, and the tasks are chosen from children’s life experiences, unrelated to school. For that reason it is more fun for the child to take and less likely to evoke antagonism. The subtests are more directly related to neuropsychological functions (global versus sequential cognitive processing, presumably related to the differential functioning of the two cerebral hemispheres) and therefore more relevant for the purpose of diagnosing disabilities. In some subjects a more detailed analysis of brain functions is required, and one has to refer these subjects to specialized neuropsychological testing. Clinical neurological examination is, in most cases, negative, and so are the routine laboratory tests, namely electroencephalography (EEG), brain computed tomography (CT), magnetic resonance imaging (MRI), and functional MRI (fMRI). At most they reveal non-specific changes that do not contribute much to diagnosis

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and even less to treatment. (They may, however, reveal previously unsuspected neurological syndromes, such as a subclinical convulsive disorder.) This may change in the future as new and more sophisticated laboratory procedures are being developed at a fast pace, but at present, clinical methods remain the best diagnostic tool. The most common reason for failing to diagnose a developmental problem is being misled by a seemingly obvious explanation for the child’s difficulties. One of our outstanding teachers in medicine used to say: “The problem with diagnosis is that, once you make it, you stop thinking”. (Prof. Harry Heller, at that time the Medical Director, Tel Hashomer Military Hospital, Israel.) A child who is exposed to an appalling home situation may, nevertheless, be affected by working memory deficiency or by dyslexia. As a matter of fact, the home situation may very well aggravate the consequence of the disability. Therefore, it is a good clinical rule to explore, at least in historytaking and in the clinical interview, any possible role of innate, biological factors, even when the reasons for the child’s problems seem obvious. Kenny N., a twelve-year-old boy, was seen in consultation, having been hospitalized in the paediatric unit of a general hospital, following a potentially serious suicide attempt: he tied a shirt around his neck and hanged himself from a hook in the bathroom. His parents were at home, took him down unharmed, and brought him to the hospital. He was seen by a child psychiatrist in the E.R., admitted to a paediatric unit under psychiatric supervision, and seen in consultation the next day. This was neither Kenny’s first suicide attempt nor his first contact with mental health services. His background provided more than one reason for him to be a problem child. A maternal uncle was described as mentally retarded and suffering from ADHD. Kenny’s maternal grandfather committed suicide when the grandmother was pregnant with Ms. N. The story had been kept secret from Ms. N. during her childhood; she felt it had been a mistake and told Kenny all about the grandfather. The maternal grandmother, to whom Kenny was strongly attached, often talked to him about her husband’s death and gave him details of the grim story, even adding that there was a suspicion that the grandfather had been murdered.

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Kenny’s parents were working-class people, the father a trained blue-collar worker, the mother a teacher’s assistant. Kenny was the second of four children. The oldest was described as “normal” but seemed to be an angry child, fighting with both Kenny and the younger sister. The youngest boy suffered from mild mental retardation and attended a special education program. The pregnancy and delivery history of Kenny were unremarkable, but at the age of twelve months he was diagnosed as suffering from “weakness of the upper extremities” and received some physiotherapy. Upon entering elementary school Kenny had major learning and adjustment difficulties, was diagnosed as suffering from ADHD, received methylphenidate (Ritalin) and was transferred to the elementary school of a child treatment facility as an “external” student. He reportedly did quite well academically and liked the place. At the age of nine, however, he was the victim of repeated sexual abuse by an older boy. He told his mother about it, and she informed the school. Following this Kenny was seen in therapy by a social worker for a year, but we know little about his emotional condition at that time. At the time of the examination Kenny was attending a regular middle school. He was still on Ritalin, his school performance was considered adequate, though he still had major difficulties in language skills and was reportedly socially isolated. Kenny’s mother was also concerned about his rapid mood swings: he would become elated and overly excited and then, just as suddenly, intensely depressed. Kenny’s first suicide attempt occurred at the age of ten, at a time when his beloved grandmother went away for an extended trip. He jumped out of the window from their second floor home (like the grandfather had, albeit from a much greater height) and was unhurt. Kenny’s second suicide attempt, this time by hanging, occurred at the age of eleven, that is, one year before the consultation. Kenny’s suicide attempts were all demonstrative and occurred in the presence of his parents. He was also openly trying to manipulate the parents, blaming them for lack of attention and excessive dedication to the younger brother. He also told the psychiatrist in the E.R. that he did it “because the parents were fighting”.

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All the same, he did express a wish to die, and the attempts were unquestionably dangerous. At the examination next day, Kenny appeared relatively small for his age, an attractive child, darkish, with long hair and a somewhat effeminate manner. He was visibly hyperactive during the entire interview but managed to remain seated until his parents entered the examination room and joined in the conversation. Then he got up and began pacing the room, but made no attempt to interfere with the interview. Kenny was initially tearful, complaining about being in the hospital, but cheered up when assured that he would be discharged, and was in a good mood during the rest of the time. He was neither inhibited nor sad when the subject of his suicide attempt was brought up, claiming, this time, that the reason was the parents’ “lack of attention” and paying “too much attention” to the younger brother. The “Draw a Person” test revealed poor visual–motor coordination and a gross distortion of the body image, with short, wide arms sticking from the middle of a rectangular body and ending in three round “fingers”. The female figure was identical, except for two window-like squares to indicate the breasts. Summing up, the history and the examination revealed a complex interaction of developmental and environmental pathogenic factors. Kenny suffered from ADHD, impaired language skills and poor visual–motor coordination. The family background and the history of sexual abuse also provided ample reason for his emotional difficulties. The repeated suicide attempts illustrate how family influences and biological factors interweave. In Kenny’s case it was the family “saga”, with a tinge of glorification, of the grandfather’s suicide, as well as the parents’ inevitable over-involvement in raising a retarded younger sibling. The main biological contribution was impulsiveness, a major symptom of ADHD. The mood swings, i.e., affect dysregulation typical of ADHD (see Chapter Three), probably also contributed significantly to suicidality. Additional factors included social isolation (also a frequent feature of ADHD) and the frustrations due to under-achievement at school. This very bright child was barely able to meet the minimum requirements at language-related

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tasks. One might also speculate about a genetic propensity to suicide, though we do not at present have the means to routinely identify such a factor by genetic mapping. The case of Kenny illustrates the complexity of the diagnostic assessment when both biological and environmental pathogenic influences are present. In Kenny’s case the biologically determined disorder was obvious, but a more subtle impairment could have been overlooked because the family background was so clearly related to the symptom. The following case is an example of an unrecognized minor developmental impairment, which might have contributed to the symptom: Sandy was a student in her junior year of high school when she requested a consultation because of a paralysing examination anxiety. She did very well at school, did not experience excessive anxiety when preparing for a test, but during the test itself her mind would go blank and she could not answer even the simplest question. Sandy was the middle child of three. The family background was unremarkable. Both of Sandy’s parents were professional, the older brother was a university student, the younger attended a grade school. Sandy was born at term, but was a low-weight baby. She was an oversensitive infant, cried excessively and relaxed only in a bath. Her motor development was slow, but otherwise she was a healthy baby and developed normally. Her academic achievements, exclusive of the tests, were well above average and no learning disabilities were ever reported. Sandy reported that she felt insecure and anxious in any competitive situation, such as an interview. At the same time she did very well in a volunteer organization in which she took part and was promoted to a responsible position. Sandy appeared somewhat shy and insecure during the examination and wanted her mother to be present, but was cooperative and candid. The examiner asked her to reflect what was on her mind when she was struck with examination-anxiety and she blurted out: “That I can never be as good as my older brother”. Sandy’s mother was dumbfounded; she confirmed that the oldest brother was indeed a brilliant student and “the family genius”,

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but the family always considered Sandy to be very bright and it never occurred to the parents to make any comparisons. We discussed at some length the meaning of competition, sibling-envy and self-esteem, and Sandy seemed relieved by letting out her “secret”. In conclusion the examiner recommended a course of cognitivebehavioural therapy including relaxation training and a mild tranquilizer before examinations, (“p.r.n.”: only if needed). In addition, the examiner referred her to a cognitive psychological test to rule out any unsuspected learning problem. Surprisingly, the test revealed a minor attention deficit, not diagnosed previously. Even more surprising was the effect of the diagnostic interview: Sandy’s examination anxiety diminished to an easily tolerable level without any treatment, and on her next test she received an A+ score. Subsequently, Sandy graduated from high school as an honours student. Summing up, Sandy’s examination anxiety was the result of an unresolved competitive feeling toward her brother, a situation not uncommon among the siblings, especially younger ones, of exceptionally gifted children (and sometimes among the children of exceptionally gifted parents). At the same time, her excessive reaction ought to be attributed to her biological vulnerability: oversensitivity in infancy, slow motor development, and previously unsuspected attention deficit. The latter was never diagnosed because of her superior intelligence, but might well have contributed to her insecurity and anxiety, as described in Chapter Four. It may also explain her particular insecurity in relation to intellectual performance. The role of innate developmental impairments in the clinical picture is not always clear, even when they are diagnosed, as illustrated by the following case: Maya was eighteen years old, a student in her senior year of high school. She was referred for psychiatric consultation because of a persistent fear that there was a “spirit” in the house that might hurt her or her parents after death. Maya felt that she was somehow to be blamed for that evil presence though she did not know why, and that she was expected to perform some sort of a ritual to forestall the threat. The parents were alarmed by the symptom,

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since a paternal uncle and two of her cousins were suffering from chronic schizophrenia, and the parents were understandably concerned about the girl’s sanity. Maya’s developmental history was uneventful, but she had been diagnosed by the school psychologist as suffering from Attention Deficit Disorder and was taking methylphenidate (Ritalin) medication before tests. Otherwise, her school adjustment was very satisfactory. She was somewhat socially shy, but had her small circle of friends. Maya’s family was stable and warm. The mother was an anxious person, herself diagnosed as having had an attention deficit disorder at school. Two brothers were also diagnosed as suffering from ADD. Maya had been complaining about obsessive concerns for years, especially about fears that something bad would happen if she did not perform an action to head it off. She was treated by a psychologist, but her present symptoms were deemed to require a psychiatric assessment. On examination, Maya appeared a petite, slender girl, looking her age, very co-operative, anxious, and very insecure. She appeared bright, her thought processes were well organized, and her reality judgement, apart from the symptom, seemed intact. She was uncertain about the reality of her concern; on the one hand she had a strong inner feeling that there was some kind of evil presence in the house; on the other hand, she reasoned that such spirits do not really exist. She was anxious, perplexed, visibly depressed and tended to cry, but the affect was congruent with the thought content and the situation (i.e., psychiatric examination), and there was no indication of an emotional impoverishment of a schizophrenic nature. The examiner felt that the emotional rapport was good, in spite of the girl’s reserve. There was no history of a traumatic event or any other precipitating cause. Maya reported that she had lost some weight; she had difficulty falling asleep, and woke up often. The psychiatrist concluded that Maya was suffering from an Obsessive-Compulsive Disorder aggravated by a depressive episode, possibly an early manifestation of a Major Affective Disorder. The diagnosis of an incipient Schizo-affective Disorder could not be entirely ruled out, but the examiner thought it was unlikely.

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He recommended a Selective Serotonin Reuptake Inhibitor (SRRI) anti-depressant with an addition of a mild tranquilizer, if needed. Maya’s condition improved significantly within a few weeks and she continued her psychotherapy. The psychiatrist had an occasion to talk to Maya eight years later: she was symptom-free, happy, had graduated from college, and was looking for employment. In this case the diagnosis of ADD was known, but its relationship to the clinical picture was uncertain. It most probably contributed to the girl’s insecurity and vulnerability and might have contributed to the severity of the obsessive symptom, bordering on a failure of reality judgement.

Adulthood Adult patients hardly ever ask for psychological treatment for cognitive difficulties, such as a learning disability or an attention deficit. Some patients may be aware of an ego regulatory dysfunction, such as failures of impulse control or memory impairment, but they hardly ever attribute the problem to an innate developmental disability. Most adult patients are referred because of such symptoms as depression, anxiety or interpersonal difficulties, often after already having been diagnosed as suffering from a neurosis or a personality disorder. It is up to the mental health practitioner, whether consultant or therapist, to be aware of the possibility that an innate developmental idiosyncrasy may have played a role in the genesis of the disorder. Evelyn D., a twenty-one-year-old single college student, was seen at the request of her mother. Ms. D. complained that Evelyn was childish, excessively dependent, and clinging. Ms. D. was particularly annoyed at Evelyn’s habit of involving the mother in personal problems and difficulties, and then criticizing the mother angrily for being “bossy” and “intruding”. During the initial visit, Evelyn, a bright, attractive young woman, appeared frank, cooperative and motivated, conveying a sense of warmth and trust. She had many critical complaints about herself, such as being impulsive, saying and doing things she regretted, “never counting to ten”. Her major source of unhappiness,

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however, was related to her intellectual performance. Though obviously endowed with high intelligence, she had reading difficulties in the first grade, which she overcame with the help of her father. She always saw herself as the “dumb” member of the family, while her gifted father and brother were “geniuses”. Her handwriting was illegible, and she made spelling mistakes. Her work record was uneven: she failed to qualify for a junior managerial position, but then did exceptionally well as a public relations officer in a government agency. Although she did fairly well in her college foreign language studies, she had to give up hopes of becoming a simultaneous translator because she could never recall the text. Poor memory, in fact, was Evelyn’s most painful symptom. For instance, she found herself unable to discuss, during a social gathering, a popular novel that she had read a few months previously. She no longer remembered what the book was about. At times she thought in desperation that hers was a case of a “juvenile Alzheimer’s Disease”, and such thoughts made her want to commit suicide. Clinical psychological tests revealed circumscribed neuropsychological impairments. There was a wide inter-test scatter in the Wechsler Adult Intelligence Scale: from a score of 7 on the Information subtest, reflecting memory problems and avoidance of reading, to a striking score of 18 on Comprehension. Visual memory was excellent: a score of 17 in Digit Symbol and an accurate recall of 8 (out of 9) forms in Bender Gestalt Test. Evelyn also achieved a good score on Digit Span by visualizing the numbers on the windowpane as the examiner read them and then “reading” them from the window. Difficulties in integrating perceptual fields were seen in Block Design and Picture Arrangement. “Draw a Person” and Bender Tests indicated a moderate impairment of visual–motor coordination and a tendency to persevere. The Rorschach protocol was unusual and complex. It showed a rich, creative imagination, i.e., positive original answers, and a basically solid reality judgement reflected in many popular answers. Yet many of those adequate percepts were tainted by inappropriate additional comments, which could lead one to score them as F-responses. That seemed to be related to anxiety, intellectual competitiveness, and, at times, to an inability to cope with several simultaneous stimuli. There were a few C/F answers and no other colour responses,

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an indication of a difficulty to integrate emotional stimuli into cognitive processes. In conclusion, it was felt that Evelyn’s emotional immaturity and instability, her narcissistic vulnerability, and her childish, adolescent-like ambivalent attachment to her mother, could be described as the effect of circumscribed, but significant neuropsychological impairments in a very bright girl, who grew up in a warm, but intellectually demanding, achievement-oriented atmosphere. It was felt that Evelyn did not require extensive therapy, even though she had the potential to use such therapy; informed counselling and a brief expressive therapy were recommended. The case that follows illustrates the emergence of subtle neuropsychological problems during the examination of a patient with an atypical clinical picture: Ms. T., a schoolteacher and mother of four, was referred for psychiatric consultation by her counsellor because of long-standing recurrent depressive moods. She was reserved and diffident, obviously uncomfortable about seeing a psychiatrist and her complaints were vague. She described herself as having “ups and downs”: these were fluctuating moods rather than clear-cut depressive states. She also described “highs”, that is, states of heightened energy and activity. She did not feel elated during these “highs”. To the contrary, she felt distinctly uncomfortable and often anxious. Both the “highs” and the “downs”, i.e., feelings of discouragement and listlessness, were clearly related to life events, that is, satisfactions and disappointments, even very minor ones. Ms. T. reported that her symptoms had begun at the age of fourteen. While in college she was briefly in treatment at a student mental health service, but she “ran away from it”. Ms. T. was vague in describing her past as much as in describing her symptoms. She complained that her memory was poor: she could not recall what she said or where she put her things. On questioning, she described other minor difficulties: she could not draw except crude “stick figures”, her visual–motor coordination was very poor (“my husband does all the sewing”), and she was partially ambidextrous. Her spatial orientation was grossly inadequate,

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and so was her right-left discrimination. Finding her way in an unfamiliar place was totally impossible. The psychiatrist tried to explain the meaning of her difficulties to the patient, and asked her: “Being a teacher, you probably know about so-called learning disabilities?” Ms. T. replied: “Yes, my two sons are dyslectic”. At this point of the interview, Ms. T. appeared more relaxed and less diffident. She still objected to any kind of medication, but suggested she might benefit from psychotherapy, apparently sensing that the psychiatrist understood her better than she had expected. Ms. T. explained that her depressive moods did not disturb her so much as her insecurity and exaggerated sensitivity to criticism or disappointment. Rather unexpectedly she added: “I am also afraid of myself”. This brief interview, though by no means an exhaustive diagnostic study, provided presumptive evidence that neuropsychological impairments, perhaps of a familial type, played a major role in Ms. T’s personality formation and later adjustment difficulties. The case of Ms. T. is not typical, in the sense that in most other cases the clinical picture, as reflected in the diagnostic interview, offers little indication of a developmental deviation. Therefore, a patient’s description of his or her neurotic symptoms may not be informative as to the presence or absence of biological factors, but the history may. Today, with the growing awareness of childhood developmental disorders, many patients, especially the younger ones, tell us that they have been diagnosed as being learning-disabled children, or as suffering from attention deficit. Some patients have been told by their parents that their delivery was particularly difficult or that they were “impossible” infants or children. Therefore, when asking about past illnesses and the personal history, it is a good practice to ask whether there was anything out of the ordinary in their early childhood, as far as they know. Another possible indicator of a developmental factor in the psychopathology of a patient is psychological assessment. Psychological tests are rarely performed if a patient is merely seen in consultation by a mental health practitioner and then referred for psychotherapy; however, in institutions where psychological tests

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are a routine part of the diagnostic evaluation, they may prove very helpful. An important source of information leading to a diagnosis of a developmental idiosyncrasy contributing to a patient’s disorder is the treatment itself, provided it is psychoanalysis or analytical psychotherapy. The developmental problem is reflected in three ways: the patient’s behaviour in the sessions, the transference and the reconstruction of childhood relationships. Cognitive or behavioural idiosyncrasies may appear in the treatment sessions and be misinterpreted as resistance. Such may be the case of memory deficit (like the case of Mr. Y. described in Chapter Three), or an inability to integrate insight into actual behaviour (behavioural rigidity). The transference pattern provides insight into the early relationship with the parents (or other significant persons in the patient’s early childhood), For example, if a patient shows a tendency toward an excessive dependence, or a persistent feeling of not being understood, the therapist ought to enquire as to the possibility that a developmental difficulty contributed to the impairment in the early relationship. This example brings us to the issue of therapeutic reconstruction, which will be discussed in Chapter Eleven. Here we will only emphasize that in our opinion, an understanding of the contribution of a patient’s childhood temperament and early developmental individuality ought to be a part of the therapeutic reconstruction. A thorough diagnostic assessment is not merely a prerequisite for a rational therapeutic plan. It may very often have a therapeutic effect. It is well known in psychiatry that a diagnostic evaluation that leads to insight into the dynamic issue underlying the symptom (an insight sometimes revealed by the patient, sometimes interpreted by the examiner) may have a significant therapeutic effect, even a dramatic one, as happened in the case of Sandy. The insight into an innate biological factor may be of therapeutic value, not less than a dynamic understanding. This is particularly important in the case of children. Understanding that the child is struggling with a problem over which he has little control helps the parents (and sometimes the school) to understand that the patient is not merely “contrary”, “mean”, or “obstinate”, but distressed. It also absolves the parents of taking the blame or being ashamed for failing to bring

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up a “normal”, well-behaved child (as mentioned in Chapter Seven). Knowing that the mental-health professional does understand the nature of the problem and is familiar with the means available to ameliorate the symptoms inspires a sense of control and relieves the confusion and helplessness created by a lack of understanding. In conclusion, paying attention during the diagnostic evaluation to the possibility of innate, biologically determined factors of psychological maladjustment ought to be an integral part of the procedure. It is richly rewarded by a more sound diagnosis, a more appropriate treatment plan, and, at times, by a direct therapeutic benefit of better insight.

CHAPTER NINE

Developmentally informed therapy

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here are several therapeutic modalities for patients whose maladjustment is, in part, a result of developmental impairment. Pharmacotherapy, remedial tutoring, physiotherapy, occupational therapy, and even exotic methods such as therapeutic horseback riding have been employed with varying degrees of success. As a matter of fact, in many cases the optimal treatment plan seems to be a combination of several modalities that complement one other. Our concern here is with remedying the adverse consequences of an atypical endowment for the emotional development of the subject, and therefore our main focus is on psychotherapy, including psychoanalysis. Nevertheless, we will briefly refer to other means of helping the patient, since they need to be included in an overall treatment plan. Such a multimodal treatment plan is illustrated by the case of Dror (Chapter Six). Our approach to the treatment of patients (and children in particular) who are affected by developmental impairments encompasses the following core elements (the order of presentation does not necessarily imply chronology or degree of importance):

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Diagnose the impairment A careful diagnostic assessment, such as the one described in the previous chapter, is an indispensable element of any rational therapeutic program. The therapeutic contribution of the diagnostic assessment is not limited, however, to the ensuing treatment plan. The emotional and behavioural manifestations of a developmental idiosyncrasy often cause the subject to experience bewilderment and helplessness. Presenting the results of the diagnostic assessment (as described in the previous chapter) provides a unique opportunity to make sense of the disorder, reduce helplessness, alleviate guilt (both of the subject and of the family), mitigate the negative selfimage of the patient, and restore a sense of internal locus of control (Chapter Eight). When interviewing a learning-disabled child, we sometimes ask him, “How smart do you think you are?” The usual answer, naturally, is: “Not at all”. We then show him the graph representing the differential score of his WISC test and tell him: “You see, in those tasks that you are good at, you are really smart, well above the average (i.e., the line corresponding to an IQ of 100; if that is the case). You just happen to have a weak memory for what has happened a short while ago (or a weak attention span, or whatever the case may be)”.

Improve the impaired function whenever feasible This is particularly important in children whose problems can be influenced favourably by such interventions as physiotherapy or remedial tutoring. While informed counselling of the parents and adjustment of the caregiving to be consonant with the child’s individual needs (such as described in Chapter Fourteen) can be effective from the beginning of life, the range of direct interventions, that is, interventions aimed at changing the condition of the child, is very limited during early infancy. It expands substantially, however, as the infant develops. With the appearance of more organized motility, such as raising head and chest, turning over, sitting, crawling, and walking, a trained observer can discern minor inadequacies of motor development and undertake appropriate intervention. (Dr. Chava Shelhav, Movement Pathology Clinic, Assaf Harofeh Hospital, Israel,

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personal communication.) Visual–motor coordination can similarly be stimulated, and speech delay can be ameliorated by parental teaching or professional speech therapy. There is disagreement regarding the extent to which practice can restore the normal development of an impaired function. There is anecdotal evidence of people whose persistent practicing made it possible to turn a disability into an asset; the legendary orator Demosthenes, for example, reportedly overcame a childhood speech impediment (Chapter Six). Such instances are rare, however. The ability of the subject to overcome an impairment through practice is highly dependent on the kind of impairment and on the age of the subject. Most clinicians would agree that skilful stimulation can significantly improve the motor development of an infant or toddler. Cognitive stimulation appears to have an effect as well, and there is some evidence of a long lasting effect, though not all studies produced unequivocal results (Denhoff, 1981). Most clinicians would also agree that the effects of intervention aimed at an adult brain are less dramatic, although there is some evidence that even an aging brain may respond favourably (Milgram, Siwak-Tapp, Araujo & Head, 2006). Some skills, such as reading, are essential for social adaptation, and practicing these skills, difficult as it may be, is unavoidable. Therefore, engaging, under proper guidance, in an impaired function is valuable, as long as the goals of such an activity are realistic and congruent with the child’s level of ability and provide enough opportunity for a successful outcome. Under these circumstances, the activity helps the child to diminish his feelings of helplessness and defeat and bolsters his sense of control. It also prevents the snowball effect of lack of practice magnifying the consequence of a disability.

Encourage the use of “detours” A great deal of frustration and distress can be avoided simply by bypassing the disability. Coaching the forgetful child to keep (and consult) notes, teaching typing to a child whose writing is hopelessly illegible, and allowing the use of such devices in the school, can go a long way to reduce the negative attitude toward school that so many learning-disabled children develop over time.

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Many bright individuals invent their own “detours”, like Mr. Y., who recalled the pages of his notes visually because of a severe impairment of his auditory memory (Chapter Three), or Evelyn D. (Chapter Eight), who had a similar problem and taught herself to visualize on a window pane the numbers read to her and then “read” them mentally. Those subjects taught themselves to substitute one form of memory for another. Another example is the high school student affected by anomia (that is, an inability to recall familiar words), described in Chapter Six, who memorized entire sentences from texts and used those sentences ingeniously to express his own ideas.

Support involvement in activities in which the child is competent Practicing deficient skills is both unavoidable and frustrating, and it often compounds the child’s poor self-esteem. Therefore, investing in well-developed skills by encouraging hobbies, sports, or creative arts instils a sense of competence and is an invaluable aid for bolstering the self-esteem. Follow the rule: “Every child has the birthright to excel at something”. The significance of attaining competence is demonstrated by the following case: Mr. K. had a fairly typical history of an undiagnosed learningdisabled child. Though highly intelligent, he had acquired only elementary academic skills and dropped out of high school. He was an embittered, suspicious, unsociable man, alienated from his original family, in conflict with his wife, and distant from his children. His only consolations were hard physical work and soccer, which he played with relish. He rejected any suggestion of treatment or counselling and even refused to meet with the school psychologist who was treating one of his sons. He never read books and could not help his children with their school work because he did not understand it. Somehow Mr. K., discovered the hobby of making silver jewellery. He became engrossed in that hobby and developed it into a profitable part-time business. Mr. K., demonstrated considerable creative talent and dexterity in this highly competitive occupation. It would be an exaggeration to claim that Mr. K’s basic

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personality changed completely. Yet, there was an amazing change in his life: he enjoyed his new work and shared it with the family; he became much more self-confident and less quarrelsome. The most impressive change occurred in his relationship with his children: he enjoyed their company and found common interests to share. Surprisingly, a creative outlet achieved what an offer of a psychological intervention could not. Engaging in hobbies in which they excel also provides some children with opportunities to gain social status and thus compensates them for the ostracism endured at school.

Mitigate the harm done to the emotional development The primary tool for this purpose is psychotherapy. The following hypothetical but common clinical case will serve as an example of the criteria for deciding on the indications for psychotherapy: An adolescent boy is referred because of underachievement, social isolation, poor peer relationships, and depressed moods. A diagnostic assessment shows ADD, which is not reflected by gross academic failure because of the boy’s exceptionally high intelligence. The patient is restless, but slow and clumsy, and his gross motor coordination is poor. He is also anhedonic and selfdeprecating, with very low self-esteem, and feels unloved and criticized by his parents. A number of therapeutic approaches can be suggested, and each will probably help to some extent. The educational program can be tailored to reduce frustration and provide opportunities for the youngster’s remarkable analytic abilities. For instance, excelling in an elective course in computer programming or advanced mathematics will enhance his self-esteem. A karate class will release pent-up aggression and enhance his neglected motor skills. Such extracurricular activities will also provide opportunity for social ties based on common interests. Stimulant pharmacotherapy (to improve attention) or antidepressant medication may also be considered. Any combination of such interventions will probably be beneficial, perhaps even sufficient to meet the therapeutic expectations of the patient and his family. Should one also advise psychotherapy?

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The decision, in this case, depends on the treatment goals. Psychoanalytic psychotherapy, if successful, will achieve all the emotional objectives mentioned above but will also have an integrative effect that the auxiliary therapies or environmental manipulations do not have. Psychoanalytic psychotherapy and psychoanalysis provide an understanding of one’s personality make-up, unexpressed wishes, aspirations, disappointments and fears. Our hypothetical patient will be able to re-examine his view of himself and to reach a realistic assessment of his disabilities and of his talents. He will be able to see the relationship between his disabilities and disappointment with his performance on the one hand, and his low self-esteem, social timidity and underachievement on the other. He will have an opportunity to reassess his view of the parents. Do they really love him less? Or perhaps they are merely disappointed by his self-defeating behaviour? Or maybe neither is true, and he merely projects on his parents the low opinion he has of himself? Only insight can bring together conflicting emotions, irrational cognitive sets and maladaptive behaviour patterns. The result is an improved integration of the self, i.e., self-understanding and self-acceptance, which not only helps the patient to overcome his present difficulties but equips him with the tools to cope more effectively with future stresses and challenges. In conclusion, a rational program of auxiliary interventions can resolve main symptoms and improve functioning greatly; psychotherapy or psychoanalysis can, in addition to improving functionality, also help to integrate the patient’s personality. This example leads us to conclude that psychotherapy is indicated when the developmental idiosyncrasy has become so deeply interwoven into maladaptive personality traits that a symptomatic intervention aimed at alleviating the effects of the impairment will no longer be effective. The traditional view of psychoanalysis (and psychiatry in general) used to be that innate, biologically determined impairments reflect “structural” changes in the central nervous system and are therefore not amenable to psychological intervention. In contrast, environmental, psychological influences cause “functional” aberrations, which are amenable to psychological intervention.

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This assumption might explain the scarce interest shown by generations of psychoanalysts in biological determinants of personality. The few clinical descriptions have focused primarily on the problems of learning disabilities (Levy, 2009; Palombo, 2001; Rothstein & Glenn, 1999). Small (1973) described the history and therapy of such a patient, Palombo (1979) treated a learning-disabled adolescent, and Simpson and Miller ( 2004) described the Tavistock project of psychotherapy with learning-disabled children (they, however, dealt mostly with subjects with subnormal intelligence). Siegel (2006) studied the wider problem of the interface of biology and psychotherapy, but hardly anyone else did. Bonaccorsi (1980) published cases of psychotherapy of what she calls “organic” children (i.e., children with innate CNS impairments), and M. K. Aleksandrowicz (1975b) published the treatment of a borderline child, described in Chapter One. To the best of our knowledge, however, most psychotherapists and psychoanalysts do not seem to take into consideration the contribution of innate developmental idiosyncrasies to the formation of personality and to psychopathology, and they avoid confronting such factors in therapy. The pessimistic attitude toward the therapy of biologically codetermined psychopathology is no longer tenable in view of the vast progress in neurobiology. The distinction between “functional” and “structural” is spurious. On one hand, “functional” processes involve (transient or long-term) changes in the brain tissue, albeit predominantly (but not exclusively) on a synaptic or intracellular level. Some such imprints, such as traumatic memories, may be quite resistant to subsequent influence and are therefore not less stable than “structural” deficits. On the other hand, brain plasticity enables the subject to modify the emotional or behavioural effects of an impairment caused by tissue damage, even though the impairment itself may not be amenable to change (Chapter Twelve). We call our psychotherapeutic approach a “developmentally informed” psychotherapy or psychoanalysis. A “developmentally informed” psychotherapist will be aware of the fact that innate or otherwise biologically determined (or co-determined) symptoms cannot be resolved merely by gaining insight into unconscious conflicts and traumatic memories. Unconscious impulses and conflicts, and symptoms derived from them, may well co-exist with biological factors and may require proper intervention, whether interpretation

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or cognitive modification. Innate difficulties, however, can be mitigated only by analysing and working through the impaired ego functions. In such analysis, impaired functions have to be accepted and integrated (albeit in a moderated form) into the conscious self-representation. This is particularly true of patients suffering from personality disorders, especially the more severe kind, e.g., Borderline Personality Disorders. When treating patients who suffer from personality disorders, we must beware of the “classical” psychotherapeutic approach intended at removing symptoms. This traditional approach to therapy, often only implicit, yet taken for granted, is rooted in an ages-old tradition pitting the healer against the illness, be it a demon to be exorcised or a tumour to be resected. This romantic view of the healer as a combatant and of therapy as a contest is ill-suited to the treatment of subjects with more severe personality disorders. Such patients rationalize their dysfunctional relationships or blame others for unfairly holding them responsible for their behaviour, and they disown unacceptable impulses and affects through gross denial or paranoid projections. Moreover, they are traumatized in their interpersonal relations, alienated, and diffident. An attempt to “remove” a maladaptive behaviour will, more often than not, be perceived as an assault on the patient’s frail adjustment to his circumstances. A therapeutic alliance with such patients can only be achieved by accepting the split-off, ego-alien parts of the patient’s personality and helping him or her to accept them and to integrate such “estranged” affects into a moderated, more adaptive behaviour. Linehan, who described an effective method of behavioural therapy for borderline patients (Linehan, 1993) coined the apt term “validation” for such an approach. One is reminded of Nathaniel Hawthorne’s poignant short story, “The Birthmark” ( 1843). The heroine, Georgina, a young woman of great beauty, has a small birthmark on her face, of which she is barely aware. Her husband, however, is totally unable to accept that blemish and develops a revulsion, which drives Georgina into desperation and leads to a tragic result. Georgina persuades her husband to devise a powerful potion, which removes the birthmark, but causes her death by poisoning. The story tells us metaphorically that the blemish is part of Georgina herself, and it is not possible to destroy it without destroying her as well.

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Innate deficiencies of ego functions, such as hypersensitivity or affect dyscontrol, are, like Georgina’s birthmark, inextricably woven into the fabric of personality. They shape the emotional development, the early object relationships, the coping mechanisms and the subject’s self-representation. The goal of therapy is not to “remove” them but to help the subject to develop more adaptive means of integrating such idiosyncratic traits into the personality. It may be an arduous task, but it is achievable. The following is a brief description of a “developmentally informed” therapy; other, more detailed descriptions are presented in the following chapters. Ms. J. (whose case has been mentioned previously in Chapters Three and Six) was a married woman in her early thirties, a mother of three children, who was referred to analysis because two years of supportive therapy failed to produce any improvement. She was suffering from severe phobias, and particularly from fear of committing suicide impulsively. She could not stand near a street or highway or enter high-rise buildings because of intrusive thoughts impelling her to throw herself down. There were other phobias, too: she was afraid of crowded or closed spaces and could not eat in a restaurant nor travel on a bus. Her range of activities had become extremely limited, and she had to be accompanied by her husband everywhere, including therapy. This disabling illness had developed about three years earlier following two traumatic events: (a) Ms. J. had quarrelled with her mother and asked her not to visit anymore, and (b) Mr. J., the patient’s husband, had a fainting spell after donating blood, and the patient was frightened, thinking that he might die. Ms. J. was a bright, perceptive woman with a considerable aptitude for self-observation and a willingness to understand herself. Nevertheless, the decision to commence analysis was taken with uneasiness because of reservations about the severity of her disturbance. Ms. J. appeared to be very self-centred, with hardly any significant object relationships, apart from an intense, unbridled, possessive attachment to her children. Her narcissistic vulnerability, raw, undisguised envy, and diffidence indicated a primitive, instinct-ridden personality structure. The psychological test report described her as a “borderline personality”, especially

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because of pathological results of the Rorschach test. Her test results included many responses, some of them imaginative and creative, but also many inadequate percepts (F+ 58%) and relatively many unmodulated emotional responses (2C, 4CF, 3FC). The decision to treat the patient by analysis was based on the clinical impression of a strong motivation and an ability to observe and reflect, as well as the patient’s ability to function relatively well before the present illness. Ms. J. was the older of two children born in a very disturbed home. Her father, a highly capable engineer and industrialist, was absorbed in his work, insensitive to his family’s material and emotional needs, given to violent temper outbursts, and abusive to the patient. The mother, an embittered, angry woman, felt rejected and unjustly treated by fate, by her parents, and by her husband. She threatened suicide on many occasions, and Ms. J., her confidante and only support, would miss school and keep watch over the mother. When Ms. J. was twelve years old the mother sent Ms. J. to buy cigarettes and, when left alone, slashed her wrists. She had to be hospitalized for several days, and Ms. J. was left with a deeply traumatic memory. Ms. J. left home when she was eighteen. Soon after, she married a man for whom she had little affection and no respect. Her parents moved to another country, divorced a few years later, and visited her infrequently. The reason for Ms. J.’s turning finally against the mother was the latter’s selfish, demanding behaviour during one of those visits and her callous indifference toward the grandchildren. It was not difficult for the analyst to see that Ms. J.’s phobias represented a fear of her aggressive, murderous impulses against the mother and a guilty identification with the mother’s suicidal impulses. That interpretation, however, had very little effect on the patient. She could barely comprehend it intellectually; emotionally it meant nothing. Ms. J. was in the grip of terrifying thoughts about losing her mind, about being submerged by affects and driven by uncontrollable impulses. Gradually it emerged that the patient, though outwardly inhibited, was in fact an intensely impulsive person, prone to emotional, irrational reactions, which she could not always control. She was easily overcome by anger, sadness, or elation, and her social judgement

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was not always sound. In other words, her fears of being out of control or losing her sanity, although grossly exaggerated, were not without some foundation in reality. It transpired gradually that Ms. J.’s impulsiveness and affective “flooding” were part of a more generalized neuro-psychological impairment, including a short attention span, an inability to attend to several stimuli simultaneously, difficulties in “shifting” cognitive or affective sets (see Chapter Three), impaired motor coordination and rightleft discrimination, mixed dominance (right eye, left hand), and poor working memory. The results of the Rorschach test could now be re-interpreted considering the clinical evidence of a subtle but pervasive neuropsychological impairment, together with a rich visual imagination, with uneven reality judgement and unmodulated, labile affect. The pathogenesis could be assumed to be a combination of an innate impairment and a highly unfavourable home environment, characterized by lack of empathy, instability, and unrestrained expressions of aggression, both hostile and selfdestructive. At this point in treatment we embarked on a systematic examination of Ms. J.’s impaired ego functions and their emotional implications: insecurity, lack of trust in her sanity or critical ability, poor self-esteem, and a need to please and to depend on others to provide ego functions in which she felt deficient, such as control of drives. At the same time, we explored the dynamic factors: her resentful dependence on the husband (in part, a continuation of her resentful but strong attachment to the mother), the possessive love for her children, deep hatred and fear of her father along with a repressed longing for his love. One could describe the course of the analysis as a pendulum motion: no sooner would we work through a neuropsychological problem and its emotional impact, when a dynamic issue would appear and vice versa. It was only when the issues of impulse control and fear of insanity had been extensively worked through, that Ms. J. found the courage to confront her repressed murderous hate for her mother. Upon that, the fears of suicidal impulses were resolved completely. At this stage of treatment the patient was free to move about, could drive her car to therapy, and even went on a trip abroad. She found work,

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first as a salesperson and later as the floor manager and buyer in a clothing store, and finally as the store manager. The case of Ms. J. illustrates the technique we apply to patients with developmental idiosyncrasies and impairments. We observe such personality traits and functional weaknesses systematically and present to the patient our tentative interpretations of their emotional impact. We interpret the effect of deviations on self-representation, especially on the patient’s sense of competence and self-esteem, on the early relationships with the parents, on the current object relationships and on transference. We also interpret how innate qualities are used defensively, e.g., passivity to disguise aggression or to control another person. In this way, not only do the analysis of adaptive ego functions and the analysis of conflicts and defences proceed simultaneously, but the reciprocal, inter-connecting threads are also explored. There are some factors limiting the potential of psychotherapy. Some patients with developmental deviations and neuropsychological impairment develop a clinical picture so severe as to preclude psychoanalytic psychotherapy or psychoanalysis. Even in such cases, however, insight into the developmental factors helps supportive therapy and rehabilitation. Another limitation of psychotherapy or psychoanalysis may be an innate lack of flexibility, the “psychic inertia” or “thinking in loops” described in Chapter Three. This inertia was observed by Freud (1937, pp. 241–242). He attributed it to an “adhesiveness of the libido” and considered it to be an obstacle to analysis. In some of our patients such inertia did not necessarily prevent achieving favourable results but caused the process to be slow and prolonged. A rather serious difficulty was encountered in the case of Mr. Y. (see Chapter Three). His poor attention span and seriously impaired sequential auditory memory interfered with continuity of treatment. At times it seemed like writing on water, even when the patient’s motivation was positive and his negativism at ebb. Worse still, the lack of continuity seemed to be paralleled by an internal inability to integrate, to experience the past, the present and the transference within an integrated Gestalt. Such integration, simultaneously cognitive and affective, is the core of psychoanalytic treatment. In this case it failed to appear, and

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the patient’s insights remained compartmentalized and isolated. Mr. Y. derived considerable symptomatic benefit from the treatment, but a fundamental change in personality appeared to be beyond his reach. Some patients have great difficulty accepting their limitations or reassessing their ego-ideals in a manner consonant with their temperament and inclinations, rather than reflecting parental ideals and expectations. Interpretation and working-through are sufficient to free some analytic patients from the incompatible internalized parental authority, but others need also a measure of benevolent support. The same applies to self-esteem. For some patients, an interpretation of the narcissistic injury and of the compensatory mechanisms is enough, whereas others need a certain amount of support before a healthy narcissism is consolidated. Confronting the devices that protect the patient from narcissistic injury requires prudence. Just as confrontation of a neurotic defence, e.g., a well-timed interpretation, is apt to increase anxiety, so might an injudicious interpretation of a narcissistic coping device result in depression. To reduce that danger, the therapist has to depend on the therapeutic alliance and the patient’s trust, as well as on his or her own sensitivity. Last but not least, there seems to be a limit to the extent to which the late effects of damage caused by a developmental deviation to the early mother–child relationship can be undone. In some patients we have observed a sense of being unloved and a propensity to feel rejected, so deeply ingrained that no amount of insight acquired in analysis could resolve them entirely, even though it could mitigate their intensity and impact. In conclusion, many patients whose emotional difficulties and maladaptive behaviours stem from developmental deviations can and should be treated by psychoanalysis or psychoanalytic psychotherapy. The following conditions will make the therapy “developmentally informed” and facilitate a favourable outcome in such patients: a. The therapist needs a clear understanding of the developmental deviations and of their impact on the patient’s emotional life and on the development of the patient’s object relationships;

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b. The therapist aims at integrating that information into the analytic process, i.e., analyses adaptive as well as defensive ego functions; and c. The patient and the therapist set therapeutic and life goals congruent with the patient’s temperamental traits and functional abilities. Human nature is infinitely complex, and so is psychoanalytic psychotherapy or psychoanalysis. Biological and environmental factors interact in ways that we are only beginning to unravel. Nevertheless, integrating developmental understanding into the therapeutic process has the potential of making it somewhat less arduous and substantially more effective.

CHAPTER TEN

Psychotherapy of a girl with minimal ADHD: Giselle, the “Girl who Tamed Dinosaurs”

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iselle was nine years old at the time of referral for consultation. She was described by her mother as “irritated and irritating”, and the main complaints were difficulties in relationship with her parents and her younger brother, two years her junior, with whom she fought most of the time. She was friendly toward her youngest brother, who was twenty months old at that time, and she willingly participated in taking care of him. Giselle’s parents reported that she often refused to comply with reasonable requests, overreacted to minor frustrations, and was occasionally physically aggressive toward her seven-year-old brother, whom they described as a friendly and lovable child. When the parents attempted to discipline her by sending her to her room, she would slam the door and kick it or throw things around to the point of causing damage. Her school performance was satisfactory though uneven: when motivated she achieved high grades, but not infrequently she would neglect or forget her assignments and sometimes did poorly on tests. There were no behaviour problems at school. Her social life, however, was fraught with difficulties: she had no girl friends, engaged occasionally in some games with a few boys from the school, but was close to no one. Attempts by the parents to engage 153

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her in extracurricular activities were short-lived, in spite of Giselle’s initial enthusiasm. The parents, though tired of her tantrums, were well aware of her abilities: she was an avid reader and watched educational television programs regularly, showing interest in topics favoured by intellectually precocious children, such as dinosaurs or the solar system. Indeed, as we worked together, she taught me a few things about dinosaurs I did not know before. Both of Giselle’s parents were professionals who worked long hours but cared about their children. Giselle’s developmental and medical history was unremarkable, and as far as I knew, there had been no traumatic events in the family or in her life. The difficulties described by the parents became evident with the birth of her middle brother and became progressively worse. Giselle’s father was more frustrated and disappointed with her; the mother, though annoyed by the oppositional behaviour, was more empathic and understanding of Giselle’s frustrations and distress. Giselle came to the appointment willingly, curious but not anxious. She was relatively tall for her age, slim, and agile. Her graceful movements reminded one of a gazelle (though the name “Giselle” has an entirely different etymology). She told me eagerly about resenting her brother’s provocations and the parents’ unfair attitudes, ignoring, as most children do, her own contribution to the problem. Her accusations, however, were not irrational and, as transpired in time, not entirely groundless. My initial impression was of a relatively benign oppositional disorder, which supportive psychotherapy accompanied by parental guidance would resolve in a relatively short time. Events were to prove me wrong. After just a few sessions Giselle’s behaviour changed drastically. She became excited, almost elated, telling me gleefully how strong she was, how she intimidated the boys in her classroom by hitting them hard, so that none dared to bully her. She seemed entirely unconcerned about the feelings of others, as well as the reasons for her social isolation, as long as she felt powerful and dominating. I was perplexed: was I dealing with a childhood narcissistic personality disorder, such as described by P. Kernberg, Weiner & Bardenstein (2000)? Yet, I could not but like the child (which rarely happens in cases of a narcissistic personality), and did not (at that

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stage) try to challenge her narcissism. Then I was in for another surprise: in one of her quiet moments she told me, as a matter-of-fact: “My father is not my real father but my adoptive father.” Had I missed something vitally important in her history? But then she added pensively: “At times he is my real father, but at other times he is my adoptive father.” That was as far as she could go in expressing her pain and longing for affection. Giselle came to therapy willingly and took an active part. She recounted current events (mostly dwelling on her brother’s “abominable” behaviour) but was consistently reserved about expressing any feelings except anger. She played most of the time with a doll house but did not enact narratives, instead decorating the doll house with minute articles and decorations, such as a vase with flowers, cut from coloured paper with great skill. With time, she constructed her own miniature doll house, skilfully constructed with paper cutouts and tape. A new symptom was restlessness: Giselle would spend the beginning of the hour talking or playing quietly but then would get up and move restlessly. Her favourite game was climbing upon the arm of an armchair and sounding the chimes of a long-defunct “grandfather” clock hanging from the wall. Initially, I stood by somewhat anxiously, but then she told me “You don’t need to hold me, I will not fall.” Indeed, not once did she lose her balance or dislodge the clock, which hung precariously from a hook. With time, her hyperactivity became more conspicuous: toward the end of the hour she would jump up and down or perform some kind of a wild “break-dance” accompanied by an almost maniacal glee. It became clear by now that she was affected by a relatively low-grade Attention Deficit Hyperactivity syndrome. She admitted that at school she often felt restless but controlled herself with a considerable effort. Her good intelligence compensated for the relatively minor attention deficit, and the school was not aware of any disability. She could do little, however, about the other components of the disorder, namely low frustration tolerance, impulsivity, affect-dysregulation, low self-esteem (compensated for by childish bragging), and poor social skills. At one time she started to make motions as if turning the arms of a screw on a pressure lock, with a considerable effort accompanied

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by “ughs”. She explained: “I am closing the air.” That was her way of expressing metaphorically the constant need to suppress restlessness and impulsiveness. I discussed my new diagnostic assessment and its implications with the parents. I felt it was my duty to bring up the issue of medication, though I felt reluctant to use methylphenidate as it might have affected the vitality of this creative and vibrant child (Panksepp, 2007), and Giselle’s academic performance was adequate though probably not quite reflecting her potential. The parents were absolutely opposed to the use of medication, and that settled the issue. We worked for a while in that manner, discussing current events and creating ever more elaborate miniature paper cuttings, and barely touching emotional issues other than anger. Giselle’s insensitivity to interpersonal situations, such as described in Chapter Three, seemed unyielding to intervention. I tried to make Giselle understand that her aggressive reactions to her brother’s subtle (and sometimes not so subtle) provocations actually encouraged him to continue. He not only made her the “bad one” (and himself, by comparison, the “good one”), he was also manipulating her, pulling the strings. Giselle could not see the point. Then I decided to take the initiative and employ a metaphoric communication other than the doll house, which had proved barren. I bought a toy dinosaur, whom we named Dino, and shortly afterwards I made a smaller one, whom Giselle named Kevin, after a school-mate she favoured at that time. I represented Dino and began to complain to Giselle about Kevin’s annoying behaviour, his attempts to monopolize the parents’ affection and our parents’ lack of fairness. Giselle was sympathetic to Dino’s plight but challenged his reactions and suggested different kinds of handling the problem, such as trying to be nice and even befriending the “villain”. At the same time she kept dressing both dinosaurs in paper coats and caps. We returned to the “dinosaur game” many times, as circumstances required. The therapy lasted for two school years, with intermissions during the summer break, at the request of the parents. Giselle’s behaviour kept improving, but the improvement was uneven; it was considerable during the summer break but was followed by regression some time after school began. I assumed that the regression was due to

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the additional stress of keeping her restlessness “locked in” during the long hours of school. The contact with the parents was irregular, owing to constraints of time, but they gradually took a more balanced attitude, realizing that the brother had his share in provoking the quarrels, and that he was taking advantage of Giselle’s impulsive reactions to make her “the bad one”. They also began to appreciate Giselle’s efforts to contain her natural impulsiveness and her anger. Toward the end of the second year her behaviour improved to such an extent that we decided to terminate the therapy. Giselle’s father called me a year later to tell me happily that Giselle was doing well, had made a few friends, and was “practicing motherhood” with her youngest brother. I met Giselle two years after terminating therapy, mainly to ask her permission to describe our work together. She was tall for her age, slender, and agile as before. She was happy to see me, curious about the case report I was about to write, and I promised to mail it to her before publishing it. She was doing well at home, had become close to her father, and had a few girl friends though none very close. She found relief for her restlessness in playing tennis and playing drums, a hobby seemingly effective in releasing motor tension. (Uri, the patient described in Chapter One, also found relief in playing drums and actually became an accomplished drum player.)

Discussion and conclusions In reviewing the case, we may conclude that the initial diagnosis of mild Oppositional Disorder was descriptively correct, but it overlooked the role played by biological factors (namely a subclinical Attention Deficit Hyperactivity syndrome) in causing a progressive deterioration of Giselle’s family relationships and social life. It is not unusual to overlook a mild ADHD in bright children who compensate for whatever working memory problems they may have by their good intellectual abilities. Some of those children, however, are troubled by behavioural symptoms of the syndrome, namely impulsivity, affect-dysregulation, low frustration tolerance, lack of self-esteem and poor social skills. Our own clinical impression is that children affected by ADHD often lack

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what is referred to as “contagious”, i.e., intuitive, empathy, though they may compensate for it by what investigators call “cognitive” empathy (Shamay-Tsoory, Aharon-Peretz & Perry, 2009). (The quotes over “cognitive” are meant to indicate that empathy, ultimately, is an emotional process, and cognition in this case is merely a component of it.) In those cases, helping the subject to improve his “cognitive” empathy may prove beneficial, and I assume that the reversal of roles while “coaching” Dino had a significantly positive effect on Giselle’s social skills, because role reversal activates the so called “theory of mind”. One has to identify projectively with another person’s frame of mind, and that is precisely what “cognitive” empathy involves. (My fortuitous choice of a dinosaur as an object of projective identification and as a representation of inadmissible impulses was appropriate insofar as dinosaurs are often perceived as symbolizing brute force.) In our experience the benefit of stimulant therapy in children and in adults in whom the emotional effects of ADHD (such as low self-esteem or interpersonal relationship problems) predominate is modest, and the treatment of choice is psychotherapy, either psychoanalytic developmentally informed psychotherapy (which in children usually takes the form of play therapy), or (in cases of more severe personality disorders) dialectic behaviour therapy (Shearin & Linehan, 1994). Developmentally informed psychotherapy, illustrated by Giselle’s treatment, is based on the following principles (see also Chapter Nine): a. Try to identify behavioural symptoms presumably due to biological factors. b. Do not attempt to resolve biologically determined maladaptive behaviours (such as affect dysregulation) by interpretation of supposedly unconscious conflicts; that frequently leads to mutual frustration and a therapeutic impasse. c. “Validate” (Shearin & Linehan, 1994) the patient’s subjective experience; he (or she) cannot help being developmentally different from what the environment expects of him (or her). d. “Work through” the patient’s maladaptive behaviours and clarify the circumstances provoking them. e. Help the patient to develop his or her own means to attenuate the maladaptive behaviours.

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f. Keep in mind the possibility that some symptoms are probably due to unconscious conflicts and may require appropriate interpretation. The case of Giselle demonstrates that, with the help of the therapy, she acquired the ability to “tame” the maladjusted affective responses and to improve her social skills. She was also able to persevere in hobbies that significantly relieved her motor restlessness. This is consistent with our clinical observations and with Panksepp’s (2007) studies regarding the therapeutic value of vigorous physical activity for children affected by ADHD.

CHAPTER ELEVEN

Reconstruction in psychoanalysis: Ms. C., the “Slow Scientist”

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reud, working with Breuer (Breuer & Freud, 1893–1895), made the historic discovery of the relationship between the symptoms of psychoneurosis and early childhood life events, including the early relationship with parents and other close family members. Since then, reconstruction of those events and relationships has become a cornerstone of the therapeutic process, as has the analysis of defences and of the transference. The primary aim of the latter is, as a matter of fact, to open the way to the reconstruction, which maintains its status as a mainstay of psychoanalysis and psychoanalytic psychotherapy (Blum, 2005). All methods of psychotherapy based on psychoanalytic theory (and not only psychoanalysis proper) include a measure of exploration of childhood life events and relationships and their relevance to a patient’s present difficulties. The task of reconstruction is not merely to uncover repressed infantile wishes and traumatic events of childhood, but also to integrate them with the adult personality: a man’s or a woman’s loves and hatreds, his or her values, fears, and hopes. Freud retracted his earlier claim that all cases of hysterical neurosis are due to sexual abuse of the patient at an early age, and he coined the term “psychical reality” to indicate that childhood fantasies, 161

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disguised as memories, have the same psychological validity as real memories and the same effect on later symptoms. That statement may lead to a conclusion that the factual reality of early memories is irrelevant, as far as the treatment is concerned, an issue to which we will return later. Freud’s retraction was not universally accepted, and some psychoanalysts and historians of psychoanalysis criticized him for backing down from an inescapable conclusion that incest and sexual abuse of children in general are much more common than society is willing to admit (Miller, 1998). That issue became a matter of a hot public debate in the 1970s and 1980s, when a number of therapists in the US began to claim vigorously to have uncovered a surprisingly high prevalence of patients with allegedly repressed memories of incest and sexual abuse. Other investigators questioned those conclusions (Hardt & Rutter, 2004), and some came to the conclusion that many, if not most, of those “repressed” and “recovered” memories were false memories, unwittingly planted in the minds of the patients by over-zealous therapists (Loftus, 1997). The discussion concerning the real or imaginary nature of recovered childhood memories became more than an academic debate, since the alleged recovery of repressed memories led to litigation, of patients against their parents and of parents against therapists, and even to criminal proceedings (Loftus, 1993). For a “developmentally informed” therapist, the question of factual versus psychic reality is particularly relevant. If subjective, “psychological” reality is all that matters, then what difference does it make if the patient’s difficulty was caused by a failure of maternal empathy or by innate oversensitivity? In our experience, understanding the contribution of innate factors does make a difference in reconstruction. True, the purpose of reconstruction is not a historical research, nor does it claim the validity of an objective historical study (if such a study exists). A therapeutic reconstruction, like a picture puzzle, is composed of bits and pieces, some more reliable than others; some are conscious recollections of events experienced or of stories told by the patient’s relatives, some are childhood experiences deduced from dreams, and some are the therapist’s interpretations, hopefully guided (but not dogmatically asserted) by an understanding of the psychology of children and of psychopathology. The purpose of reconstruction is neither to exonerate the patient’s parents

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from the responsibility for his or her present predicament, nor to indict them. The zealous therapists who persuaded the clients to press charges against their parents for alleged abuses (rather than leave it to the patients to decide), claiming a supposed therapeutic benefit, perverted the purpose of therapeutic reconstruction. The purpose of a reconstruction is to expose the pathogenic experiences of childhood to a re-assessment by the patient’s mature ego, in order to mitigate their adverse influence. In our view, the understanding of the role of innate, biological factors, over which neither the patient nor the parents have any control, is an important contribution to such an objective, mature re-assessment of childhood experiences. One cannot fully understand the events of a patient’s childhood without studying them in the context of the developmental stage in which they occurred and taking into account the patient’s developmental individuality, be it a temperamental idiosyncrasy or impairment. The following case illustrates a “developmentally informed” reconstruction in the course of psychoanalysis. Ms. C., whose case has been mentioned previously (Chapter Four), was a divorced woman in her early thirties, a highly capable research scientist, who came to treatment because of a sense of pervasive unhappiness and dissatisfaction with her lifestyle: “I live next to life,” in her words. Her work was humdrum, her mood was mostly depressed, and her love relationships invariably led to heartbreak. She felt inhibited, at times overcome by anxiety, and had a very low opinion of herself. As a child she had been very attached to her intellectual, aloof, biologist father, whom she admired greatly. Ms. C. had always resented her mother and described her as controlling, overcritical, and insensitive to Ms. C.’s emotional needs. The mother objected to Ms. C.’s boyfriends, clothes, and recreations; she had been particularly vigorous in her criticism of Ms. C.’s passivity, lack of initiative, and preference for lying down and leisurely enjoying reading or listening to music. Passivity, over-compliance, and lack of initiative were also prominent in the patient’s adult life and in analysis. The analyst became aware of conflicting feelings early in the analysis; an empathic identification with the forlorn, lonely girl, and an increasing impatience with the slow progress of treatment. This attitude of impatience and a wish to “push” the patient were so

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similar to the description of Ms. C.’s mother that the analyst came to the conclusion that they represented a projective identification with the un-empathic, pushing mother. He shared with the patient the feeling that she was casting him in her mother’s role. Ms. C. seemed encouraged by the interpretation and seemingly relieved at not being attacked or criticized; yet the slow, plodding treatment went on. The analyst, therefore, felt that something was amiss in the dynamic assessment. Two points that emerged from the clinical data seemed in need of further clarification: a. In spite of Ms. C’s strong indictment of her mother’s attitudes and the bitter arguments between the two, one could feel an undercurrent of genuine caring by daughter and mother alike. Indeed, Ms. C.’s mother emerged from the description as an intrusive, over-critical mother, but not an uncaring or cold person at all. b. The patient’s passivity was not just an expression of negativism. Somewhat timidly she described her moments of serene enjoyment: reading a book by the lakeshore or listening to a concert. The analyst interpreted this as a plea to understand that her passive pleasures were not always idle or contrary, and the interpretation was received with relief. Ms. C. agreed that some of her best moments were passive and leisurely, but she herself took the initiative to point out that her passivity served also as a form of timid defiance toward the mother. We could now reassess the dynamics of Ms. C.’s childhood. She had been a slow child, with poor gross motor coordination (she still lacked a sense of balance and often needed help when walking down a hillside trail), inattentive and timid. Her spatial orientation was poor, and she relied on visual clues to find her way when driving. In darkness or in a fog she would panic. We have often observed that poor motor development undermines a child’s sense of competence and his self-esteem and fosters a passive-dependent relationship with the caregivers. Moreover, an impairment of spatial orientation seems to delay autonomy and increase separation anxiety (Chapter Five). It was easier now to understand the nature of the early relationship. Ms. C.’s mother was a vivacious, emotional, restless woman,

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warm but impatient and quick-tempered. She was also a competent, vigorous and competitive business woman, proud of her ability to handle difficult situations. Such a person could never understand nor cope with a slow, clumsy, clinging child without becoming exasperated and critical. The message conveyed to the little girl was not, “I don’t want you,” but “I want you close to me, but can’t you ever do anything right?” The situation was made worse by the mother’s unhappiness with her marriage and the father’s failure to provide emotional support for the girl, even though he was very attached to her. Having despaired of ever living up to her mother’s standards and expectations, the little girl found a measure of comfort in negativism, which allowed her to exert some control and indirectly give vent to her suppressed rage. The price for it was an internalization of an extremely negative, over-critical view of herself. This, in turn, combined with guilt over unresolved Oedipal ambivalence, contributed to the development of a self-defeating, masochistic lifestyle. We will not attempt to present here all the complexities of this patient’s unconscious conflicts as they emerged in a lengthy analysis. The point we want to make is that at that particular stage of treatment, an empathic understanding of Ms. C.’s temperamental individuality, combined with an understanding of her mother’s reaction to it, facilitated and enriched a therapeutically effective reconstruction. This was shown in several ways: a. There was a slow but dramatic change in Ms. C.’s relationship with her mother, which became more relaxed and more mature. b. There was a perceptible strengthening of the therapeutic alliance. c. The reconstruction was followed by the recollection of a considerable number of childhood memories and aspects of relationships with both parents, of which the patient was only dimly aware previously. d. Insight into the “mismatch” between the patient’s and her mother’s temperaments led to an exploration of Ms. C.’s difficulties with regard to her feminine identification and to a re-evaluation of her ego ideals. She no longer felt compelled to achieve her mother’s efficiency or social adroitness and began to explore her natural inclinations and to shape them into adaptive patterns.

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In summary, the developmental understanding did not replace but rather complemented and facilitated the psychoanalytic process of interpretation of transference, exploration of defences and resolution of unconscious conflicts. It led to a strengthening of a “true” Self (i.e., one consonant with the patient’s temperament and inclinations) and a reassessment of the ego-ideals. In conclusion, a psychoanalytic reconstruction may be facilitated and enriched by insight into the patient’s temperamental idiosyncrasies and developmental lags and impairments. Understanding a child’s temperament and developmental pattern adds a significant dimension and enhances the therapist’s empathic identification with the young child’s yearnings, fantasies, and pain as they emerge from the patient’s description. Moreover, such understanding helps the patient and the analyst to get a more comprehensive picture of the parents’ behaviour and motivations. A therapeutic reconstruction, as we said before, is not merely an emotional catharsis. It is also an integration of childhood experiences with the patient’s adult personality. An ability to reassess objectively the parents’ past behaviour paves the way for resolving infantile idealizations or vilifications of the parent, which are often the last residue of infantile fantasies of parental omnipotence. Unconscious fantasies of parental omnipotence are hard to dispel. We have encountered, not infrequently, persons whose seemingly successfully completed analysis had not, it appeared, confronted the problem adequately. Therapists are tempted to accept too readily their patients’ infantile perceptions of the parents, and shadows of parental omnipotence find their way into many psychoanalytic interpretations. The sobering realization that adequate care-giving is determined by a complex interaction between a baby, his parent, and the environment helps one to take a more balanced view of a patient’s personal past as well as of psychoanalytic theory of infant development.

CHAPTER TWELVE

Psychoanalysis of a patient with borderline personality disorder and minimal encephalopathy: Mr. G., the “Great White Hunter”

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he issue of possible innate or acquired biological determinants in personality formation and in psychopathology is particularly relevant in cases of BPD. This diagnostic category comprises various clinical entities with some common and characteristic features (Gunderson, 2008; Gunderson & Singer, 1975). One of these features is an impairment or weakness of the integrative functions of the ego, such as repression, affect control, drive inhibition, or reality testing under stress (O. F. Kernberg, 1984). Such functions depend on effective operation of the brain, and it is therefore understandable that numerous investigators assumed that conditions that interfere with the optimal functioning of the brain might contribute to the formation of a borderline personality. More advanced techniques for the exploration of the structure and function of the living brain have confirmed that assumption. (We have listed the relevant publications in Chapter Three.) Over the last decade, researchers have shown increasing interest in psychotherapy of BPD and in the evolution of therapeutic modalities designed for that purpose (Gunderson, 2008), such as Dialectical Behaviour Therapy (Shearin & Linehan, 1994), Transference-Focused Therapy (O. F. Kernberg, Yeomans, Clarkin & Levy, 2008), and mentalization-based psychotherapy (Bateman, 2009). 167

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Here we describe a “developmentally informed” psychoanalysis of a young man diagnosed as suffering from Borderline Personality Disorder and presumably from a subclinical form of encephalopathy, and we discuss the factors that seemed to have facilitated a favourable outcome.

Introduction Mr. G. was in his late twenties when I first met him, an inpatient in the hospital unit, to whom I had been assigned as a physician. He was a law school dropout with a long-standing history of maladaptive behaviour. He had been hospitalized following a turbulent period of uncontrollable drinking, accompanied by physical complications (regional ileitis and a bleeding peptic ulcer), during which he had been unable to continue his studies and spent most of the time in a drunken stupor. He had also engaged in irresponsible behaviour, such as associating with delinquents and wrecking the family car in front of the courthouse where a friend of his father’s was sitting as a judge.

Background history Mr. G. was the eldest son of a highly successful lawyer and senior business executive. The father, whom I met only once, appeared to be a very polite, almost unassuming man, and he was known for his liberal political inclinations. Mr. G., however, explained that there were other aspects to the father’s personality: among his colleagues he was known as a “two-fisted”, aggressive lawyer in court, and at home he was an overly critical, sarcastic, and cutting parent and spouse. He also had a tendency to drink, and his drinking became more serious over the years. The patient felt deep anger toward the father and blamed the father for all his troubles. Mr. G. described his mother as “solid”, by which he meant conscientious and dependable, a strong (in his eyes) and unemotional woman; however, she was given to rare temper outbursts in which she completely lost control of herself. He found those outbursts incomprehensible and frightening. Mr. G. felt that she stood by her children in whatever they did, hardly ever reprimanded him, and exhibited an attitude of: “my son right or wrong”, in his words. From Mr. G.’s perspective, whatever he did was wrong in his

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father’s eyes and made no difference to the mother. As a result he felt confused and lacking guidance. A brother two years younger was described as “slow” and diagnosed as suffering from severe learning disability. Mr. G. felt distant from this brother. The patient’s second brother, seven years his junior, was the main target of Mr. G.’s envy and hatred. The patient described his brother as cold, manipulative, and selfish, and he envied him for earning the parents’ affection by being the “good” child, and respect by being a successful young lawyer. The only person in the family with whom Mr. G. had a genuinely warm relationship was his teenage sister. Mr. G. was born at term following a difficult pregnancy, complicated by pre-eclampsia. The labour was prolonged and difficult, but no data regarding the degree of foetal distress were available. He was described as an active, restless baby, who would rock in his crib for long periods of time. At the age of fourteen months he fell down a staircase, was diagnosed as having suffered a “mild concussion”, and was under medical observation for a number of days. According to the family the early symptoms of maladjustment appeared during his middle childhood, around the age of six or seven, when he developed nightmares and sleep-walking, as well as excessive fears. He also became oppositional and verbally aggressive toward the mother. Mr. G. himself had no memories of those events, but he remembered occasional violent outbursts of rage. Once, when another boy stepped on his sand-castle, Mr. G. took off his belt and hit the other boy on the head with the buckle, making him bleed. The father, who was present, was so appalled that he did not even react. On another occasion Mr. G. pushed the finger of a boy who was teasing him into a grinder. Such behaviours earned him the epithet of “little Hitler” from his father. In adolescence those rage outbursts apparently diminished, but he remembered provoking his father’s anger by more subtle means, such as reading up on some well-documented facts that contradicted the father’s views. Mr. G.’s school performance was erratic. At times he excelled and at other times made barely passing grades. He did well in college, but after he entered law school (which he did against the father’s advice, who thought that Mr. G. “did not have what it takes to study law”) his drinking, which began in adolescence, became heavier. Drinking and the associated regional ileitis were the main reason

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for his dropping out of school in the last year, but Mr. G. recalled an event that was the precipitating cause: The law school arranged “mock trials” during which the students were supposed to defend their cases effectively. Mr. G. did so vigorously, was carried away by his fervour and became quite aggressive toward his “opponent”. At this point he was seized by violent anxiety, had to quit and never returned to the school. A similar incident occurred in one of his short-lived attempts to hold employment. He had been working in a low-level position for some time, when the supervisor came in and announced in front of everyone in the room that Mr. G. had been promoted to a higher position. Mr. G. was seized by an intense anxiety, fainted and was taken to a hospital by ambulance. Mr. G. told me that whenever he felt that he got the upper hand in an argument (which was not unusual because of his sharp mind and unconventional views), he would become excited, filled with a sense of immense power, feeling that “he could rip the world apart”, in his words. Then he would be seized by an uncontrollable, paralysing anxiety, which could only be overcome by drinking. According to Mr. G., the psychiatrist whom the parents consulted told them that their son was “an incurable psychopath” and advised them to have him committed to a psychiatric hospital. The parents, however, persuaded Mr. G. to voluntarily enter a state facility for “detoxification” and then to accept hospitalization in a private hospital. At the time I first saw him, he had improved symptomatically to a considerable extent, after a prolonged hospital stay, characterized by progress alternating with regressions. His drinking had ceased, and he had become strongly motivated to help himself and was beginning to form some social ties. At the same time he was still a very troubled young man, moody, angry, and morbidly suspicious, with stormy family relations and hardly any affectionate ties. He related to most of the staff with a barely disguised haughty contempt and was particularly antagonistic toward the black members of the staff and African Americans in general. Mr. G.’s physical condition was stable, with no gastrointestinal symptoms at that time. Neurological consultation revealed a slight limp, a shortening of the left leg with slightly reduced muscle power of the left extremities and asymmetrical deep reflexes, The neurologist assumed a minor deficit of the right hemisphere and, in view

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of the pre- and perinatal history as well as the concussion suffered in early childhood, diagnosed the patient as suffering from a “Mild Congenital Encephalopathy”. Further investigations were not performed (MRI and other computerized techniques were not yet available at that time). The psychiatric diagnosis at the time of admission was “Borderline Personality Disorder with Narcissistic Features” and remained so during his hospital stay. Initially I was assigned to Mr. G. as his hospital physician, but within a short time it was decided to discharge him and continue outpatient psychotherapy. Mr. G. indicated indirectly that he was considering psychoanalysis: he related dreams and fantasies and seemed to be searching for unconscious roots of his troubles. After discussing the issue with my supervisor, I decided to suggest psychoanalysis, in spite of the seemingly unfavourable prognosis. The analysis lasted for over four years. The patient soon developed a positive attitude toward the treatment and invested considerable effort to make it effective. He was helped by his superior intelligence and a natural curiosity to understand himself, and also by the kind of image he developed of me as his analyst. As a psychoanalyst and a Jew I was “expected” to be a liberal, but at the same time, as an Israeli I was supposed to be capable of fighting and of being comfortable with my own aggression, while capable of keeping it under control when necessary. That idealized image could be metaphorically visualized as a picture of me holding a book by Freud in one hand and an Uzi in the other. This “idealizing transference” (Kohut, 1971) was also associated with expressions of competitiveness and envy, a fantasy that the therapist had a “formula of good life” but was withholding it from the patient. At one point Mr. G. developed a conviction that he had a comprehensive theory of psychology but could not reveal it for fear that I would “steal” it. Mr. G.’s hold on reality was precarious in times of stress. He developed a warm relationship with a young woman, but when her husband came to town to sign the divorce papers, Mr. G. became agitated, decided that world war was imminent (it happened to be a time of critical tension during the Vietnam war), and that he would “take some food, a rifle and escape to the hills with his girlfriend”.

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On another occasion he had a repeated sensation that the handgun he was keeping on his table at night (as a protection against “black robbers”) was turning around and pointing at him. He was not sure whether it really happened or not, and I persuaded him to turn the gun in to the hospital staff. Mr. G. told me that the time he felt most happy and at ease was during his hospitalization for regional ileitis. The nurses were taking care of his needs and pampering him (he was a handsome young man), and, more importantly, he felt entirely harmless, lying in bed and tied to the drip line. At one time Mr. G. told me about a fantasy he intended to make into a short story: A famous white hunter, while on a hunting expedition in Africa, suffers from a mysterious illness. He then retires to his tent, his body covered with boils, and little black devils begin to emerge from the boils. We interpreted the story as representing two fantasies: (a) The hunter as his father, giving birth to, but also repelling his evil son; and (b) the patient himself projecting his split-off evil self into the “blacks” and expelling it. This fantasy, I believe, represented Mr. G.’s core dilemma, namely how to disown the “evil” part of his self. The choice of the main protagonist, a “white hunter”, also reflected the patient’s basic concern: the hunter was not only a “white” among “Africans”, he was also a killer, socially sanctioned, but a killer nevertheless. The “illness” could be seen as a form of retribution. There was also a hint at feminine identification, which I chose not to interpret. As a rule, I was reserved about forcefully interpreting unconscious material, perhaps more reserved than was needed, because I was concerned about the patient’s ability to tolerate anxiety. Most of my interpretations dealt with the prominent father transference. Analysis of it revealed the split between the conscious bitter resentment toward the father and the repressed idealization and longing for affection. Mr. G. recalled gradually his early admiration for the father, who would return home on leave from military service in his splendid Navy officer’s uniform. He also recalled the happy moments of his early childhood when his father would sit by his bed and read stories to him. Mr. G. also exhibited that particular weakness of spontaneous, intuitive empathy, which we discussed in the case of Giselle (Chapter Ten). That weakness manifested itself in an occasional failure of affection, which led to the diagnosis of “narcissistic personality features” (and made some of the treatment team pessimistic about

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the patient’s prospects). It was exemplified by the following incident: Mr. G. came to the session visibly upset. His girlfriend had admitted to him that she had done something improper and asked him to forgive her. Mr. G. told her that he did not mind at all, an answer that annoyed the girlfriend very much. Mr. G. was flabbergasted and hurt: he felt that he was being magnanimous and tolerant, and could not understand what went wrong. I “borrowed a page” from drama therapy technique and asked Mr. G. to assume that the opposite took place: he had confessed to having been disloyal, and his girlfriend did not mind at all. To this, Mr. G. said: “I would think that she did not love me enough if she was not jealous.” In other words, Mr. G. also needed help in applying “cognitive” empathy when his spontaneous, intuitive empathy failed. Another important aspect of the treatment was the “here and now” analysis of his uncontrollable anxiety and aggressive impulses and fantasies. With time, as we worked through his violent impulses and the fear of them, Mr. G. became more composed, and more comfortable in social relationships. He eventually became financially self-supporting, formed some close friendships, and consolidated his relationship with the girlfriend.

Discussion Three themes dominated the therapeutic process: (a) the use of primitive defence mechanisms (a feature typical of borderline personality organization), namely splitting and paranoid projections; (b) the inability to contain his rage and the resulting paralysing anxiety; and (c) the inability to contain the elation following narcissistic gratification. The term “splitting” is used differently by different psychoanalytic writers. It may refer to splitting-off and disowning unacceptable parts of the Self or splitting of the object representation. O. F. Kernberg (1984) uses it to refers to the tendency of some patients, and patients with borderline personality in particular, to project on some people the internalized representation of the “good object” and on others that of the “bad object”. As a result, some people are idealized whereas others are demonized. Kernberg attributes this symptom to a developmental arrest at a pre-Oedipal level and a resulting inability of the ego to contain contradictory feelings toward the same object, i.e., to experience ambivalence.

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In Mr. G.’s case the idealized “good” objects were perceived as strong, wise, and possessing a “formula”, an elusive clue to a balanced personality. The “bad” objects were seen as being contemptible and were treated with derision (e.g., mental health personnel), or were perceived as persecutory, threatening figures (“blacks”), which represented a projection of his unacceptable aggression. The use of such paranoid defence mechanisms is also a frequent feature of borderline personality. Mr. G.’s personality was characterized by an unusual degree of dysregulation of affect. His childhood rage attacks, as reported by him, the exceptionally intense hostility reflected in his attitudes and fantasies, as well as the paralysing anxiety they caused, were a major feature of his illness. His overwhelming fear of his own aggressive impulses was probably augmented by having witnessed his mother’s loss of control during her outbursts, but it seems to have a deeper root in his perception of the weakness of his ego-integrative abilities, as demonstrated by the other aspects of his personality. Even more conspicuous was his reaction to an experience of success and power, namely, elation leading to a manic excitement and a horrifying anxiety. Freud described patients unable to tolerate success (Freud, 1916) and attributed this symptom to an unresolved Oedipus complex. Mr. G.’s case most probably involved an Oedipal component, namely an unconscious but fierce competition with his father, as we could deduce from the transference. At the same time, the catastrophic reactions he experienced point to a more serious pathological condition, specifically, a basic defect in the ego’s ability to regulate affect, in this case, elation. We know from the reconstructed history of Mr. G.’s childhood that the parents did not handle his difficulties well. The mother failed to set limits, probably out of helplessness, which the patient interpreted as indifference. The father responded to the child’s rages in the worst possible way: instead of setting limits he berated the son, compounding his negative self-image of an evil “little Hitler”. These failures, however, do not help us to understand the basic problem of affect modulation and drive control impairment. It is not difficult to speculate that some major breakdown in the earliest infant–mother relationship or gross early traumatization might be the cause of such an ego defect. In the case of Mr. G., however, we do not have any evidence of such a factor. We have, however, presumable evidence of

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an innate factor, besides an unusually severe dysregulation. There is a history of pre- and perinatal risk factors, infantile irritability, perhaps a minor infantile brain injury (concussion), and the presence of minor neurological signs, which the consulting neurologist diagnosed as a “mild congenital encephalopathy”. Minor brain impairments (which some clinicians call “subclinical encephalopathies”) and developmental aberrations are more common than many clinicians assume. The prevalence of ADHD in children in the US is estimated at 8.7% (Froehlich et al., 2007) and that of adult ADHD at 4.4% (Kessler et al., 2006), but besides such well-defined syndromes there are numerous subtle deficits, described in Chapter Three, such as late or poor gross motor coordination (the “clumsy child syndrome” of some paediatricians), innate slowness, hypersensitivity, or hyper-reactivity. Even seemingly minor aberrations may have a profound effect on emotional development, on self-representation and on ego functioning. A “developmentally informed” therapist (Chapter Nine) will not automatically assume that every maladaptive behaviour is necessarily the result of an unconscious conflict and a repressed infantile wish. (I refer to “behaviour” in a broad sense, including “motor behaviour” i.e., action, and “visceral behaviour”, i.e., affective response.) Innate, biologically determined factors mesh with interpersonal processes to consolidate personality, and separating the two in therapeutic reconstruction is challenging to say the least. Yet, one ought to consider the possibility that basic ego defects, such as gross affect dysregulation, cannot be “interpreted away”. The goal of the psychoanalysis in such a case becomes to integrate the untamed and disowned impulses and affects into the conscious self, without the need for the ego to employ primitive defences such as split or projection. This is accomplished by a dispassionate but benevolent analysis of the transference as well as of the “here and now” life situation. In conclusion, the case of Mr. G. illustrates that the approach that we call “developmentally informed” psychotherapy or psychoanalysis can facilitate the therapy of patients with severe psychological maladjustment, such as a borderline personality disorder. This applies especially to those patients in whom innate, presumably biological, factors co-determine the deficiency of ego-integrative functions, of emotional development and of interpersonal relations.

CHAPTER THIRTEEN

Shahar: art therapy of a boy with Attention Deficit Hyperactivity Conduct Disorder

Introduction Hyperactive children are prone to be also impulsive and aggressive, especially if the home environment does not provide both adequate limit-setting and emotional support. The problems of behavioural maladjustment of such children are frequent and occasionally serious enough to justify a distinct diagnostic category, namely Attention Deficit Hyperactivity Conduct Disorder (ADHCD). We have already mentioned in Chapter Six that such a diagnosis should not automatically imply that the child presents the features of an antisocial personality, and it should be applied sparingly. Children with ADHD are frustrated by their developmental impairments (it should be remembered that many children with attention deficit present also other impairments) and angry, like most other developmentally handicapped children. In most cases, however, children with ADHD have an internalized sense of social values (in other words, an integrated super-ego) and a capacity to form affectionate relations, both in the family and outside of it. Their main difficulty is not inadequate socialization but impairment of drive inhibition, affect dyscontrol, and impulsivity. Such children can derive 177

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considerable therapeutic benefit from “developmentally informed” psychotherapy, supplemented by parental guidance, in addition to any other therapeutic modality, as described in Chapter Nine. In this chapter we present the psychotherapy, by means of art therapy, of a young boy manifesting the symptoms of ADHCD.

Background Shahar was four-and-a-half years old when referred by the parents for psychiatric evaluation, on advice of the pre-school educational counsellor. The main reason for referral was unusually aggressive behaviour toward other children and, occasionally, toward the staff. He was also described as being aggressive toward the animals in the pre-school, namely a rabbit and some gerbils. (It should be remembered that cruelty toward animals is a very serious negative prognostic sign. Serious cruelty has been considered as a risk factor for future severe aggression toward people, though some studies produced equivocal results (Felthous & Kellert, 1987).) He was described by the teacher as follows: “Shahar is a likeable, affectionate, inquisitive and creative child, but controlling and demanding, intolerant of frustration and tries to impose his will on everyone. Shahar cannot delay gratification, does not take responsibility for his actions, and finds it difficult to understand their implications. At the same time his cognitive capacity is superior, his vocabulary rich, his comprehension quick, and imagination prolific.” He was also described as being insensitive toward the other children, e.g., stepping on another child in the playground in order to reach the ladder he wished to climb. The other children complained about his hitting them; they avoided him, and he became socially isolated. According to the teacher, Shahar found it difficult to adjust to the pre-school environment and provoked a great deal of anger, including complaints by the other children’s parents, who signed a petition demanding his transfer to another school. The teacher, who had a good relationship with the boy despite his behaviour problems, objected and referred the case to the school’s counsellor. The counsellor suggested referring Shahar to a psychiatric facility. Shahar was the older of two siblings. His one-and-a-half-yearold sister was described as an easygoing baby, and his relationship

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with her was warm and protective, seemingly in sharp contrast to his inconsiderate and bullying attitude to his peers. The parents were a middle class couple, the mother a social worker, the father a junior business executive. The family atmosphere was warm, but the mother was notably over-permissive, allowing both children to sleep with the parents, while the father, who worked very long hours, did little to intervene. Shahar was the first-born grandchild on both sides of the family, which earned him a great deal of affection and attention. His pre- and perinatal history was unremarkable, and his early development, according to the parents, generally precocious but uneventful. That had to be taken with a grain of salt, since the parents, especially the mother, had a tendency to gloss over Shahar’s symptoms and emphasize the positive aspects of his personality. During the diagnostic interview the mother emphasized Shahar’s maturity, describing him as self-sufficient and reliable to the extent that she allowed him the use of sharp instruments, such as a box cutter. According to the parents’ report, Shahar’s difficulties began when he was placed in a small day-care setting at the age of a year and eleven months, and they became progressively worse. He was described as incapable of tolerating frustration, aggressive toward the staff and other children, and throwing temper tantrums. The parents consulted a paediatrician, who thought that Shahar’s problems were due to a lack of limit-setting at home. Shahar was then seen at a child development centre and referred, at the mother’s request, to psychological treatment. That was unsuccessful, as both the child and the parents felt a lack of rapport with the therapist. Following this, the boy was re-evaluated at the child development centre and diagnosed (again) as suffering primarily from emotional difficulties. The parents felt confused and helpless and asked for an additional consultation with a child neurologist, who diagnosed Shahar as “seriously hyperactive” and recommended stimulant therapy (Ritalin), since a mild herbal tranquilizer had had no effect. The parents were unhappy with the recommendation and requested a TOVA test. The test was performed only after the boy began his therapy and did not show significant improvement in attention after administration of methylphenidate (Ritalin). Another attempted behaviour modification program at home, based on the pre-school teacher’s daily report, did not produce results,

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either. Finally, the school recommended referral to a psychiatric evaluation.

Diagnostic evaluation Shahar came accompanied by both parents. He appeared well developed for his age; he was diffident initially, clinging to his mother, but he relaxed fairly soon. He was lively and inquisitive, in a cheerful mood, visibly hyperactive, with a short attention span, examining the items in the examination room, and shifting his attention from one to another. He appeared well developed intellectually for his age, with a rich vocabulary. His visual-motor coordination was good, but the execution impulsive. There was no evidence of depression or excessive anxiety. The diagnosis was not conclusive. The psychiatrist’s impression, based on the history of very early onset, as well as on the examination, was that of Attention Deficit Hyperactivity Disorder, manifested mainly by behavioural symptoms and aggravated by inadequate limit-setting, but the evidence seemed insufficient. The psychiatrist recommended a follow-up, further investigation (TOVA), psychotherapy, and parental guidance.

Therapy Shahar came to the first session willingly and established an emotional relationship with the therapist in a matter of a few sessions. He came to the weekly sessions regularly. In addition, the parents attended guidance sessions every few weeks. The guidance sessions dealt mostly with understanding the clinical implications of ADHD, such as affect dyscontrol, impulse dysinhibition, and misinterpreting social situations. The therapist and the parents discussed also the need for consistent, clearly defined limits, considerate but firm. Shahar’s therapy was in the early morning hours. He appeared full of energy and verve, eager to enter the therapy room, with a big smile on his face. Initially, his behaviour was disorganized, his movements brisk but poorly controlled. He seemed to have difficulty in perceiving the position of his limbs in space, or being aware of the force of his movements and the degree of his impulsiveness. He insisted on getting what he wanted, when he wanted it, and seemed unable to sense or to understand the other person.

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From the start it was clear that Shahar was unable to work sitting at the table, and he needed the entire space of the art therapy room. He examined the toy animals’ corner and the sand box, picked up a horse and a lamb, and created a sand pile with some Styrofoam balls fixed on top. He then buried the lamb deep in the sand-pile and declared: “I cover her all over, this is her home.” The therapist interpreted (to herself, at that stage) that Shahar was attempting to “bury” the tender part of himself, leaving exposed only “the horse”, a symbol of strength and masculinity. During the sessions that followed, the main issue was aggression and setting of limits. Shahar demanded that the therapist, like his mother at home, allow him to use a box cutter in order to cut cardboard. After a clarification and some negotiating of limits, Shahar settled down and began to engage in expressive activity, dominated by manifestations of aggression. He was attracted to the sand box and to various materials in the room. For a while, he engaged mainly in reducing to pieces any material in the room that could be broken up: crushing dry clay and chunks of soil, tearing paper, cardboard and Styrofoam to tiny bits, and mixing all this together. In one of the sessions, Shahar asked the therapist to “make a picnic”. It transpired that at home the children had no regular meals before leaving for day-care or school, and Shahar usually skipped meals in the morning. From then on, having a “picnic” together with the therapist became a kind of ritual, to which the boy attributed considerable importance. At that time Shahar began to organize his play around the topic of the “bad guys” against the “good guys”. Initially he was one of the “bad” ones and the therapist represented the “good” ones, fighting them. Then the roles reversed, and Shahar became one of the “good” ones, while the therapist had to represent the “bad” ones. In the latter part of the year his play activity gradually changed from destruction to construction. He mixed the various particles with sand, water, and glue. He then began to build various objects, such as “a house”. He then built a “House of Darkness” under the table, and then changed it into “The Jail”. The therapist was supposed to put “all the angers” into the Jail and “handcuff” them. Toward the end of the year, as the therapist brought up the topic of termination, Shahar became visibly sad but did not act aggressively, and there was no regression in his behaviour. He did, somewhat sadly, ask the therapist to do some things “like we did before”, such

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as having a sandwich together under the table. In the last session, he and the therapist jointly made chocolate balls, he said goodbye and went home, happily clutching his sweet treasure. The therapy lasted for one school year. During that time both Shahar and his parents made considerable progress. The boy’s behaviour changed progressively and drastically. He was still hyperactive, but his aggressive outbursts, insensitivity, and intolerance of frustration diminished impressively, and his relationships with peers improved. There were changes at home, too. The parents, jointly with the counsellor, developed a set of rules for behaviour at home and a method of limit-setting, firm but considerate of the child’s needs. There were new challenges, as well. As his sister grew older, Shahar became jealous and more negative toward her; the parents handled that issue skilfully. The therapist also encouraged the father to be more actively involved in the upbringing of the boy and to provide more opportunities for identification, a suggestion that the father took up with eagerness and pleasure. The therapist found Shahar a very likeable child who was enjoyable to work with, thanks to his liveliness and rich imagination. Despite his anger, impulsiveness and initially being very demanding, he responded well to limit-setting, and there was never a need to restrain him physically.

Epilogue and discussion Looking back, the initial diagnosis of Attention Deficit Hyperactivity Disorder, manifested mostly by behavioural symptoms, seems justified. The very early onset (twenty-three months) and the pronounced hyperactivity both point to an innate determinant. The discrepancy between social maladaptation (insensitivity, inadequacy of empathy, and intolerance of frustration) on the one hand and the internalization of social values together with a conspicuous sense of guilt (the need to “handcuff the badness”) on the other hand, is fairly typical of ADHD behavioural symptoms. In other words, many if not most children affected by ADHD present behavioural symptoms that are not entirely ego-syntonic and therefore are more amenable to treatment. Children like Shahar are distressed not only because they diverge from parental expectations but also because

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they perceive their affect and impulse dysregulation as a threat to the sense of control. In the case of Shahar, the insufficient limit-setting at home certainly contributed to the social maladjustment, and the effectiveness of the counselling was instrumental in achieving a favourable outcome. The rapid and persistent improvement in spite of the seriousness of the symptoms is also consistent with the diagnostic assessment. Today, Shahar is attending the fifth grade at an elementary art school, doing very well academically and enjoying the opportunity for creative activity. According to his parents (whose permission to publish we requested), he is still hyperactive and lively and has his “good days and bad days”, but the gross behaviour problems are a matter of the past. His parents are of the opinion that he does not need either medication (a view shared by us) or educational help, and they have not referred him for psychological testing. As yet, attention constitutes no problem at school, in part due to his high intelligence and in part due to the special curriculum of the school. The parents are aware, however, that in the future Shahar may need some help in that regard.

CHAPTER FOURTEEN

Parent counselling and early intervention

H

elping an infant or a child afflicted by a developmental problem is a joint endeavour of the therapist and the parents, and the parents’ cooperation is a prerequisite to any intervention. Moreover, in many cases, especially those involving younger children, the clinician merely provides guidance, and the agents of change are the parents. Therefore, the topic of early intervention overlaps almost completely with that of parental guidance. In our many years of clinical practice, we have very rarely encountered parents who truly did not care about being “good enough” parents. The motivation may be genuine affection for and empathy with the child. It may be a narcissistic wish to prove to others (and to oneself) that one is capable of competent parenting. Most often the motivation is a combination of both. It is prudent, therefore, for the clinician to start with the premise that parents who fail to provide adequate parenting are probably aware of the fact (though they may find it difficult to admit it) and pained by it. It is also helpful to assume that their parenting, misguided as it may be, is the best they are capable of doing without external help. Even parents who aggressively project blame do so out of helplessness, 185

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and they may be able to respond positively to a frank discussion of the problem, painful as it may be. I was working as a consultant to a special education middle (junior high) school for children with “social adjustment problems” (a euphemism for antisocial youngsters). I was asked to consult about Rick O. Rick was twelve years old, an incorrigible bully, unruly, disrespectful to teachers, and terrorizing weaker children. The teachers also suspected him of stealing small items from other children, though nothing of that kind was ever proven. At the time of his referral to the special education program he was diagnosed as manifesting an Attention Deficit Hyperactivity Conduct Disorder. I was invited to meet with Rick’s father, together with the homeroom teacher, the counsellor, and the principal (all three of them women). Rick’s father was adamant: It was all the school’s fault; they did not understand the boy and did not know how to handle him. According to the father, the proof was that Rick attended an extracurricular music class “where he was wellliked and respected.” (Several weeks later Rick was expelled from that activity for unruly behaviour.) The father was not only critical of the school but also contemptuous of the female members of the staff, suggesting that “they did not understand boys.” I lost patience with the father and his aggressive accusations, and I did something unprofessional. I told him bluntly: “Mr. O., I know you love your son, but the way you protect him and justify his misbehaviour, you are doing him great harm.” Mr. O., became pale, and the teachers thought he was going to hit me. He controlled himself, however, and instead blurted out: “How can you say anything about my son? You haven’t even seen him.” To which I replied: “You are right on this, I will be quite willing to see him; your son needs help. I think, however, that you may prefer to take him to a psychiatrist of your choice. In that case, we will be glad to work with that other doctor.” Mr. O., to everybody’s surprise, answered: “I want you to schedule an appointment.” The importance of informed, supportive counselling for the parents of children with developmental deviations cannot be

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overestimated. We emphasize the term “informed” because counselling is most effective when it is founded upon a robust understanding of the deviation and its effects. In many cases it is the only intervention needed. Some developmental deviations are amenable to intervention from infancy. There are various stimulation methods that may be applied to facilitate motor, perceptual, or language development. In most cases of infants and very young children, however, the way to ensure that such an early intervention will be optimally effective is to delegate the role of an agent of change to the parents. Early intervention, in the form of mother–infant dyadic therapy, has become quite a popular form of treatment; numerous programs provide it, and there is ample literature describing it. Our work differs only by introducing the “developmentally informed” approach (similar to that described by Osofsky and Danzger (1974)), which we have described in previous chapters. Once we have come to a conclusion that the primary problem is not an emotional difficulty on the part of the mother but a developmental idiosyncrasy of the child (or, sometimes, a combination of both), we can devise a suitable intervention plan, sometimes quite elementary. We then relate to the emotional difficulties of the parents (preferably both parents) as needed. The type of counselling and its objectives will be dictated by the needs and the resources of each family, but the overall approach is based on the same principles outlined in the chapter on therapy (Chapter Nine), which are as follows: a. Making a thorough diagnostic assessment of the child’s impairments and abilities, and sharing it with the parents and the child. b. Helping the parents of an infant to devise comforting and stimulating methods, and the parents of an older child to design child-rearing methods suitable for their child’s idiosyncratic needs. c. Improving impaired or delayed functions by practice or other means. d. Helping the older child to use “detours” to compensate for functional deficits. e. Promoting and encouraging well-developed functions. f. Accepting the child and his developmental idiosyncrasy.

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In what follows we discuss each of these principles in the context of early intervention.

Diagnostic assessment We have pointed out in previous chapters (Chapters Two–Four) that many developmental irregularities can be diagnosed very early, sometimes soon after birth, and possibly even during intrauterine existence. It is necessary, however, to determine whether such an early diagnosis is beneficial. Should professionals, especially neonatologists, as well as neonatology and public health nurses, be encouraged to look for such aberrations, and should time and resources be invested in training them to do so? The crucial question is whether early diagnosis will result in an effective therapeutic intervention or merely in unnecessary labelling and parental anxiety. In the paragraphs that follow we elaborate on this issue (see also Chapter Eight) and discuss what types of interventions are likely to be effective under specific circumstances. Diagnostic assessment, though crucial for effective intervention, is not free of potential side effects. Labelling a child as “different”, “deviant”, or “impaired” may lead to self-fulfilling expectations of failure or maladjustment. This is especially true if the school or other community agencies are involved prematurely. A label of “normalcy” may be more helpful in some cases than any special treatment by community agencies, and parents who resist involving the community may be right. This is particularly true of educational programs for children with “special needs”. Such programs can be of great help in many instances, but they label the child as “different” and often isolate him from the natural social environment of his neighbourhood. One may be faced with a difficult decision of whether to refer the child or accede to the parents’ reluctance to do so, and forgo the potential benefits of specialized care in order to avoid labelling. Once an intervention has been indicated, a thorough assessment of a young child’s motor, perceptual, cognitive and emotional development is essential in order to establish a therapeutic alliance with the child and the parents, to dispel fears and fantasies, and to instil in them a trust in the professional who is well-informed and familiar with the bewildering array of problems they are facing. We have

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discussed in Chapter Seven the discouragement and helplessness caused by the breakdown of empathic dialogue, i.e., reciprocal reinforcement, between the infant and the caregiver. The parents’ frustration and confusion are compounded by criticism and conflicting advice offered by well-intentioned but misguided relatives, friends, and professionals who are not fully aware of the nature of the problem. It is an immense relief to encounter someone who offers not merely support but a conceptual grasp and emotional understanding of their plight. Presenting the family with the broad outlines of a plan for action is equally reassuring. In milder cases, such as that of Laura (described below), helping the parents to understand the problem and suggesting basic guidelines may be all that is needed. Many parents whom we have counselled were able to mobilize enough psychological resources of their own to help the child once the nature of the problem was explained to them. One cannot fail to be impressed by the courage, wisdom, and perseverance some of these parents display. Yet love and determination are seldom sufficient; most parents need at least enlightenment as to the nature of the problem and guidelines for coping, based on a developmental assessment. Many parents have unspoken questions that need to be explored. “Am I a bad parent? Have I damaged my child, physically or emotionally? Is it hereditary? Is my child retarded; is he going to be insane?” The best reassurance is to bring such fantasies to the surface and to answer questions openly. It often helps to share with the parent the process of arriving at our conclusions, to point out the relevant data, especially those that can dispel the parents’ concerns. For instance, we explain to the parents of older children that occasional concrete cognition or lapses in reacting to social situations are common symptoms of neuropsychological impairment and not a sign of insanity. We explain that a child who is able to maintain object relationships, e.g., an affectionate relationship with a school friend, is certainly not suffering from an autistic spectrum disorder. One of the important issues to clarify is the child’s low selfesteem. Parents need to understand that some of the disturbing things that their children say or do are clumsy attempts to protect their vulnerable narcissism or to compensate, by means of childish self-aggrandizement, for feelings of incompetence and

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worthlessness. Above all, parents need to know that the child’s low self-esteem is an inevitable result of a developmental deviation and not in itself a proof of poor parenting. Last but not least, sharing the diagnostic process with the parents allows us to present an intervention plan that makes sense to them and to secure their participation. In presenting the intervention plan we emphasize that patience and perseverance do produce results, no matter how painful the situation may be at present. At the same time we caution the parents that some of the objectives take a long time, perhaps years, to achieve, and that new developmental stages, such as entering school or adolescence, may well bring with them new problems to cope with. Cognitive and emotional idiosyncratic development often seems not only delayed but uneven; it seems to proceed in spurts that are difficult to predict. A child who has been emotionally immature, clinging, and absorbed with wish-fulfilling fantasies may suddenly mature, assume new responsibilities, and join his peers in age-adequate activities. Cognitive abilities also mature late and in “leaps”. Behaviour may mature, but it may also regress, especially during adolescence. Stressful life events, such as a move to a new residence and a new school, may also cause regression, especially in children with difficulties in adapting to novelty. Finally, we note that setting up a therapeutic contract requires a clarification of the therapeutic relationship and of the role of the therapist. A therapeutic alliance should not lead to an excessive dependence. It is important to clarify that the therapist is not an omniscient oracle and that he, or she, and the parents proceed cooperatively, by trial and error. It is always prudent for the therapist to maintain a humble, realistic assessment of his own wisdom and powers.

Devising parenting skills consonant with the child’s individuality We have already described how children’s developmental idiosyncrasies induce the parents to adopt unusual and often counter-productive child-rearing practices. The task of the clinician is to help the parents to devise handling methods that will be reasonably effective without interfering with long-term developmental objectives. The idiosyncratic, “difficult” small infant can often be helped by adjusting care-giving, and specifically comforting and stimulation,

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to his idiosyncrasy, be it hyper-sensitivity, intolerance of novelty, or any other atypical response. The following example illustrates such a simple yet effective intervention. Amos was a slightly pre-term boy born after several miscarriages. A breach presentation required general anaesthesia, but there was no significant foetal distress. He was healthy, with slight signs of immaturity, such as frequent tremors. His parents requested consultation when he was ten days old. They were concerned because Amos was difficult to handle: he responded negatively to many visual and auditory stimuli, cried a great deal and resisted having his diapers changed, being washed or other physical contact. He could not be soothed by hugging and displayed the characteristics of a “non-cuddly” baby (Brazelton, 1973). In view of the child’s apparent over-sensitivity, we suggested reducing the amount of tactile stimuli, keeping the baby well-wrapped and cuddled up in a small cradle, and avoiding excessive light or noise. He seemed to be perfectly happy in that low-stimulus, as-if-intrauterine condition. We also noticed that Amos, when awake, was most comfortable in a situation of limited body contact, freedom of movement of his arms, and a wide visual field. We encouraged the parents to adjust their care-giving to the child’s idiosyncratic preferences. Mother did so by holding the baby leaning on her lap, and Father by carrying him propped against the shoulder. The tension was reduced, and the interaction became much more relaxed and enjoyable. Eventually, a gradual and progressive exposure to more stimuli enabled the boy and his parents to engage in a normal and rich “mediated learning” experience and to develop a close emotional relationship. In this case, a simple but timely intervention averted a potentially serious difficulty in the parent-child relationship. The special needs of the “difficult” child require patience and flexibility, because they change as the child develops. In infants, soothing techniques and monitoring of stimulation are usually the crucial issues. Later on, children with developmental deviations may need more guidance in organizing their time, e.g., eating and sleeping patterns, and play and work activities. Children whose impulse control is impaired need more supervision and a firm, consistent structure.

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The guiding principle for raising a child with developmental deviation can be defined in the following way: Whenever a regulatory ego function is delayed or impaired, the parents have to substitute for it an external auxiliary ego. Such a need for external ego support, however, should not hinder the child’s emotional growth and in particular his autonomy and sense of responsibility. This requires flexibility; one has to be willing to proceed by trial and error if need be. The parents also have to confront the child’s inappropriate behaviours while avoiding further narcissistic injury and damage to his self-esteem. They have to learn how to supervise closely without being intrusive. All that is, admittedly, a formidable task that may take a long time to master.

Improving functions Once a developmental lag has been diagnosed, the parents will wish to know whether and how it can be corrected. Many techniques have been devised, and some have been mentioned in the chapter on therapy (Chapter Nine). One has to decide whether such interventions are, indeed, to be recommended and also to whom to assign the implementation. We have already mentioned that in younger children it is usually preferable to instruct the parents to provide developmental stimulation under the guidance of a professional. What the parents lack in professional skills is compensated for by more time available for the intervention and, more importantly, by the emotional relationship. The motivation of the child is a crucial factor in such early intervention. The fun of the activity and the fun of playing with the caregivers act synergistically. In addition, working together has a considerably positive effect on the relationship. In older children the opposite may apply: an outsider, a tutor or a professional, may be in a better position to motivate the child, who has already developed an antagonistic attitude toward the parents’ demands. Delegating the task and the responsibility for progress to an outsider helps to eliminate areas of friction in the family. Some parents, labouring under pressure of guilt and worry, find the additional burden of responsibility to be simply too much, whereas others find relief in the opportunity to “do something”. In devising an intervention aimed at ameliorating a developmental deficiency or lag, we need to keep in mind the “matrix” model of early development presented in Chapter Two. It implies that an early intervention ought to rely on the following two premises:

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1. An understanding of impaired emotional development requires an examination of the other developmental sequences, namely sensory, motor and cognitive lines of development. 2. Some cases of a disturbed early emotional development can be ameliorated by intervention in another developmental sequence. The case described below illustrates this idea. We have seen Laura, a two-and-a-half year old toddler, whose parents noticed that she was unusually sensitive to frustration, cried easily, and was excessively dependent and insecure. Her medical and developmental history were unremarkable, with the exception of neonatal jaundice and late walking (fifteen months). On examination she was found cognitively precocious but considerably below age in her motor development. She was hypotonic, her walk was wobbly, and she had difficulty climbing stairs unassisted. We explained to the parents that the girl’s delayed motor development was the cause of her insecurity and encouraged them to set up a systematic program of motor stimulation in the form of entertaining games of tasks that were progressively more demanding, but always well within the girl’s ability. They began by balancing on a thick log, with help first and then without, proceeded to “playing the kangaroo” and finally to jumping from a step. Laura delighted in those games and engaged in them willingly. At the same time we counselled the parents not to allow the girl’s impressive intellectual precociousness, of which they were justly proud, to become an excuse for avoiding more active games and activities. The girl made conspicuous progress in motor development within a few months and at the same time her emotional state changed drastically: she enjoyed the motor games and became more outgoing and self-confident. Some functions, e.g., attention or impulse control, can be improved by medication. In such cases, too, the informed participation of the parents is crucial in order to set up and maintain a rational program of pharmacotherapy. Our experience leads us to suspect that a substantial percentage of the parents whose children supposedly

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receive medication do not comply, but conceal the fact. This is particularly true in cases where the medication is prescribed under overt or implied pressure from the school authorities, and the parents suspect that the physician’s decision is influenced by this pressure (See also Chapter Seven).

Using “detours” “Detours” are alternative methods for accomplishing a task in spite of an impaired function, e.g., a colour-blind person may rely on the fact that the red traffic light is always above the green one. Some “detours” consist of a device, e.g., a laptop computer for a child whose handwriting is unintelligible. Other “detours” depend on substituting one function for another, e.g., using visual instead of auditory memory, as Mr. Y. did (Chapter Three). Some subjects invent highly ingenious methods, like the boy with a partial nominal aphasia, i.e., occasional inability to recall words, who memorized sentences from textbooks and used them to construct compositions (Chapter Six). Not all children are imaginative enough to invent “detours”, and it becomes the task of the parents and the therapist to suggest them. The parents also need to understand that what seems to be a strange way of doing things or an unreasonable demand may merely be a way of finding a “detour” to bypass impairment. For instant, a child who insists on going to school with an older sibling may have a serious impairment of spatial orientation. In such cases, the clinician has to be the voice of the child, who is not yet able to articulate his problem.

Promoting well-developed abilities This is an important and often overlooked aspect of an early therapeutic intervention. The child, who is expected to practice tasks that for him are difficult and frustrating, needs also to excel in some other activities to boost his morale. Promoting well-developed abilities, e.g., hobbies, requires the cooperation of the parents, especially if it involves demands on their time or finances. Most parents are glad to see their child happy with his newly found competence, but a measure of caution is required. The parents have good reason to

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take pride in their child’s accomplishments, but they need to assume a balancing role and not collude with his attempts to use such occupations as a cover-up or excuse for avoiding other domains, such as social relationships or physical activity.

Acceptance In many cases the most important and often most difficult goal of counselling is to help the parents to accept the child’s “imperfections” (unlike the perfection-obsessed protagonist in Hawthorne’s short story, “The Birthmark” (1843), described in Chapter Nine). The anger provoked by the “difficult” child is often quickly moderated by understanding and practical advice. The issue of narcissism is apt to be more difficult. The therapist may need to confront empathically but candidly the narcissistic injury experienced by parents whose child fails to fulfil expectations. A particularly sensitive but often vitally important issue is the problem of the parent who recognizes, or disowns, a trait of his own personality, present also in the child (Chapter Seven). It may be a temperamental trait or a failing; if the parent hates it in himself, it will take considerable skill on the part of the therapist to resolve the parent–child antagonism. In conclusion, counselling parents of a child with developmental deviation is based on an assessment of the child’s developmental impairments and idiosyncrasies as well as an understanding of the emotional dynamics of the family. In order to reduce the negative effects of a deviation on the shaping of a child’s personality, we need to understand the emotional impact of the developmental deviation on the child and on his environment. At the same time we need insight into those unresolved emotional conflicts of the parents that enmesh with the child’s difficulties. We also need to recognize and to foster the psychological resources and the motivation of the parents, as well as the personality assets of the child. Various therapeutic modalities improve the child’s functional ability and enhance his competence. Confronting the basic emotional issues of the child and of his parents requires, however, a psychoanalytic frame of reference, even though the actual therapeutic technique may vary according to the individual circumstances of each case.

CHAPTER FIFTEEN

Mastery, aggression, and narcissism

“[The will to power ...] is the primeval tendency of the protoplasm.” —(Nietzsche, 1901) “There’s gold, and it’s haunting and haunting; it’s luring me on as of old; Yet it isn’t the gold that I am wanting, so much as just finding the gold.” —(Service, 2001)

Ori, a two-and-a-half-year-old toddler, tries very hard to join some pieces of Lego in a manner known only to himself. He is visibly frustrated by the difficulty and angrily rejects offers of help, saying, “Not that!” Finally he succeeds in putting together a sort of a landing platform, which he raises in a triumphal gesture, his face beaming with pleasure, and announces proudly: “My Auntie Ettie ‘teached’ me!” What is the motivational force driving Ori’s efforts? What drive release provides the source of his joy? These seemingly simple 197

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questions pose a challenge to the psychoanalytic theory of drives. Exploratory behaviour, manipulation of the physical as well as the social environment, practicing skills for their own sake: all these seem to form a life-long continuum of an urge to master one’s own body as well as the environment. Like Ori, we all invest occasionally considerable effort into these activities and derive joy or frustration from success or failure. Numerous psychoanalysts, beginning with Freud, were aware of the issue of mastery, but their attempts to integrate it into the theory of drives were different and sometimes contradictory. Freud used the term “instinct for mastery” on several occasions (Freud, 1905, pp. 159, 188, 193). He hints at its origin that it “is concerned with the satisfaction of the other [that is, not the sexual] and, ontogenically, the older of the great instinctual needs” (p. 159), meaning, presumably, the self-preservative instinct. Nevertheless, he never formulated a comprehensive theory as to the relation of such an instinct to the drive theory. His earlier writings followed the accepted biological theory of his day, i.e., the division between sexuality (libido) and self-preservative instincts, which he also called ego-instincts (Freud, 1915, pp. 124–126). Mastery of the environment would then be considered an expression of the self-preservative instinct. In his second, or “intermediate”, theory Freud already attributed self preservation to narcissism (Freud, 1914, pp. 73–74), and therefore mastery would be a manifestation of the libido. This view was further elaborated in “The Ego and the Id” (Freud, 1923, pp. 40–59). At the same time, the aggressive manifestations of the urge to master, such as competitiveness, would be tamed expressions of the death instinct turned upon the object. Curiosity, which is the affective aspect of exploratory behaviour, was discussed by Freud only in the context of sexual curiosity, primarily directed to the child’s own body, especially the genitals, and followed by the sexual curiosity of the Oedipal stage (Freud, 1905, pp. 156–157, 192; Freud, 1915, pp. 127–130). He seems to have disregarded the infant’s manifest intense interest in his surroundings, which can be observed from the earliest weeks of life and is followed by a life-long striving to explore. (Consider Sir Hillary’s famous statement that he climbed Mount Everest “because it was there.”) In all his writings Freud implied that the different manifestations of the urge to master, to explore or manipulate the environment to one’s advantage, are components of either one of the basic drives: libido on the one

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hand, and the “self-preservative instinct” (in his earlier writings) or the death instinct, deflected from the self and directed at the environment (in his later works), on the other hand. It seems, however, that the vigorous urge to master one’s body and to exert control over the environment is such a pervasive and peremptory phenomenon as to deserve a place of its own in the theory of drives. Psychoanalysts following Freud considered different manifestations of the urge to master the environment, such as exploration, manipulating objects or practicing skills, to be expressions of one of the following: (a) the sexual drive; (b) the aggressive drive; (c) a “neutral” form of drive energy; or (d) an independent “third” drive. Below we will discuss each of these approaches in turn. Much of the work we review here dates from the middle of the twentieth century; this is not because of any bias against later contributions but because the fundamental principles of psychoanalytical drive theory were formulated at that time.

The sexual drive: sublimation of libido “Sublimation” was a term coined by Freud (1914, pp. 94–95; 1923, pp. 39–40) to describe pleasure-oriented activities in which the aim and often the subject of the sexual drive have been modified to comply with the demands of reality and/or of the super-ego, i.e., with the parental injunctions and ultimately with the moral standards of the society. The term seems to apply to many activities involving mastery of one’s body or manipulating objects, particularly in the realm of creativity. In some activities, like the visual arts or ballet dance, the sexual element is barely disguised, if at all. Some sports, like archery, may well express symbolically a sexual wish; in many other sports, however, the dominant element is purely the excellence of performance. Likewise, symbolic play, which has a major role in a child’s psychic life, may contain unmistakably sexual elements. Other forms of children’s play, however, including many games and construction activities, can only be interpreted as sexual symbols by a vast stretch of imagination. Even a casual observer will notice that children invest a great deal of time and energy in practicing skills for the skills’ sake (Dissanayake, 2000, pp. 99–128; McCall, 1974). The uniform aim of the games played by older infants and young children, like that of little Ori, is achieving a desired effect. It is not

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necessarily the particular content of the activity that is the source of joy but the fact that the child has achieved exactly what he or she intended. Hence, while some games and playful activities may well involve sublimated sexual drive, it does not appear to be a constant or necessary component.

Aggression There can hardly be any doubt that the urge to master is intimately related to aggression. The term “mastery” in common language, as in “the master race”, implies social domination and a forceful imposition of one’s will on others. If we extend, however, the meaning of the term to describe the ability or the striving to control one’s body and mind (within limits of reality) and to induce favourable changes in the environment, not only social but also physical, then we encounter considerable difficulty in ascribing all aspects of mastery to aggression. Many adaptive activities do contain an aggressive element; e.g., many social encounters, even affectionate ones, involve some measure of competitiveness or envy. Physical work often involves cutting, breaking or otherwise mutilating inanimate matter. Other challenging tasks, however, seem to elude any reference to aggression. Can solving a mathematical equation or composing a symphony be attributed to the aggressive drive? Several psychoanalysts have dealt with the issue of adaptive activities that seem closely related to aggression and yet cannot easily be considered as manifestations of the aggressive drive. We will limit the discussion to the views of Rochlin, Kohut, and Parens as the most pertinent to the topic under consideration. We will not attempt to give an exhaustive overview of their contributions but rather present a few salient points, relevant for our discussion. Rochlin (1973) made a distinction between human aggression and aggression in animals. Human aggression, he suggests, is unique because its primary source is a defence of narcissism, a singularly human quality. According to Rochlin, aggression is not a primary drive, but it appears whenever there is a threat of injury to the selfesteem. He, like several theoreticians before him, opposed equating aggression with destructiveness and recognized the adaptive, even creative manifestations of aggression. Today we may have some doubts as to Rochlin’s assertion that narcissism and narcissistic injury are uniquely human. There may

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well be a difference between the conscious experience of an injury to self-esteem, which appears to be uniquely human, and an emotional experience of having failed or having been demoted and humiliated, an experience that can be observed in numerous higher animals, especially social ones. Nevertheless, Rochlin’s valuable contribution is the recognition of the central role that narcissism plays in generating aggression. Kohut (1977) likewise recognized the link between narcissism and aggression, though he did not go so far as to deny the existence of an aggressive drive. He emphasized the role of the nondestructive manifestation of aggression, namely assertiveness, and considered that manifestation to be primary, whereas destructive aggression (exemplified by rage) is secondary, evoked by traumatic, i.e., excessive, frustration. H. Parens (1979) wrote an exhaustive study of the different manifestations of the aggressive drive, its developmental vicissitudes, and its relation to adaptive behaviours. According to Parens there are four categories of aggression, as follows: a. “Unpleasure-related destructiveness”, which he assumed to be an inherent or innate “disposition of the infant to tear down a structure against resistance”. Such destructiveness, according to Parens, is “accompanied or associated with an affective state of unpleasure” (p. 112). b. “Non-affective destructiveness”, i.e., an activity that results in the destruction of the object but is devoid of any hostile intention and is not related to unpleasure. A typical example would be feeding. Parens pointed out that such destructiveness cannot be assumed to derive from deflected self-destructiveness; in fact it serves selfpreservation. c. “Non-destructive aggression”, by which he meant manifestations such as “pressured” manipulation and exploration, determination to assert oneself or to control, and manifestations of the “thrust toward mastery of self and environment” (p. 113). He claimed that the “inner-driveness” of such activities and their constant appearance “gives one the impression of drive activity and of aggression”. d. “Pleasure-related” manifestations of aggression appear later during the development and include various forms of sadistic

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behaviour, very common in children, but not relevant to this discussion. Parens’s formulation leaves unanswered the question of what should be the essential attribute that qualifies a given behaviour as an expression of “aggression”, namely a quality that applies to all three forms (and all four manifestations) of the aggressive drive. If neither destructiveness nor unpleasure are indispensable characteristics of the aggressive drive, then what is? His criterion of “unpleasure” as the specific affect of aggression is also questionable. Unpleasure resulting from frustration certainly arouses aggression but need not accompany it. In fact, most activities aimed at mastery are accompanied by a conspicuously pleasurable affect as long as they are successful. Such activities, therefore, would be “affectrelated”, but not “unpleasure-related”. Neither would they qualify as “pleasure-related” in the sense used by Parens and referring to sadistic manifestations of aggression. The affect most closely related to aggression is anger in its various forms, from mild resentment to murderous rage. It seems more appropriate to assume that the essential characteristic of aggression is an antagonistic aim and, in higher animals at least, an angry affect of any shade. That will allow us to exclude those adaptive behaviours that have no apparent relation to aggression, e.g., exploration or creativity. Lorenz (1966, Chapter Three) distinguished between “intraspecies” and “inter-species” aggression, i.e., aggression directed at individuals of the same or of another species, respectively. It seems to us that a more applicable distinction would be between “alimentary” and “competitive” aggression. Alimentary aggression is usually, though not inevitably, directed at organisms of another species and is inevitably destructive. It is not easy, however, to draw a line at which point alimentation, which is clearly a form of mastering the environment, involves aggression. Plants obtain their resources from inanimate elements; some lower organisms feed on decaying matter. Is munching grass an act of aggression? It certainly does not seem to involve any hostile affect on the part of the cow, though it is destructive as far as the grass is concerned. (Indeed, many plants defend themselves by various means against such “non-affective” destructiveness.) Predation, in contrast to such placid destructiveness, does involve manifestation of aggressive

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affect. It is particularly dramatic in those predators (like leopards) that attack animals larger than themselves. In such situations we may observe facial and body expression of intense fury. We may conclude, therefore, that alimentation is a form of mastering the environment, and aggression seems to be directly related to the object’s resistance to satisfying the need. Competitive aggression, in contrast to alimentary aggression, is more often than not directed at individuals of the same species and is usually aimed at obtaining resources (e.g., food), reproductive opportunities, or social dominance. In higher animals it may be intense but is rarely destructive. In conclusion, mastery of the social environment is, by its very nature, aggressive, though not necessarily destructive. Mastering the inanimate environment, like digging a burrow or nest-building, may or may not be destructive and need not be aggressive. In other words, despite the close relationship between mastery and aggression, the two are far from identical. Some empirical studies also lead to the conclusion that mastery needs to be differentiated from aggression. Person (1993) studied sadistic fantasies in men and came to the conclusion that the primary aim of such fantasies is not aggression in itself but a narcissistic wish for power, a defence against the fear of lack of male competence, and a fear of being rejected and ridiculed. Przybylski, Ryan and Rigby (2009) studied aggressive video games and concluded that the degree of violence contributes little to the enjoyment of the game or to the motivation to play it again. Instead, it is the sense of competence that correlates with enjoyment and motivation. In other words, in some seemingly typical manifestations of aggression, the underlying motivation is not aggression as such but a sense of power and competence.

Neutralized energy Freud (1914, pp. 94–95) assumed that instinctual energy, more precisely libidinal energy, can be displaced and either sublimated or “neutralized” to serve adaptive ego functions. Sublimation refers to an aim-inhibited release of instinctual energy, still under the influence of the pleasure principle, albeit tamed by the reality principle. In contrast, neutralization would imply a total detachment of the psychic energy from the original drive and its diversion into

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an adaptive function, entirely under the control of the ego and the reality principle. Freud, however, was not entirely clear as to the distinction between sublimation and neutralization. Hartmann (1939) pointed out that many adaptive ego functions could not be explained in terms of conflict resolution, which means they could not fit into the accepted dynamic theory, and thus he coined the term “conflict-free ego zone” to describe such adaptive functions. He developed further the concept of innate “neutral” psychic energy to account for self-preservative (adaptive) ego functions that serve an individual’s biological and social needs, including mastery over the environment. This ingenious hypothesis helped to expand the horizons of psychoanalysis in order to become a general theory of human behaviour, but it also raises serious difficulties. To begin with, the concept of “psychic energy” became more and more problematic with time. Even Freud was aware of the fact that the term “psychic energy” does not refer to any concrete entity and is, at most, an apt metaphor that describes the peremptory power of the drives (Freud, 1940, pp. 163–164). Unlike affects, “psychic energy” can hardly be experienced subjectively, and there is no evidence of its being in any way correlated with the intensity of neuronal stimulation. The second difficulty with the concept of “neutral” psychic energy is that it can hardly account for the intensity of pleasure upon achieving a goal, since pleasure was assumed by Freud to express the consummatory release of drive tension. The “neutral energy” theory also seems to disregard a distinction between those adaptive (i.e., ego) functions, like perception or memory, that are stimulus-bound and those, like exploratory behaviour, that seem to derive from an inner urge. The first ones hardly require any assumption of “psychic energy”: they are a direct response, “energized” by the stimulus. The others, however, require an assumption of a self-activating internal process, manifested in all drive-related behaviours. The concept of “psychic energy” does not appear to be the best assumption to explain such self-activating processes, and we will return to this point later.

“Third drive” theories White (1959) presented numerous examples from animal studies as well as from infant and adult human behaviour that demonstrate

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the urge to explore and to manipulate the environment in order to produce stimuli (rather than react to them), and the pleasure that many creatures seem to derive solely from the sense of success and from “attaining a more differentiated cognitive map of the environment” (p. 320). White presented strong arguments to suggest that this urge is neither a tension-reducing urge (like the sexual drive) nor a response to environmental stimuli, though, admittedly, external stimuli do play a role in determining its direction. Rather, it seems to be the effect of internal neural processes. It is, metaphorically, “what the neuromuscular system wants to do when it is otherwise unoccupied” (p. 321). White suggested the term “effectance” to describe this urge and assumed that its ultimate adaptive goal was to foster competence. Hendrick (1942, 1943) was the most prominent psychoanalytic exponent of the “third instinct” theory. He presented a detailed account of the motivational force and the pleasure derived from mastery, beginning in infancy, and then resulting from work, in later life. He derived his conclusions from the developmental studies of McGraw (1935) as well as from his own observations of young children, and he argued that the need to master and the urge to practice skills, when devoid of any competitive or hostile intention, could hardly be viewed as a derivative of the aggressive drive. Therefore, he suggested the hypothesis of a third, independent drive. In his later paper (Hendrick, 1943) he postulated the existence of a “work principle”, operating in the service of the drive of mastery, as opposed to the “pleasure principle” related to the sexual drive. He argued that not all pleasure derived from work can be explained as reaction formation to repressed libidinal or aggressive fantasies, and he claimed that the pleasure derived from a well-accomplished act is evidence of a drive separate from libido and aggression. Hendrick’s papers were received with considerable scepticism by other leading psychoanalysts. Besides the natural reluctance to adopt such a fundamental revision of the psychoanalytic metapsychology, there are serious drawbacks to the assumption of three, rather than two, basic drives. Not only is the model of two opposing drives and the balance between them endowed with a philosophical elegance (yin and yang, good and evil), but, more importantly, it is consistent with the observation that countless natural phenomena can best be described in terms of two opposing forces. Such is the case of the coordination of an athlete’s voluntary movements, a bird’s

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flight, the motion of planets, the flow of an electrical current, or the matter-antimatter theory: an admittedly broad range of phenomena. Much can be gained by having a model of psychic functioning based on the same principle. The most important reason, however, to preserve the dual-drive conflict theory is its invaluable contribution to the understanding of human behaviour in general and of neurotic symptoms in particular. The two basic drives, i.e., libido and aggression, are different from the urge to master in an additional aspect. Each one of them is inseparable from its specific affects: libido affects range from tenderness to sexual excitement; aggressive affects range from assertiveness or irritation to vehement rage. In each case the continuity of the affective range, broad as it may be, is unmistakable and so is its specific connection with the drive. No such specific affect seems to precede and drive exploratory or play behaviour, even though the success of the action does result in pleasure. In order to elucidate the elusive nature of “effectance” we propose to review the phylogenesis of the urge to master as well as its ontogenesis, i.e., its development in the infant.

Infant development (ontogenesis) A newborn infant is capable of directing his gaze to follow visual and auditory stimuli (Brazelton, 1973; Wolff, 1966). He will also spontaneously direct his gaze at the environment, especially at the people near to him. In that manner he can “choose” what to look at, or exert a rudimentary control over the visual field, i.e., over the visual stimuli he receives. Within the next months he develops the basic social skills to initiate and to terminate contact with the caregiver (Stern, 1985), i.e., a measure of control over his most vital emotional need, the primary object relationship. During that time the infant delights in “games” with the caregiver. The content of those “games” is an exchange of stimuli, often imitation by the adult of the infant’s vocalizations or actions, and later mutual stimulation by the infant and the caregiver. For instance, most infants delight in the “game” of the mother tickling the baby’s belly while the baby laughs, and they keep repeating this over and over. The essential element in those “games”, however, is the expectation of the caregiver’s response. If the latter fails to respond or responds in an unexpected way, the

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infant appears uncomfortable or distressed. (Incidentally, the same is true of the mother: she is invariably distressed if the infant fails to respond to her advances.) Thus, the first mastery acquired by the infant is a (relative) control of his social environment. Beginning from the second half of the first year, the infant dedicates himself to practicing control over his inanimate environment. Opportunities for triumph and frustration abound. Banging objects, taking them apart or putting them together, or rolling a ball: all these provide endless opportunity for practicing skills. Many of these activities may result in damage to objects, but a careful observer will not fail to see that in most cases the damage is neither intentional nor gratifying. Quite the opposite: the infant may become visibly distressed and cry if the manipulated object unexpectedly breaks apart. Neither is such exploratory activity accompanied by an angry affect, unless the child is frustrated first. The goal is to achieve the desired (and expected) effect, be it a sound or a motion of the object. It is precisely the achievement of a predicted outcome that results in delight. Praise and admiration on the part of the adult add greatly to the child’s pleasure but are not an indispensable element of it. The triumph of achievement is a goal in itself; pleasure results from accomplishing a task. The more challenging the task, the longer the toil, the greater the elation following success, like the joy of the prospector in Service’s poem (2001). H. Papousek and Bernstein (1969) studied contingent conditioning in four-month-old infants. The subjects were presented with a series of coloured lights, which were lit by the infants turning their heads in a specific way, e.g., two turns to the left followed by one turn to the right. The infants, once they learned the rules, engaged in this “game” with obvious delight and persistence. The authors add an interesting comment: “Sometimes we had the impression that successful solving of a problem elicited more pleasure in the subject than did the reward,” i.e., the coloured lights. More recently Dissanayake (2000) wrote an exhaustive study of the urge “to do things with one’s hands”, of its importance in child development and in the culture of pre-industrial societies. She came to the conclusion that the intensely pleasurable affect that accompanies the successful completion of a manual task has presumably an evolutionary significance and, in her opinion, played a critical role in the evolution of Man as a thinking animal.

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“Doing” also seems to play a significant role in cognitive development. Some cognitive investigators have recently questioned the traditional view of cognition as developing merely by way of an unfolding of innate abilities in interaction with external stimulation. Thelen and Smith (1994) claim that acting stimulates learning. For instance, they presented evidence that infants learn names of objects more efficiently when they manipulate the object while hearing its name. During the second and third years of life, the child’s urge for mastery finds expression primarily in the rapidly developing motor competence, i.e., control over one’s own body. At the same time social skills also become more evolved and more complex, and the emerging issues of dominance and competition inevitably introduce an element of aggression. Control, no matter how benevolent, of another human being involves inevitably a clash of wills and encroachment on the other’s autonomy and therefore an element of aggression. From that stage on, the aggressive drive becomes intertwined with the striving for social status, dominance, and sexual competition. However, even in adult life there are innumerable instances of sheer joy of competence, devoid of aggressive intent or angry affect, like the scenes of delight in NASA’s control room when a spacecraft enters its orbit.

Phylogenesis of mastery Freud assumed that the basic drives are characteristics of all living organisms. Therefore, to understand the origin of the urge to master, we need to trace its roots all the way back into the evolution of living organisms. Nietzsche (1901) ascribed this urge to the “will to power”, which he considered a primary motivation of all living matter, the adaptation being only a secondary derivative. Today such an idea seems too anthropomorphic to be useful, but it contains an element of truth, as will be explained in the following paragraph. Life arose on earth when complex molecules, probably RNAs (or so-called “mini-RNAs”), acquired the ability to replicate themselves (Hazen, 2005; Orgel, 1973), a process that requires absorbing matter (in order to offset loss and allow growth) and energy (in order to offset entropy). In the course of evolution those “protobiotic” systems developed into more complex organisms, always maintaining the

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ability to obtain those two essential resources from the environment. Hence, this ability is not merely a characteristic of living matter—it is a precondition to life. During the process of evolution, living organisms developed increasingly complex and efficient means of controlling the environment and maintaining internal stability, i.e., homeostasis. These two goals are achieved by motor systems and by control systems, respectively. The internal stability of the organism is assured by the integrated operation of the immune, endocrine, and autonomic nervous systems. For most vertebrates and many invertebrates the organs of locomotion became the main, though not exclusive, means of controlling the environment. The motor system of many animals is also the primary instrument for expressing aggression, but there is no reason to assume identity between the two, or to conclude that every motor activity is necessarily an expression of the aggressive drive, as many analysts seem to assume. It is a far cry from the pseudopodia of the amoeba engulfing a food particle to the toddler’s delight in constructing a Lego platform. Nevertheless, it is possible to trace throughout evolution the development of an organism’s means to manipulate the environment to its own advantage. Higher organisms have developed more efficient motor systems compared with lower ones, but the most dramatic evolutionary achievement is that of the control systems. The complexity and effectiveness of the control systems of higher organisms, especially mammals, is truly astounding. The toddler’s main control system, i.e., his central nervous system, is infinitely more complex than that of any invertebrate; it is capable of integrating internal and external sensory input with stored information, of developing an “action plan” and evaluating feedback, both from his action (proprioception) and from its effect (perception). The most striking quality of mastery in human beings (and seemingly in many mammals) seems to be the delight of “effectance”. At some point in our evolution, essential adaptive behaviours became endowed with affects. We know very little about the antecedents of affects in lower animals, but we can see clearly that in mammals and birds, at least, survival and reproduction “lean” (to use Freud’s term (1905, pp. 181–182)) on the affects expressing the two basic drives, libido and aggression. What is, then, the affect concomitant

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with mastery? The obvious answer is a sense of competence and enhancement of self-value, i.e., narcissistic gratification (Broucek, 1979). Here we have to agree with Rochlin (1973) that the effect of achieving a desired goal on one’s self-regard is a uniquely human quality. In man, the “protobiotic” need to obtain resources from the environment evolved into a conscious urge to exercise skills and acquire competence, to explore and to control the environment, and to assert one’s place in the social fabric.

Conclusion We can now formulate what seems to us the most appropriate definition of the urge to master. The urge to master is an evolutional product of a basic characteristic of living matter, a biological imperative, not a quality of living matter but rather a precondition to life. At some point in the evolutionary process, this urge became imbued with a positive affect. In man it is driven by narcissism, i.e., a derivative of the libido, and has a critical impact on self-regard. It is closely associated with aggression, since any challenge to the urge to master mobilizes aggression in one form or another. That, in turn, is a highly adaptive process, as aggression is the most natural means to overcome obstacles to mastery. We should not, however, be misled into equating aggression with the urge to master. The latter can manifest itself entirely devoid of antagonistic intent or angry affect, which are the essential features of aggression. In conclusion, the urge to master deserves a place of its own in the theory of drives. It is not analogous to the two basic drives, libido and aggression, but is served by both of them. Its roots are to be found in the dawn of life, and it is a derivative of a most elementary feature of living matter, more basic than libido or aggression, namely the ability to obtain in a most effective way the resources indispensable for survival and reproduction. In man, the motivating force driving the urge to master is the desire for competence, and the reward for mastery is a narcissistic gratification.

CHAPTER SIXTEEN

Cognition in psychoanalysis and psychotherapy

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sychoanalysis, from its very inception, was conceived of as a cognitive process, influencing the emotional life of the subject, i.e., the person undergoing psychoanalytic treatment. We have in mind, naturally, Freud’s first model of the mind, the “topographical” model (Freud, 1923). Freud recognized three domains of psychic processes motivating behaviour: conscious, pre-conscious (i.e., not conscious but available to consciousness), and unconscious. This division was not, in itself, an innovation. The existence of unconscious mental processes had already been recognized by philosophers and psychologists from Leibnitz onward (Massey, 1990). Freud’s groundbreaking idea was the concept of the dynamic, i.e., repressed unconscious, an idea so revolutionary that it is being disputed by some cognitive theorists (e.g., Daniel Schacter) and neuroscientists (e.g., Karl Pribram) even today (both quoted in Loden (2001)). Freud came to the conclusion that some unconscious contents are maintained in that state by the force of repression, and that some of those repressed contents, mainly unacceptable impulses and painful traumatic memories, are at the roots of psychoneurotic symptoms. Therefore, the process of psychoanalysis involves removing the repression and bringing the unconscious content 211

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into consciousness. Other models of the mind followed, and the understanding of psychoanalytic therapy became more complex, during Freud’s life and after Freud, but the fundamental idea of making unconscious, repressed content conscious remained one of the mainstays of psychoanalysis. The declared goal of psychoanalysis— i.e., gaining insight—implies, therefore, acquiring new knowledge about one’s own unconscious psyche, and this process is unquestionably a form of learning, i.e., a cognitive process. In view of this, it is quite notable that exceedingly few psychoanalytical theorists studied cognition and learning, neither in general nor in the specific context of the psychoanalytic process (Bieber, 1980a; Bucci, 1997; Greenbaum, 1985). The reason for such apparent neglect, most probably, was that Freud, like Breuer, considered affect to be the primary mover in the causation and in the cure of psychoneurotic disorders, and he assigned cognition an auxiliary role in both (Bieber, 1980a, p. 25). Other analysts followed the same approach and implicitly treated cognition as merely an instrument in the process of psychoanalysis. In general, psychoanalysts who did study cognitive processes directed their interest predominantly to the issue of memory and repression (Shevrin, 2002). Bieber (1980a, 1980b) was, to our knowledge, the only analyst who investigated in depth the cognitive processes occurring during psychoanalysis. He called attention to the fact that the therapeutic process involves not only changes in affects, such as decrease of anxiety, but also profound changes in cognitive sets, such as reassessment of unconscious irrational beliefs. An example of such a cognitive reassessment is the re-examination of infantile fantasies as they emerge in the transference and the analytic reconstruction. Bieber called his approach “cognitive psychoanalysis”. In spite of its obvious merits, Bieber’s contribution seems not to have attracted much attention. In contrast to the scant attention paid by psychoanalysts to the wider issues of cognitive science, the opposite relationship, i.e., the impact of emotion on cognition, has been well recognized by cognitive psychologists, beginning with the groundbreaking experimental studies of Gardner Murphy half a century ago (Murphy, 1956). It also became clear with time that laboratory studies of the classical, so-called “Pavlovian” conditioning, in which emotions, beyond the desire for a reward or fear of the aversive stimulus, were supposed to

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play no role, did not well represent real-life events. Animal trainers have known for centuries that the emotional relationship of the animal with the trainer plays a major, sometimes critical, role in the training process. It is said that an Indian elephant handler (who is usually a boy or a teenager) will make “his” animal perform tasks that it will refuse to do for anyone else. Such a dramatic demonstration of the power of a relationship makes a deep impression on the onlooker, in view of the size difference between the huge animal and the little boy commanding it. In other words, an emotional relationship is a powerful incentive to learning in many animals, not less than in people. Cognitive-behavioural (CBT) therapists have come a long way from the early mechanistic view of behaviour modification to the present-day understanding of the role of the relationship between the patient and the therapist (Linehan, 1993; Young, 1999). Linehan (1993) even used the concept of patient-therapist “alliance”, a term coined by psychoanalysts. The fact that an emotional relationship is an incentive to learning is implicitly or explicitly recognized by psychoanalysts (Liss, 1955; Youell, 2006). The reverse process, the contribution of learning to the relationship, has hardly ever been examined. In the paragraphs that follow we will examine the issue of learning and relationship and its relevance to the therapeutic process. Subsequently, we will examine that issue as it relates to “developmentally informed” therapy. In order to understand the vicissitudes of learning in psychoanalysis, we have to return to the outline of early development described in Chapter Two. During the first few months of an infant’s life, the caregivers are providers of biological and emotional needs (the latter refer to the needs for closeness and for comfort). At the same time, even at this early stage, the infant is eagerly absorbing impressions of his environment and, presumably, organizing his perception of it. The caregiver is, obviously, a foremost part of that environment, and the infant absorbs perceptions of her appearance and actions, including her smiles, talk, and fondling. In this way the caregiver participates actively in the process of early learning. The development of gross and fine motor functions and especially the acquisition of visual–motor coordination introduce a new and important dimension into the infant–caregiver relationship. The reason for the change is that the infant now engages vigorously in acquiring and practicing skills to master the inanimate

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environment: touching objects, shaking them, throwing them, and putting them in his mouth. Such activities are the source of strong affects: success (i.e., achieving the expected result) produces pleasure, while failure produces frustration. Success, therefore, is an effective instrumental (or contingent) conditioning reward that leads to further practicing. There is, however, an additional source of pleasure, namely the problem-solving ability per se (H. Papousek and Bernstein, 1969). In the words of White (1959), “expanding the integrative capacity of the central nervous system” (or of the ego) is by itself a source of positive affect. In other words, solving a problem evokes a sense of control associated with pleasure. The association between understanding and control is vividly expressed by the metaphor of “grasping” a problem. The issue of pleasure from learning becomes more complicated when an action results not in a pleasurable reward but in an aversive response, e.g., frustration or social censure. The affect in such a situation is unquestionably negative, and the subject may well feel angry at the person imparting the negative feedback. Yet, frustration does not inevitably influence the relationship in a negative way. If that were so, children would invariably (other things being equal) be attached to permissive parents more than to relatively strict parents. This is not necessarily true: in our clinical practice we often encounter children, especially teenagers, who are alienated and even hostile toward very indulging parents. To explain this seeming paradox we need to refer to the above observation of H. Papousek and Bernstein (1969), that the experience of solving a problem, i.e., having learned something (namely, “expanding the integrative capacity of the central nervous system” (White, 1959)), is gratifying per se, and sometimes more so than the reward itself. In other words, we have to separate the emotional response to the consequence of an action (reward or aversive response) from the emotional effect of having learned as result of the action. The child who learns to control, inhibit or deflect his drives as a result of parental prohibitions experiences the frustration of not having achieved the object of his desire, but, at the same time, he also experiences an enhanced sense of mastery of himself. In our experience, admittedly not supported by empirical evidence, there is a grain of satisfaction in having learned something from an unpleasant

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experience, a satisfaction perceptible once the initial resentment has cooled off. The following anecdote may illustrate this notion: Dr. B., a colleague of ours, told us the following story: “You know, a couple of weeks ago I happened to say something disparaging about the Institute to a group of junior staff members. The Boss somehow got word of it and called me in ‘for a discussion’. Actually, he was not too harsh, but he made it clear that something like that is not acceptable. He told me that a person in a responsible position making such negative comments to junior staff undermines the morale. I felt very bad; you know how much I respect him. Yet, I am not mad at him; if anything I respect him more. To begin with, he did not put me down. Secondly, he was right. Thirdly, I have learned to keep my big mouth shut. Moreover, he presented me with a good demonstration of how to deal with an undisciplined subordinate.” In conclusion, the process of learning is accompanied by an intrinsic positive affect, the result of an increased sense of competence. An infant’s learning takes place in the context of the infant-caregiver relationship, as the caregiver shares with the infant the acquisition and practicing of skills. The caregiver now becomes an infant’s teacher besides being a provider of needs. The joy of learning is shared, and it becomes a potent force in cementing the attachment. Any casual observer will notice how quickly older infants and toddlers become attached to adults or older children who show them pictures, read stories to them, teach them new games, or play old games with them. We can modify the thesis of Liss (1955) and Youell (2006) by agreeing that a relationship constitutes a motivation for learning, but adding that the reverse also holds true: learning cements a relationship. In other words, a school-age child learns because he loves his teacher, but he also loves his teacher because he learns from her. The reciprocity between attachment and learning does not seem to be unique to humans. It appears to be a trait deeply ingrained in the mammalian nature and, in some form, in most birds. It probably provides a survival advantage by introducing an element of stability of behaviour. For mammals, learning is an essential element of coping with the environment, and learning the elementary skills

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from the same adult reduces the risk of haphazard acquisition of incompatible behaviour patterns. In addition, it creates conditions favourable to survival by combining the two essential roles of the parent: protector of the young and their teacher. As a result, when the protector is available, so is the teacher and vice versa. The reciprocity between learning and attachment has significant implications for psychotherapy and psychoanalysis. On one hand, the acquisition of insight, the disclosure of unconscious ideation, and the reconstruction of the childhood experiences constitute one uninterrupted process of learning, which is assisted, or “mediated” (Feuerstein, 1979), by the therapist. On the other hand, all these processes take place in the context of an emotionally rich relationship. This is particularly emphasized by the “relational” school of psychoanalysis (Mitchell, Aron, Harris & Suchet, 2007), but all analysts recognize that the relationship with the therapist, manifested by trust, dependence and transference, is an essential component of the process. The transference, by definition, is a distortion of reality, but the therapist inevitably assumes a parental role also in reality, by virtue of serving as a “mediating” parent, as a teacher. Moreover, the two parental roles, the illusory parent of the transference, and the realistic teacher-parent, become inextricably linked together, since the attachment fosters the learning and the learning strengthens the attachment. The role of the therapist as a “mediator” (Feuerstein, 1979) becomes even more distinct in “developmentally informed” therapy. The “informed” therapist has to share some of his understanding of early development, its deviations, and their impact on the emotional life of the child. Such knowledge is not hidden in recesses of a patient’s unconscious and has to be provided, as it were, from the outside. One is reminded of Freud’s approach to symbolism in dreams: since they are universal and not private phenomena, they cannot, as a rule, be arrived at through the dreamer’s associations, and their meaning has to be supplied by the analyst (Freud, 1900, pp. 350–404). All this should not be interpreted to imply that the analyst ought to lecture to the patient, who, like a devoted disciple, ought to “absorb the wisdom of the sage”. The truth is quite the opposite. The patient is the one who leads the inquiry. The therapist provides assistance, by interpreting the unconscious content and by supplementing the

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patient’s understanding of the vicissitudes of his development. In therapy, as in many other life situations, it is best to preserve the “locus of internal control” and allow the patient to consolidate his or her sense of competence. (Such an approach, incidentally, seems now to be also shared by enlightened educators and is considered to be more effective than the traditional authoritative approach (Edwards, Gandini & Forman, 1995).) The association between learning and relationship applies equally to counselling parents and families. The therapist relies on the therapeutic alliance to make the parents listen and consider ideas that may be novel or objectionable, not necessarily accepting those ideas, but considering them carefully. At the same time, the process by which the parents acquire a better understanding of their dilemma consolidates the relationship. In counselling, the therapist has to take even more care not to fall into the role of an authority directing the actions of the clients. Counselling, not less than therapy, is a cooperative process, with the locus of control shared between the clients and the professional. Last but not least, we need to return to the subject of the positive affect associated with learning per se. We have encountered a number of patients in whom curiosity about the unknown aspects of their own personalities played a distinct role in their motivation for therapy, sometimes as a part of their expectations (conscious or not), sometimes only later, as the analysis revealed “things they didn’t know about themselves”, as they put it. Some patients undergoing psychoanalysis (and not just the analytic candidates) develop a more general curiosity about human nature. The interest in the study of psychology, which many patients express, is not merely the identification with an idealized image of the therapist-parent. It may also represent a genuine interest, as demonstrated in the case of Mr. G. (whose analysis is described in Chapter Twelve), who came to a conclusion that he had discovered what he called “a comprehensive theory of psychology”. The positive affect associated with learning stems from an enhanced sense of competence and mastery, as described above. That is particularly relevant for the patient with developmental impairments because he is especially prone to feel bewildered and helpless, as we have pointed out several times. This feature of therapy is, naturally, more pronounced in those therapies whose main goal is

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insight, such as psychoanalysis and psychoanalytic psychotherapy. It is a significant asset, providing a counter-balance to the emotional tribulations faced by a person undergoing analysis. Achieving insight into one’s unacceptable impulses is not merely a time- and resource-consuming undertaking, it is also often a painful one, and it presents a formidable challenge to the patient’s narcissism. The popularity of therapeutic shortcuts, including not only short-term therapies but also unscientific “quick-fix” methods, is a proof of the burden facing an analytic patient. Therefore, the gratification of learning is a valuable ally of the therapeutic alliance. The emotional hardships of psychoanalysis and psychotherapy are not limited to the patient. The therapist or the psychoanalyst has to deal with the emotional stress of the countertransference, whether hostile or erotic, and with the slow progress and the occasional failures or limitations of what therapy can achieve. The satisfaction derived from the patient’s gratitude is not assured, and if present, has to be tempered by a critical examination through the prism of transference. The financial compensation is, in most countries, meagre, and the social status hardly commensurate with the education required. The natural result may be a sense of boredom and disillusionment, the so-called “burnout” syndrome (Farber & Heifetz, 1982). In our opinion, the most effective antidote to the narcissistic starvation of a therapist is the rich learning experience associated with practicing psychoanalysis and psychotherapy. As one prominent analyst put it: “The aspect of psychoanalysis I enjoy most is that every analytic case is a research project”. (Paul Ornstein in an informal conversation.) In conclusion, learning is an essential part of the process of psychoanalysis, and a learner–teacher relationship is an unavoidable aspect of the patient–therapist relationship. The gratification of learning is a significant factor in consolidating the relationship and a motivating force for the patient and the therapist alike.

CHAPTER SEVENTEEN

Neurobiological perspective

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he last decades have witnessed dramatic progress in neurobiology, largely owing to the introduction of new brain imaging techniques such as CT, MRI, fMRI, positron emission tomography (PET), and single photon emission computed tomography (SPECT). These imaging techniques, together with more advanced methods of interpreting EEG tracing, give an unprecedented picture of the structure and function of the living brain. These methods do, however, have their limitations and shortcomings. For instance, fMRI, the instrument most widely used to study brain function, has been criticized as showing simultaneously areas of the brain (“vixels”) containing very large numbers of neurons and as giving only an indirect, not always reliable, indication of neuronal activity (Logothetis, 2008; Logothetis, Pauls, Augath, Trinath & Oeltermann, 2001). Therefore, we should interpret with caution such findings as an enhanced fMRI signal (i.e., increased blood flow) that occurs in a certain brain area while the subject is experiencing a certain affect or engaged in a specific task: It would be premature to consider this type of finding as clear-cut evidence that the function under observation is “localized” in the active brain area. Nevertheless, the yield of the new imaging methods is prodigious, 219

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and the insights they afford would have been relegated to the realm of science fiction half a century ago. The same applies to the decoding of the human genome and the consequent genetic explorations. It would not be an overstatement to say that the twenty-first century has ushered in new chapters in the study of human nature. A number of investigators undertook a re-examination of some basic premises of psychoanalytic theory, in view of the discoveries of neurobiological investigations, with particular focus on studies concerning the biology of affect and of motivation. The result was the emergence of a new branch of science: neuropsychoanalysis (Kaplan-Solms & Solms, 2000; Panksepp, 1998; Solms & Turnbull, 2002). In this chapter, we will briefly review a few neurobiological investigations that might have a bearing on the subject of developmental deviations and their treatment.

Empathy and infant–caregiver relationship The most extensive studies of the neurobiology of empathy, attachment, and early trauma are those of Schore (2000, 2001). In brief, Schore presents evidence that the child’s right hemisphere, which is the dominant hemisphere in infants (Chiron et al., 1997), interacts with the right hemisphere of the caregiver in a manner that ultimately results in attachment and the acquisition of emotional regulation (Schore, 2000). An early injury to the right hemisphere is apt to result in a behavioural syndrome characterized by attention deficit and often by failure to interpret social cues (Voeller, 1986). Therefore, an innate or early traumatic impairment or dysfunction of the right hemisphere might be the underlying cause of the lack of social sensitivity we have observed in some children with ADHD, and which is described in Chapter Three. Empathy, as we have mentioned before (Chapter Three), can be conceived of as referring to two distinct emotional processes: (a) spontaneous, “contagious” or primary empathy, and (b) “cognitive” empathy involving the so-called “theory of mind”, that is, understanding the other person. Brain studies conducted by Shamay-Tsoory, Aharon-Peretz, and Perry (2009) indicate that the two kinds of empathy are indeed related to different brain areas.

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In our view, one should consider the results of these investigations as preliminary. Attachment, empathy, and social sensitivity are complex functions most probably involving numerous parts of the intricate network that is the human brain. Nevertheless, it is interesting to note that some circuits seem to play a major role. Analysing the relationships between the different brain areas might eventually give us clues regarding the component functions and the development of such vitally important aspects of psychic functioning.

Anxiety Melanie Klein (Klein, 1946; Segal, 1989) theorized that there are two kinds of anxiety, which she called “paranoid” and “depressive” anxiety, respectively. In simplified terms, we might say that “paranoid” anxiety is experienced as a threat to existence, whereas “depressive” anxiety is experienced as a threat of loss of the “good” object. Our clinical observations support the notion of two kinds of anxiety, which we call “psychoneurotic” (or “super-ego”) and “ego deficiency” (or “ego disintegration”) anxiety, respectively (Chapter Four). We base our distinction on the presumed psychic configuration in each case. In the first case (typically in a phobia) we assume the operation of the “classic” psychoanalytic model of anxiety. In a schematic (somewhat oversimplified) way, we may say that a drive-motivated impulse or idea, conflicting with the subject’s value system (the super-ego) and therefore unacceptable to the conscious self representation, is repressed but not quite successfully. Therefore, in a situation where the forbidden impulse is activated (by a stimulus that triggers it), the super-ego mobilizes anxiety in order to ward off the repressed content and prevent it from becoming conscious. The stimulus that activated the impulse then triggers anxiety. In the second case, the ego perceives itself unable to maintain psychic integration, and the subject experiences an existential threat. This occurs, for instance, in subjects with a borderline personality in a state of de-compensation under stress, in the initial stage of an acute schizophrenic episode, or in states of delirium. These two kinds of anxiety largely overlap, in our opinion, with the two kinds described by Klein; that is, depressive anxiety corresponds, broadly, to our super-ego anxiety, while paranoid anxiety corresponds to ego-disintegration anxiety.

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Yovell (2009), in a paper delivered at the International Neuropsychoanalysis Congress, presented neurobiological evidence for the hypothesis of two kinds of anxiety. He based his conclusion mostly on the work of Panksepp (1998, Chapter Eleven, pp. 206–222). Panksepp distinguished two neural systems related to anxiety: One, the more ancient system, is triggered by activity in the central and lateral nuclei of the amygdala, mediated by the neurotransmitters glutamate and GABA (Panksepp’s “FEAR” system), and is the neural base of the fear of annihilation. The other, evolutionally more recent, common to all mammals and birds, is triggered by activity in the anterior cingulate gyrus, parts of the thalamus and the hypothalamus (Panksepp’s “PANIC” system), and is related to attachment and to separation anxiety. It is not too far-fetched to assume that what we call “super-ego anxiety” is ultimately derived from fear of separation and loss of object, since the super-ego is formed by internalization of parental injunctions. Therefore, defying the parental injunctions implies, in the mind of the little child, fear of being rejected, or abandoned, by the love-object. Likewise, “ego-deficiency” anxiety is ultimately derived from the (evolutionally older) fear of annihilation, since the efficient operation of the adaptive and integrative ego functions is a pre-condition for survival in animals. It seems, therefore, that the clinical hypothesis of two kinds of anxiety finds indirect support in the investigations of brain functioning.

Neurobiology of drives Recent advances in neurobiology have stimulated a renewed interest in the psychoanalytical theory of drives, as drives are the most biological aspect of analytic metapsychology. According to Freud, drives are the psychic representatives of biological needs, and a theory of drives ought to take into consideration the findings of biology (Freud, 1915). Panksepp (1998) is one of the leading investigators of the neurobiology of affects and motivation, and his studies are relevant for psychoanalytic drive theory. Panksepp conducted his studies on rats, and it is well known that transferring to people conclusions drawn from animal observations can be misleading. In the case of affects, however, animal observations seem to be often applicable to human psychology. Affects are generated and controlled

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primarily by midbrain structures, notably the amygdala and the limbic system (although the neocortex, especially the prefrontal cortex, also plays a major role in modulating affective responses). The midbrain is anatomically and presumably functionally quite similar in all mammals; it is the neocortex that is so strikingly more developed in humans. Moreover, drive-related behaviours, such as rage, nurturance of the newborn, and sexual acts, are mediated by the same neurotransmitters and neuropeptides in all mammals, including man (Panksepp, 1998). Panksepp came to the conclusion that there is a “SEEK-ANDPLAY” system, unrelated to the fear-rage system, associated with the amygdala–hippocampus–orbito–frontal circuit (LeDoux, 2003) and with the sex-nurturance circuits, which control hormone secretion and sexual behaviour (Panksepp, 1998, Chapter Twelve). He proposes that this SEEK-AND-PLAY system activates exploratory and play behaviour. Panksepp came to the conclusion that the primary seat of the SEEK-AND-PLAY system is in the periaqueductal grey matter, an evolutionally very old part of the mammalian brain, and that it is self-activating rather than triggered by stimuli, a hypothesis strikingly similar to that of White (1959). Thus, animal studies seem to support the hypothesis of an evolutionally primeval, independent, self-activating urge to explore the environment and exercise skills for their own sake, a hypothesis that we have described in the chapter on mastery (Chapter Fifteen).

How psychotherapy works A number of investigators have recently published studies demonstrating changes in brain function concomitant with successful CBT (Paquette et al., 2003; Schwartz, 1998). Psychoanalytic psychotherapy and psychoanalysis proceed much more slowly than CBT, and the criteria for a successful outcome are much more complex than the disappearance of the symptoms. Therefore, a psychoanalytic methodology based on imaging brain function before and after a successful outcome cannot be implemented as easily. This applies both to cases in which we assume the presence of biological factors co-determining the symptomatology and to patients in whom no such factors seem to play a role. Yet, we know from experience that

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most patients affected by innate impairments, like those in whom no such factors can be discerned, do improve significantly with treatment. In order to make a hypothesis regarding the neural correlates of psychoanalytic therapy, we need to make a schematic outline of the relationship between psychoanalysis and the brain. Psychoanalysis deals with maladaptive behaviours (i.e., neurotic symptoms and personality traits, such as dysfunctional attachment patterns) that result from repressed early developmental aberrations, caused by unfavourable experiences and/or by innate developmental deficits. Such unfavourable experiences and developmental deficits occur in early childhood, and they become integrated into the CNS before the prefrontal cortex, which is responsible for the higher cognitive and regulatory functions, fully matures (Schore, 1996). (According to some investigators, the full maturation of the prefrontal cortex is achieved only in adolescence (Fuster, 2001).) Those aberrations, imprinted in the CNS, are presumably represented by maladaptive connections in circuits controlling emotional and interpersonal functions. We cannot assume that psychoanalysis erases those imprints, because it does not remove the memory of the pathogenic experiences. Quite the opposite, the analytic process brings the pathogenic memories into consciousness and elaborates them. This apparent contradiction may find an answer in an animal model described by Quirk and his collaborators (Milad & Quirk, 2002; Milad, Rauch, Pitman & Quirk, 2006; Quirk, Garcia & González-Lima, 2006). Quirk and his associates demonstrated that the extinction of a conditioned fear reflex in rats does not abolish the activation of the amygdala (which evoked the conditioned fear response in the first place), but it involves an increased activity of the connections between the amygdala and the medial prefrontal cortex. The latter, presumably, suppresses the behavioural fear response, including the subjective experience of fear. This paradigm, translated into human psychological terms, would be: the therapy of an acquired fear response does not imply unlearning but re-learning. Such a model would apply equally well both to acquired (that is, caused by an unfavourable environment) and to innate, biologically determined, maladaptive connections. We may speculate that bringing into conscious focus the developmental maladaptive responses, and analysing both the precipitating circumstances and the emotional consequences (a process we called “the analysis of ego

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functions”), stimulates an increase of bilateral connections between the amygdala and the limbic system (the primary areas where affects are generated and regulated), and between the amygdala and the pre-frontal cortex (the area most involved in affect monitoring and modulation, and in the higher executive functions, including, presumably, insight). The original maladaptive imprint is not erased, but its effects are radically modified. Future research will, hopefully, elucidate that issue. Freud coined the term “after-education” (“Nacherziehung”, Freud, 1916) to describe the acquisition, in the course of treatment, of an ability to tame adaptively instinctual impulses and desires, an ability one failed to acquire during the original process of maturation. Such a concept, implying a corrective repetition of an unsuccessful process of subjugating affect-driven behaviours to cortical monitoring and control, could become a paradigm of the neurobiology of the process of psychoanalysis.

The brain as a network Some brain scientists caution against over-interpreting the results of brain imaging studies as true reflections of the operation of the brain. They point out the fact that each neuron is connected, through innumerable and changing synapses, to many millions of other neurons, either directly or through the intermediary of other cells. Therefore, the fact that a certain cortical area or a brain nucleus shows increased activity or increased blood flow under specific circumstances tells us little about the response of other cells, in other brain regions. In other words, the brain operates as a complex network, rather than as a system of interconnected specialized regions (Sporns, Chialvo, Kaiser & Hilgetag, 2004). The study of complex networks is methodologically and conceptually more complex than the study of localized brain regions; at this stage we can only speculate that it will support our clinical observations of the inter-dependence between the developmental sequences, an inter-dependence that we call “the developmental matrix” (Chapter Two).

Conclusions In conclusion, psychoanalytic theories derived from individual clinical observations and theories derived from empirical brain

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sciences are worlds apart. They speak different languages, use entirely different methods of data collection, and apply different criteria of validity. Nevertheless, one cannot ignore the fact that both investigate the same subject matter: human nature. Therefore, each one holds ample potential of enriching the other. An integration of the two will come only in the distant future, if ever, but even today one can discern points of contact that make us look at the subject of our study from a broader perspective and hopefully foster a better understanding.

CHAPTER EIGHTEEN

Conclusions

D

evelopmental aberrations, temperamental idiosyncrasies, and subtle deficits in sensory, motor, or cognitive development are frequent occurrences. Their impact on the early infant–caregiver relationship, their effect on the way the infant experiences his world, and their role in shaping the personality are profound. Their significance is often recognized in theory, but largely ignored in clinical practice. Developmental deviations are the subject of exceedingly few investigations, in contrast to the vast amount of research dealing with the effect of the early environment and of traumatic events. Few, if any, psychoanalysts or psychotherapists pay attention to innate, presumably biologically determined factors in the course of therapy. The attention devoted to the early object relationships and to early traumas is entirely justified; the lack of attention to innate factors is not. We have tried in this book to address the clinical issue of developmental individuality. Many of our patients, children as well as adults, manifested patterns of maladjustment, psychoneurotic symptoms or maladaptive personality patterns that were determined or (more often) co-determined by developmental idiosyncrasies. Such idiosyncrasies often lead to a “mismatch” between 227

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the developing infant or child and his caregivers. The aberrations may be innate, genetically determined, or acquired very early in life owing to adverse events (e.g., foetal distress or physical trauma), and their cause is biological rather than interpersonal. More often than not they remain unrecognized, to the detriment of the therapeutic process, be it psychoanalysis or psychotherapy. It is true that the patient is usually not aware of such an influence of innate factors on his or her emotional life (though he may be aware of their presence), and that we cannot always determine how a given developmental factor will affect a particular patient. The same, however, can be said about parental behaviour and traumatic life events. The purpose of an “in-depth” therapy is to unravel those influences and “connect the dots”. We call such an attitude “developmentally informed” psychotherapy and psychoanalysis. In practice it means that a biologically determined (or co-determined) maladaptive behaviour cannot be removed by interpretation of an unconscious conflict, like a psychoneurotic symptom. It can, however, be moderated by insight into its nature and integrated into a more adaptive attitude or behaviour. The insight into early developmental idiosyncrasy and its impact does not aspire to be a historical, objective investigation, a search for “the Truth”, any more than a psychodynamic interpretation does. Our assumptions are hypothetical, with no possibility for verification or falsification, except in very rare instances. Nevertheless, we have found such insight to be therapeutically useful, in adult as well as in child patients, as a means of reducing anxiety and guilt (in the case of the parents of an affected child), and restoring a sense of internal locus of control. The decrease in anxiety and a better integration of the self-representation were achieved in our patients by systematic analysis of the adaptive ego functions, parallel to the analysis of the dynamic forces, such as repressed drive expressions and unconscious conflicts. The clinician, in order to recognize the presence and the role of developmental determinants in psychopathology, has to be familiar with the basics of infant and child development. Fortunately, the importance of early development has now been widely recognized, and most educational programs, including psychoanalytic institutes, provide studies of infant development in their curricula. Less fortunately, many of those studies focus exclusively on mother–infant

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relationship, a topic of the highest importance but not covering the entire range of the field. Our hope is that this book will stimulate interest in developmental individuality, among clinicians not less than among development investigators. We also hope that such interest will find expression in educational programs of psychotherapy and in psychoanalytic institutes. The exponential growth of neuro-behavioural science has evoked a renewed interest in the reciprocal relationship between brain function and subjective experience, namely, the impact of interpersonal experiences on brain function and structure, on one hand, and the effect of brain function (and dysfunction) on subjective experience and behaviour, on the other. Two domains of psychoanalytic theory seem, at present, to derive the most input from neurobiology, namely the theory of drives and the role of “conflict-free” (Hartmann, 1939, 1961), i.e., adaptive (as opposed to defensive), ego functions. We have attempted to address both. Our hope is that this book will contribute to a more inclusive and, in some cases, a more effective approach to the multifaceted and complex challenges facing a psychotherapist.

GLOSSARY

Countertransference: Strictly speaking, the therapist’s emotional (not always conscious) response to the patient’s transference. Sometimes it is used to mean more generally a therapist’s emotionally motivated, not rational, attitude to the patient. Drives: Psychic motivational forces serving the elementary needs of the organism, i.e., survival and reproduction. Freud’s German “Trieb” was originally translated as “instinct”; today most analysts prefer the term “drive”, since “instinct” has a specific and different meaning in biology. In his later works Freud distinguished two basic drives operating in all living organisms: the libido, i.e., the sexual or the “life instinct”, and the destructive, or the “death instinct”. Ego: In Freud’s works initially synonymous with Self (the “I”), later came to refer more to the complex of mental functions (i.e., a “psychic structure”) serving adaptation (e.g., perception, memory) and internal stability (e.g., repression, affect regulation). In this book the term is used in the latter sense.

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Ego-dystonic: A wish or a thought that the subject finds objectionable and tries to disown (e.g., an intrusive thought of aggressive or sexual content). Ego-syntonic: A psychic process (such as a wish or action) that is acceptable to the subject himself. Insight: (a) In psychiatry: an awareness of being ill. (b) In psychoanalysis: an understanding of the (previously) unconscious motivation for a symptom or a maladaptive behaviour. Narcissism: Self-love, in Freud’s terms, “the cathexis (attachment) of the libido to the self, as opposed to ‘object love’”. Initially considered a sign of emotional immaturity, more recently most analysts recognize the need of a healthy, adaptive narcissism (provided it is not accompanied by failure of object love). Projection: Attributing to the outside world, usually to another person, a negative attribute of the subject himself, e.g., a malevolent intention, or improper sexual attraction. Psycho-sexual development: Freud assumed the existence of the following stages of emotional development: a. The oral stage, corresponding to the first year of life (infancy), when the emotional (or instinctual) life of the infant is centred on providing relief from hunger (and the person providing it) and sucking as discharge of instinctual tension. b. The anal stage, corresponding to the second year and part of the third year (toddlerhood), when control of the sphincters and parental demands for cleanliness dominate the instinctual life and the interpersonal relations. c. The Oedipal stage, until the end of the fifth or sixth year, during which the child becomes more aware of his or her sex and typically becomes more attached to the parent of the opposite sex, while feeling competitive toward the parent of the same sex. Those relationships often reverse, sometimes temporarily, sometimes persistently. d. Latency stage, from the end of the Oedipal stage until puberty. During that stage the sexual drive, in Freud’s view, abates and intellectual and social interests become dominant.

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Freud’s outline has since been greatly modified, as a result of child therapy and systematic observations, as can be seen in Chapters Two and Five. Split: Sometimes used to describe an unconscious, ego-dystonic and disowned (“split-off”) part of the subject’s personality, sometimes used to denote a tendency to unrealistically experience other people as either all bad or all good (demonization and idealization). Super-ego: A psychic agency whose function is to restrain the drives and assure an individual’s adaptation to social norms. It is formed by the internalization of parental prohibitions and guidance (and later those of other important persons) and represents the moral values of the society. Freud assumed that its critical development occurs with the resolution of the Oedipus complex (around the age of five), but many analysts believe it develops much earlier. Freud believed that the moral code developed as a result of civilization (“moral relativity”), but today many biologists tend to assume the existence of an evolutionally determined predisposition to inhibitions and moral principles, at least in social animals. Therapeutic alliance: The rational aspect of a positive relationship between therapist and patient, reflecting common purpose and based on trust. Transference: A patient’s relating to the therapist in a way that is a repetition of his or her childhood relationship with a parent (or another important person), often not congruent with the reality of the situation.

REFERENCES

Abel, E. L. (2004). Paternal contribution to fetal alcohol syndrome. Addiction Biology, 9: 127–133. Ainsworth, M. D. S. (1982). Attachment: Retrospect and prospect. In: Parkes, C. M. & Stevenson-Hinde, J. (Eds.), The Place of Attachment in Human Behavior (pp. 3–30). New York, NY: Basic Books. Ainsworth, M. D. S., Blehar, M. C., Waters, E. & Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum Associates. Aleksandrowicz, D. R. (2009). Mastery, aggression and narcissism: A contribution to psychoanalytic drive theory. Archives of Psychiatry and Psychotherapy, 2: 13–21. Aleksandrowicz, D. R. & Aleksandrowicz, M. K. (1989). Developmental Deviations and Personality. New York, NY: Gordon & Breach. Aleksandrowicz, D. R., Davis, M. & Aleksandrowicz, M. K. (1990). Selfesteem in learning-disabled children. Presented at the 12th International Congress of the International Association for Child and Adolescent Psychiatry and Allied Professions, Kyoto, Japan, June 16–20. Aleksandrowicz, M. K. (1975a). The biological strangers: An attempted suicide of a seven-and-a-half year old girl. Bulletin of the Menninger Clinic, 39: 163–176.

233

234

REFERENCES

Aleksandrowicz, M. K. (1975b). The little prince: Psychotherapy of a boy with borderline personality structure. International Journal of Psychoanalytic Psychotherapy, 4: 410–425. Aleksandrowicz, M. K. & Aleksandrowicz, D. R. (1974). Obstetrical pain-relieving drugs as predictors of infant behavior variability. Child Development, 45: 935–946. Aleksandrowicz, M. K. & Aleksandrowicz, D. R. (1975). The molding of personality: A newborn’s innate characteristics in interaction with parents’ personalities. Child Psychiatry and Human Development, 5: 231–241. Aleksandrowicz, M. K. & Aleksandrowicz, D. R. (1976). Precursors of ego in neonates: Factor analysis of Brazelton Scale data. Journal of the American Academy of Child Psychiatry, 15: 257–268. Aleksandrowicz, M. K. & Aleksandrowicz, D. R. (1987). The Palm Hill Project: A field experiment in early intervention in a disadvantaged Israeli community. Bulletin of the Menninger Clinic, 51: 133–143. Aleksandrowicz, M. K., Bason, I. & Aleksandrowicz, D. R. (1997). “Tippukhiya”: A place to nurture mothers in Israel. Zero to Three, 17: 52–53. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association. Andrulonis, P. A., Glueck, B. C., Stroebel, C. F. & Vogel, N. G. (1982). Borderline personality subcategories. The Journal of Nervous and Mental Disease, 170: 670–679. Aslin, R. N., Pisoni, D. B., Hennessy, B. L. & Perey, A. J. (1981). Discrimination of voice onset time by human infants: New findings and implications for the effects of early experience. Child Development, 52: 1135–1145. Babcock, T. & Ornstein, C. S. (2009). Comorbidity and its impact in adult patients with attention-deficit/hyperactivity disorder: A primary care perspective. Postgraduate Medicine, 121: 73–82. Bateman, A. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Amercian Journal of Psychiatry, 166: 1355–1364. Bayley, N. (1993). Bayley Scales of Infant Development: Manual (2nd ed.). New York, NY: Psychological Corporation. Bergman, P. & Escalona, S. K. (1949). Unusual sensitivities in very young children. The Psychoanalytic Study of the Child, 4: 333–352. Bieber, I. (1980a). Psychoanalysis—A cognitive process. Journal of the American Academy of Psychoanalysis, 8: 25–38. Bieber, I. (1980b). Cognitive Psychoanalysis. New York, NY: Jason Aronson.

REFERENCES

235

Bion, W. R. (1962). Learning from Experience. London, UK: William Heinemann Medical Books. Bion, W. R. (1970). Attention and Interpretation: A Scientific Approach to Insight in Psycho-analysis and Groups. London, UK: Tavistock. Blum, H. P. (2005). Psychoanalytic reconstruction and reintegration. Psychoanalytic Study of the Child, 60: 295–311. Bobrick, B. (1995). Knotted Tongues: Stuttering in History and the Quest for a Cure. New York, NY: Simon & Schuster. Bonaccorsi, M. (1980). La psicoterapia analitica del bambino organico. Milano, Italy: Emme Edizioni. Bos, A. F., Einspieler, C. & Prechtl, H. F. R. (2001). Intrauterine growth retardation, general movements, and neurodevelopmental outcome: A review. Developmental Medicine & Child Neurology, 43: 61–68. Bowlby, J. (1982). Attachment and Loss, Volume I: Attachment (2nd ed.). New York, NY: Basic Books. Brackbill, Y. (1979). Obstetrical medication and infant behavior. In: Osofsky, J. D. (Ed.), Handbook of Infant Development (pp. 76–125). New York, NY: Wiley and Sons. Brakel, L. A. (2007). Music and primary process: Proposal for a preliminary experiment. American Imago, 64: 37–57. Brazelton, T. B. (1973). Neonatal Behavioral Assessment Scale. Philadelphia, PA: Lippincott. Brazelton, T. B. & Cramer, B. G. (1991). The Earliest Relationship: Parents, Infants and the Drama of Early Attachment. London, UK: Karnac Books. Brazelton, T. B. & Nugent, J. K. (1995). Neonatal Behavioral Assessment Scale (3rd ed.). London, UK: Mac Keith Press. Breuer, J. & Freud, S. (1893–1895). Studies on Hysteria (1893–1895). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 2. London, UK: Hogarth Press; 1957. Bridger, W. H. (1961). Sensory habituation and discrimination in the human neonate. The American Journal of Psychiatry, 117: 991–996. Bridges, K. M. B. (1932). Emotional development in early infancy. Child Development, 3: 324–341. Broucek, F. (1979). Efficacy in infancy: A review of some experimental studies and their possible implication for clinical theory. International Journal of Psycho-Analysis, 60: 311–316. Bucci, W. (1997). Psychoanalysis and Cognitive Science: A Multiple Code Theory. New York, NY: Guilford Press. Carey, W. B. & McDevitt, S. C. (1978). Revision of the Infant Temperament Questionnaire. Pediatrics, 61: 735–739. Chiron, C., Jambaque, I., Nabbout, R., Lounes, R., Syrota, A. & Dulac, O. (1997). The right brain hemisphere is dominant in human infants. Brain, 120: 1057–1065.

236

REFERENCES

Colombo, J. & Fagen, J. (Eds.). (1990). Individual Differences in Infancy: Reliability, Stability, Prediction. Hillsdale, NJ: Lawrence Erlbaum Associates. Conners, C. K., Sitarenios, G., Parker, J. D. A. & Epstein, J. N. (1998a). The revised Conners parent rating scale (CPRS-R): Factor structure, reliability and criterion validity. Journal of Abnormal Child Psychology, 26: 257–268. Conners, C. K., Sitarenios, G., Parker, J. D. A. & Epstein, J. N. (1998b). Revision and restandardization of the Conners teacher rating scale (CTRS-R): Factor structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26: 279–291. Coopersmith, S. (1967). The Antecedents of Self-Esteem. San Francisco, CA: W. H. Freeman. Damasio, A. (1999). The Feeling of What Happens: Body and Emotion in the Making of Consciousness. San Diego, CA: Harcourt. Denhoff, E. (1981). Current status of infant stimulation or enrichment programs for children with developmental disabilities. Pediatrics, 67: 32–37. Dissanayake, E. (2000). Art and Intimacy: How the Arts Began. Seattle, WA & London, UK: University of Washington Press. Doll, E. A. (1953). Vineland Social Maturity Scale: The Measurement of Social Competence: A Manual for the Vineland Social Maturity Scale Minneapolis, MI: Educational Test Bureau, Educational Publishers. Edwards, C., Gandini, L. & Forman, G. (1995). The Hundred Languages of Children: The Reggio Emilia Approach to Early Childhood Education. Norwood, NJ: Ablex. Elliott, F. A. (1982). Neurological findings in adult minimal brain dysfunction and the dyscontrol syndrome. The Journal of Nervous and Mental Disease, 170: 680–687. Emde, R. N. (1988). Development terminable and interminable. II. Recent psychoanalytic theory and therapeutic considerations. International Journal of Psycho-Analysis, 69: 283–296. Erikson, E. H. (1963). Childhood and Society (2nd ed.). New York, NY: W. W. Norton. Erikson, E. H. (1979). Dimensions of a New Identity: The Jefferson Lectures in the Humanities. New York, NY: W. W. Norton & Company. Escalona, S. K. (1969). The Roots of Individuality: Normal Patterns of Development in Infancy. Chicago, IL: Aldine. Faraone, S. V., Glatt, S. J. & Tsuang, M. T. (2003). The genetics of pediatric-onset bipolar disorder. Biological Psychiatry, 53: 970–977.

REFERENCES

237

Farber, B. A. & Heifetz, L. J. (1982). The process and dimensions of burnout in psychotherapists. Professional Psychology, 13: 293–301. Felthous, A. R. & Kellert, S. R. (1987). Childhood cruelty to animals and later aggression against people: A review. American Journal of Psychiatry, 144, 710–717. Feuerstein, R. (1979). Ontogeny of learning. In Brazier, M. T. (Ed.), Brain Mechanisms in Memory and Learning: From the Single Neuron to Man (pp. 361–372). New York, NY: Raven Press. Fox, N. & Calkins, S. D. (2003). The development of self-control of emotion: Intrinsic and extrinsic influences. Motivation and Emotion, 27: 7–26. Freud, A. (1936). The Ego and the Mechanisms of Defense. London, UK: Karnac; 1992. Freud, S. (1900). The Interpretation of Dreams. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 5. London, UK: Hogarth Press; 1953. Freud, S. (1905). Three Essays on the Theory of Sexuality. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 7 (pp. 123–246). London, UK: Hogarth Press; 1953. Freud, S. (1914). On Narcissism: An Introduction. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14 (pp. 67–102). London, UK: Hogarth Press; 1974. Freud, S. (1915). Instincts and Their Vicissitudes. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14 (pp. 109–140). London, UK: Hogarth Press; 1957. Freud, S. (1916). Some Character-Types Met With in Psycho-Analytic Work. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14 (pp. 309–333) London, UK: Hogarth Press; 1974. Freud, S. (1918). From the History of an Infantile Neurosis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 17 (pp. 1–124). London, UK: Hogarth Press; 1955. Freud, S. (1923). The Ego and the Id. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19 (pp. 1–66). London, UK: Hogarth Press; 1961. Freud, S. (1937). Analysis Terminable and Interminable. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 23 (pp. 209–254). London, UK: Hogarth Press; 1964. Freud, S. (1940). An Outline of Psycho-Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 23 (pp. 139–208). London, UK: Hogarth Press; 1964.

238

REFERENCES

Fries, M. E. & Woolf, P. J. (1953). Some hypotheses on the role of the congenital activity type in personality development. The Psychoanalytic Study of the Child, 8: 48–62. Froehlich, T. E., Lanphear, B. P., Epstein, J. N., Barbaresi, W. J., Katusic, S. K. & Kahn, R. S. (2007). Prevalence, recognition, and treatment of AttentionDeficit/Hyperactivity Disorder in a national sample of US children. Archives of Pediatrics and Adolescent Medicine, 161: 857–864. Fuster, J. M. (2001). The prefrontal cortex—An update: Time is of the essence. Neuron, 30: 319–333. Gartstein, M. A. & Rothbart, M. K. (2003). Studying infant temperament via the Revised Infant Behavior Questionnaire. Infant Behavior and Development, 26: 64–86. Gelman, S. A. & Markman, E. M. (1986). Categories and induction in young children. Cognition, 23: 183–209. Greenbaum, H. (1985). The role of learning in the psychoanalytic relationship. Journal of the American Academy of Psychoanalysis, 13: 1–14. Gunderson, J. G. (2008). Borderline Personality Disorder: An overview. Social Work in Mental Health, 6: 5–12. Gunderson, J. G. & Singer, M. T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry, 132: 1–10. Hardt, J. & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood experiences: Review of the evidence. Journal of Child Psychology and Psychiatry, 45: 260–273. Hartmann, H. (1939). Ich-Psychologie und Anpassungsproblem. Internationale Zeitschrift für Psychoanalyse und ‘Imago’, 24: 62–135. Hartmann, H. (1961). Ego Psychology and the Problem of Adaptation, translated by Rapaport, D. New York, NY: International Universities Press. Hawthorne, N. (1843). The birthmark. In: The Complete Short Stories of Nathaniel Hawthorne (pp. 227–238). Garden City, NY: Doubleday; 1959. Hazen, R. M. (2005). Genesis: The Scientific Quest for Life’s Origin. Washington, DC: Joseph Henry Press (NAP). Hendrick, I. (1942). Instinct and the ego during infancy. The Psychoanalytic Quarterly, 11: 33–57. Hendrick, I. (1943). Work and the pleasure principle. The Psychoanalytic Quarterly, 12: 311–329. Herman, J. L., Perry J. C. & van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146: 490–495. Johnstone, B., Hexum, C. L. & Ashkanazi, G. (1995). Extent of cognitive decline in traumatic brain injury based on estimates of premorbid intelligence. Brain Injury, 9: 377–384.

REFERENCES

239

Judd, P. H. (2005). Neurocognitive impairment as a moderator in the development of Borderline Personality Disorder. Development and Psychopathology, 17: 1173–1196. Kanner, L. (1973). Childhood Psychosis: Initial Studies and New Insights. Oxford, UK: V. H. Winston & Sons. Kaplan-Solms, K. & Solms, M. (2000). Clinical Studies in NeuroPsychoanalysis. London, UK: Karnac. Kaufman, A. S. & Kaufman, N. L. (2009). Kaufman Assessment Battery for Children, Second Edition. San Antonio, TX: Pearson. Kermoian, R. & Campos, J. J. (1988). Locomotor experience: A facilitator of spatial cognitive development. Child Development, 59: 908–917. Kernberg, O. (1968). The treatment of patients with borderline personality organization. International Journal of Psycho-Analysis, 49: 600–619. Kernberg, O. F. (1984). Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT: Yale University Press. Kernberg, O. F., Yeomans, F. E., Clarkin, J. F. & Levy, K. N. (2008). Transference focused psychotherapy: Overview and update. The International Journal of Psycho-Analysis, 89: 601–620. Kernberg, P., Weiner, A. S. & Bardenstein, K. K. (2000). Personality Disorders in Children and Adolescents. New York, NY: Basic Books. Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Faraone, S. V., Greenhill, L. L., Howes, M. J., Secnik, K., Spencer, T., Ustun, T. B., Walters, E. E. & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. The American Journal of Psychiatry, 163: 716–723. Kestenberg, J. S., Marcus, H., Robbins, E., Berlowe, J. & Buelte, A. (1971). Development of the young child as expressed through bodily movement. Journal of the American Psychoanalytic Association, 19: 746–764. Key, E. (1911). The Century of the Child. New York, NY: G. P. Putnam. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psycho-analysis, 27: 99–110. Koester, L. S., Papousek, H. & Papousek, M. (1989). Patterns of rhythmic stimulation by mothers with three-month-olds: A cross-modal comparison. International Journal of Behavioral Development, 12: 143–154. Kohut, H. (1971). The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. New York, NY: International Universities Press. Kohut, H. (1977). The Restoration of the Self. New York, NY: International Universities Press. Korner, A. F. (1964). Some hypotheses regarding the significance of individual differences at birth for later development. Psychoanalytic Study of the Child, 19: 58–72.

240

REFERENCES

Korner, A. F. (1971). Individual differences at birth: Implications for early experience and later development. American Journal of Orthopsychiatry, 41: 608–619. Korner, A. F. & Grobstein, R. (1967). Individual differences at birth: Implications for mother-infant relations and later development. Journal of the American Academy of Child Psychiatry, 6: 676–690. LeDoux, J. (2003). The emotional brain, fear, and the amygdala. Cellular and Molecular Neurobiology, 23: 727–738. Levitt-BinNun, N. (2009). The development of the Self, the importance of stability and balance: A model integrating brain dynamics and clinical insights. Presented at the Israeli Forum for Neuro-Psychoanalysis, in Tel Aviv, Israel, May 22. Levy, R. (2009). The Unique Child: A Therapeutic Privilege and Challenge (in Hebrew). Jerusalem, Israel: Ashalim. Lichtenberg, J. D. (1983). Psychoanalysis and Infant Research. Hillsdale, NJ: Lawrence Erlbaum Associates. Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press. Linehan, M. M. (1997). Validation and psychotherapy. In: Bohart, A. C. & Greenberg, L. S. (Eds.), Empathy and Psychotherapy: New directions to Theory, Research, and Practice. Washington, DC: American Psychological Association. Liss, E. (1955). Motivations in learning. Psychoanalytic Study of the Child, 10: 100–116. Loden, S. (2001). Report on the Second International Neuro-Psychoanalysis Congress: Neuroscientific and psychoanalytic perspectives on memory, New York Academy of Medicine, 20 to 22 April, 2001. Neuropsychoanalysis, 3: 263–265. Loftus, E. F. (1993). The reality of repressed memories. American Psychologist, 48: 518–537. Loftus, E. F. (1997). Creating false memories. Scientific American, 277: 70–75. Logothetis, N. K. (2008). What we can do and what we cannot do with fMRI. Nature, 453: 869–878. Logothetis, N. K., Pauls, J., Augath, M., Trinath, T. & Oeltermann, A. (2001). Neurophysiological investigation of the basis of the fMRI signal. Nature, 412: 150–157. Lorenz, K. (1966). On Aggression. San Diego, CA: Harcourt Brace. Luria, A. R. (1963). Restoration of Function after Brain Injury. New York, NY: Macmillan. Mahler, M., Pine, F. & Bergman, A. (1975). The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York, NY: Basic Books; 2000.

REFERENCES

241

Massey, I. (1990). Freud before Freud: K. A. Scherner (l825–l889). Centennial Review, 34: 567–576. McCall, R. B. (1974). Exploratory Manipulation and Play in the Human Infant. Monographs of the Society for Research in Child Development (No. 155, Vol. 39(2)). Chicago, IL: University of Chicago Press. McCormick, M. C., Brooks-Gunn, J., Buka, S. L., Goldman, J., Yu, J., Salganik, M., Scott, D. T., Bennett, F. C., Kay, L. L., Bernbaum, J. C., Bauer, C. R., Martin, C., Woods, E. R., Martin, A. & Casey, P. H. (2006). Early intervention in low birth weight premature infants: Results at 18 years of age for the Infant Health and Development Program. Pediatrics, 117: 771–780. McDevitt, J. B. (1983). The emergence of hostile aggression and its defensive and adaptive modification during the separation-individuation process. Journal of the American Psychoanalytic Association, 31S: 273–298. McGraw, M. B. (1935). Growth: A Study of Johnny and Jimmy. New York, NY: Appleton. McGuffin, P., Riley, B. & Plomin, R. (2001). Genomics and behavior. Toward behavioral genomics. Science, 291: 1232–1249. Mendelson, W., Johnson, N. & Stewart, M. (1971). Hyperactive children as teenagers: A follow-up study. The Journal of Nervous and Mental Disease, 153: 273–279. Meynert, T. (1868). Neue Untersuchungen über den Bau der Grosshirnrinde und ihre örtlichen Verschiedenheiten. Allgemeiner Wiener medizinische Zeitung, 13: 419–428. Meynert, T. (1890). Klinische Vorlesungen über Psychiatrie. Vienna, Austria: Braunmüller. Milad, M. R. & Quirk, G. J. (2002). Neurons in medial prefrontal cortex signal memory for fear extinction. Nature, 420: 70–74. Milad, M. R., Rauch, S. L., Pitman, R. K. & Quirk, G. J. (2006). Fear extinction in rats: Implications for human brain imaging and anxiety disorders. Biological Psychology, 73: 61–71. Milgram, N., Siwak-Tapp, C., Araujo, J. & Head, E. (2006). Neuroprotective effects of cognitive enrichment. Ageing Research Reviews, 5: 354–369. Miller, A. (1998). Thou Shalt Not Be Aware: Society’s Betrayal of the Child, translated by Hannum, H. & Hannum, H. New York, NY: Farrar Straus and Giroux (originally published in German in 1981). Mitchell, S., Aron, L., Harris, A. & Suchet, M. (Eds.) (2007). Relational Psychoanalysis. New York, NY: Routledge. Molfese, V. J. & Molfese, D. L. (Eds.). (2000). Temperament and Personality Development Across the Life Span. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

242

REFERENCES

Morgan, W. (2003). Non-targeted and delayed effects of exposure to ionizing radiation: II. Radiation-induced genomic instability and bystander effects in vivo, clastogenic factors and transgenerational effects. Radiation Research, 159: 581–596. Murphy, G. (1956). Affect and perceptual learning. The Psychological Review, 63: 1–15. Murray, M. E. (1979). Minimal brain dysfunction and borderline personality adjustment. American Journal of Psychotherapy, 33: 391–403. Nietzsche, F. (1901). The Will to Power, translated by Kaufmann, W. New York, NY: Random House; 1967. Noy, P. A. (1969). Revision of the psychoanalytic theory of the primary process. International Journal of Psycho-Analysis, 50: 155–178. Orgel, L. E. (1973). The Origins of Life: Molecules and Natural Selection. Hoboken, NJ: Wiley. Osofsky, J. D. & Danzger, B. (1974). Relationships between neonatal characteristics and mother-infant interaction. Developmental Psychology, 10: 124–130. Palombo, J. (1979). Perceptual deficits and self-esteem in adolescence. Clinical Social Work Journal, 7: 34–61. Palombo, J. (2001). Learning Disorders and Disorders of the Self in Children and Adolescents. New York, NY: W. W. Norton. Panksepp, J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. New York, NY: Oxford University Press. Panksepp, J. (2007). Can PLAY diminish ADHD and facilitate the construction of the social brain? Journal of the Canadian Academy of Child and Adolescent Psychiatry, 16: 57–66. Papousek, H. & Bernstein, P. (1969). The functions of conditioning stimulation in human neonates and infants. In: Ambrose, A. (Ed.), Stimulation in Early Infancy (pp. 229–252). London, UK: Academic Press. Papousek, H. & Papousek, M. (1983). Biological basis of social interactions: Implications of research for an understanding of behavioural deviance. Journal of Child Psychology and Psychiatry and Allied Disciplines, 24: 117–129. Papousek, M. (2007). Communication in early infancy: An arena of intersubjective learning. Infant Behavior and Development, 30: 258–266. Paquette, V., Lévesque, J., Mensour, B., Leroux, J. -M., Beaudoin, G., Bourgouin, P. & Beauregard, M. (2003). “Change the mind and you change the brain”: Effects of cognitive-behavioral therapy on the neural correlates of spider phobia. NeuroImage, 18: 401–409. Parens, H. (1979). The Development of Aggression in Early Childhood. New York, NY: J. Aronson.

REFERENCES

243

Pereira, A. & Smith, L. B. (2009). Developmental changes in visual object recognition between 18 and 24 months of age. Developmental Science, 12: 67–80. Person, E. S. (1993). Male sexuality and power. In: Glick, R. A. & Roose, S. P. (Eds.), Rage, Power and Aggression (pp. 29–44). New Haven, CT: Yale University Press. Pines, M. (1984). Reflections on mirroring. International Review of PsychoAnalysis, 11: 27–42. Piontelli, A. (1987). Infant observation from before birth. International Journal of Psychoanalysis, 68: 453–463. Piontelli, A. (1992). From Fetus to Child: An Observational and Psychoanalytic Study. London, UK: Routledge. Prechtl, H. F. R. (1990). Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Human Development, 23: 151–158. Prechtl, H. F. R. & Einspieler, C. (1997). Is neurological assessment of the fetus possible? European Journal of Obstetrics & Gynecology and Reproductive Biology, 75: 81–84. Przybylski, A. K., Ryan, R. M. & Rigby, C. S. (2009). The motivating role of violence in video games. Personality and Social Psychology Bulletin, 35: 243–259. Quirk, G. J., Garcia, R. & González-Lima, F. (2006). Prefrontal mechanisms in extinction of conditioned fear. Biological Psychiatry, 60: 337–343. Rapaport, D. (1967). Collected Papers. New York, NY: Basic Books. Resnick, S., Goodman, M., New, A. & Siever, L. (2005). Recent findings and future approaches to the study of impulsive aggression and affective instability. In Reich, J. (Ed.), Personality Disorders: Current Research and Treatments (pp. 43–74). New York, NY: Routledge. Rochlin, G. (1973). Man’s Aggression: The Defense of the Self. Boston, MA: Gambit. Rothbart, M. K. (1981). Measurement of temperament in infancy. Child Development, 52: 569–578. Rothstein, A. A. & Glenn, J. (1999). Learning Disabilities and Psychic Conflict: A Psychoanalytic Casebook. Madison, CT: International Universities Press. Rowling, J. K. (1997). Harry Potter and the Philosopher’s Stone. London, UK: Bloomsbury. Saint-Exupery, A. (1943). The Little Prince. New York, NY: Reynal & Hitchcock. Salten, F. (1928). Bambi: A Life in the Woods. (Cooney, B. Illustrator & Chambers, W. Trans.). New York, NY: Simon and Schuster; 1988.

244

REFERENCES

Schmahl, C. & Bremner, J. D. (2006). Neuroimaging in borderline personality disorder. Journal of Psychiatric Research, 40: 419–427. Schore, A. N. (1996). The experience-dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology, 8: 59–87. Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment and Human Development, 2: 23–47. Schore, A. N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22: 201–269. Schore, A. N. (2003). The human unconscious: The development of the right brain and its role in early emotional life. In: Green, V. (Ed.), Emotional Development in Psychoanalysis, Attachment Theory, and Neuroscience: Creating Connections (pp. 23–54). New York, NY: BrunnerRoutledge. Schuez, A. (1978). Some facts and hypotheses concerning dendritic spines and learning. In: Brazier, M. A. B. & Petsche, H. (Eds.), Architectonics of the Cerebral Cortex (pp. 129–135). New York, NY: Raven. Schwartz, J. M. (1998). Neuroanatomical aspects of cognitive-behavioural therapy response in obsessive-compulsive disorder. An evolving perspective on brain and behaviour. The British Journal of Psychiatry. Supplement: 38–44. Segal, H. (1989). Klein. London, UK: Karnac. Service, R. (2001). The spell of the Yukon. In: The Best of Robert Service (p. 3). Toronto, Canada: McGraw-Hill. Shamay-Tsoory, S. G., Aharon-Peretz, J. & Perry, D. (2009). Two systems for empathy: A double dissociation between emotional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain, 132: 617–627. Shearin, E. N. & Linehan, M. M. (1994). Dialectical behavior therapy for borderline personality disorder. Acta Psychiatrica Scandinavica, 89: 61–68. Shevrin, H. (2002). A psychoanalytic view of memory in the light of recent cognitive and neuroscience research. Neuropsychoanalysis, 4: 131–139. Shuttleworth, J. (1989). Psychoanalytic theory and infant development. In: Miller, L., Rustin, M., Rustin, M. & Shuttleworth, J. (Eds.), Closely Observed Infants (pp. 22–51). London, UK: Duckworth. Siegel, D. J. (2006). An interpersonal neurobiology approach to psychotherapy: Awareness, mirror neurons and neural plasticity in the development of well-being. Psychiatric Annals, 36: 248–258.

REFERENCES

245

Simpson, D. & Miller, L. (2004). Unexpected Gains: Psychotherapy with People with Learning Disabilities. London, UK: Karnac. Small, L. (1973). Neuropsychodiagnosis in Psychotherapy. New York, NY: Brunner-Mazel. Solms, M. & Turnbull, O. (2002). The Brain and the Inner World. London, UK: Karnac. Sporns, O., Chialvo, D. R., Kaiser, M. & Hilgetag, C. C. (2004). Organization, development and function of complex brain networks. Trends in Cognitive Sciences, 8: 418–425. Stechler, G. (1982). The dawn of awareness. Psychoanalytic Inquiry, 1: 503–532. Stern, D. N. (1977). The First Relationship: Mother and Infant. Cambridge, MA: Harvard University Press. Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York, NY: Basic Books. Thelen, E. & Smith, L. B. (1994). A Dynamic Systems Approach to the Development of Cognition and Action. Cambridge, MA: The MIT Press. Thomas, A. & Chess, S. (1977). Temperament and Development. New York, NY: Brunner & Mazel. Thomas, A., Chess, S. & Birch, H. G. (1968). Temperament and Behavior Disorders in Children. New York, NY: New York University Press. Voeller, K. K. (1986). Right-hemisphere deficit syndrome in children. American Journal of Psychiatry, 143: 1004–1009. Wechsler, D. (2003). The Wechsler Intelligence Scale for Children—Revised (3rd ed.). San Antonio, TX: The Psychological Corporation. Weil, A. P. (1978). Maturational variations and genetic-dynamic issues. Journal of the American Psychoanalytic Association, 26: 461–491. Weil, A. P. (1981). Anxiety in childhood: Developmental and psychopathological considerations. In: Anthony, J. E. & Gilpin, D. C. (Eds.), Three Further Clinical Faces of Childhood (pp. 135–149). New York, NY: Spectrum. Weiss, G., Hechtman, L. & Perlman, T. (1978). Hyperactives as young adults: School, employer, and self-rating scales obtained during ten-year follow-up evaluation. American Journal of Orthopsychiatry, 48: 438–445. Werner, E. A., Myers, M. M., Fifer, W. P., Cheng, B., Fang, Y., Allen, R. & Monk, C. (2007). Prenatal predictors of infant temperament. Developmental Psychobiology, 49: 474–484. White, R. W. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66: 297–333.

246

REFERENCES

Wilson, S. A. K. (1923). Pathological laughing and crying. Proceedings of the Royal Society of Medicine, 16: 39–40. Winnicott, D. W. (1967). Mirror-role of mother and family in child development. In: Lomas, P. (Ed.), The Predicament of the Family: A PsychoAnalytical Symposium (pp. 26–33). London, UK: Hogarth Press and the Institute of Psycho-analysis. Wolff, P. H. (1966). The causes, controls and organization of behavior in the neonate. Psychological Issues, 5: 1–105. Youell, B. (2006). The Learning Relationship: Psychoanalytic Thinking in Education. London, UK: Karnac. Young, J. E. (1999). Cognitive Therapy for Personality Disorders: A Schema Focused Approach. Sarasota, FL: Professional Resource Press. Yovell, Y. (2009). Neuropsychoanalysis: Who needs it? Paper presented at the International Neuropsychoanalysis Congress 2009, Paris, France, June 27–28.

INDEX

infusion of 80 organization of the expression of 28 pleasure-related manifestations of 201 aggressive sadistic fantasies 5 Aleksandrowicz, D. R. 20, 26–27, 37–38, 57, 103 Aleksandrowicz, M. K. 20, 27, 36–38, 57, 81, 100, 103, 145 alerting response 37 Alzheimer’s disease 134 American psychiatric association 91 amygdala–hippocampus–orbito– frontal circuit 223 antisocial behaviour 95 anxiety 7, 36, 38, 48–52, 61–65, 68, 74, 76–77, 88, 90–92, 101–102, 105, 107–108, 110, 119, 125, 130–131, 133–134, 151, 163–164, 170, 172–174, 180, 188, 212, 221–222, 228

acceptance 15, 85, 144, 195 acrophobia 92 action plans 56 adaptive ego functions 109, 150, 204, 228 adaptive slowness 39 adolescence 45, 80, 82, 84–85, 117–119, 169, 190, 224 developmental objectives of 84–85 adulthood 41, 43, 61, 63, 82, 91, 121, 133–138 adultomorphic expression 25 affect-driven behaviours 225 affective flooding 47–48 affect-modulating complex 75 aggression 14, 86, 88, 90, 98, 115, 118, 143, 149–150, 174, 178, 181, 200–203, 205–206, 208–210 competitive 203 excessive 81 fusion mobilized 15

247

248

INDEX

ego-deficiency 222 ego-disintegration 221 paranoid and depressive 221 psychoneurotic 221 anxiety-inducing stimulus 62 art therapy 177 attention deficit disorder (ADD) 42, 44, 83, 132–133, 143 attention deficit hyperactivity conduct disorder (ADHCD) 177 art therapy of 177 attention deficit hyperactivity disorder (ADHD) 33–34, 41, 45, 48, 85, 93, 116, 127–129, 175, 177, 180, 182, 186, 220 adult 45 behavioural symptoms 182 Conners rating scale 123 emotional effects of 158–159 prevalence of 175 psychotherapy of girl with 153 syndrome 45, 155, 157 autistic spectrum disorders 33 Bader, Douglas 69 behavioural idiosyncrasies 137 behavioural maladaptation 33 behavioural response 78 behavioural syndrome 220 Bender-Gestalt 49–50 test 50, 134 Bergman, P. 17, 24–25, 27–28, 37, 59, 73, 110 bewildering array of problems 188 bipolar disorder 48 block design and picture arrangement 134 borderline personality 13, 15, 52, 146–147 organization 173 structure 52 borderline personality disorders

(BPD) 48, 52, 146, 168 formation of 167 neuroimaging studies in 52 psychoanalysis of patient with 167 psychotherapy of 167 regulatory functions 52 syndrome 52 with narcissistic features 171 brain as a network 225 brain imaging techniques 219 Brazelton, T. B. 20–21, 38, 103–104, 191, 206 scale 21 Breuer, J. 161, 212 burnout syndrome 218 caregiver–infant interaction 19 Carmel ability 109 behaviour 107 case 109 differential response 108 intense 109 tolerance 108 categorizing criteria 110 central neural mechanisms 64 chaos theory 53 child accomplishments 195 developmental impairments and idiosyncrasies 195 emotional growth 192 frustration 112 functional ability 195 idiosyncratic needs 187 “imperfections” 195 individuality 190–192 intellectual ability 124 self-experience 63 childish self-aggrandizement 189 chronic schizophrenia 132

INDEX

clinical psychological tests 134 cognition 26, 28–29, 53, 56, 78, 82–83, 124, 158, 189, 208, 211–212 in psychoanalysis and psychotherapy 211 cognitive and emotional inflexibility 85–86 cognitive behavioural therapy (CBT) 131, 213, 223 cognitive detours 90 cognitive empathy 41, 158, 173, 220 cognitive idiosyncrasies 137 cognitive organization 56, 59, 75, 110 cognitive psychoanalysis 212 cognitive psychological test 131 cognitive stimulation 141 compensatory mechanisms 151 complementary series model 35 conflict-free ego zone 204 Conners rating scale 123 constitutionally defective individuals 20 coping mechanisms 69, 147 countertransference 218, 231 crying-demanding pattern 108 CT 219 Dean, James 85 defence mechanisms 11, 13, 62, 87–88, 90–91, 98, 173–174 defensive manoeuvres 87 Demosthenes 89, 141 despised self-representation 88 detours 90, 141–142, 182, 187, 194 detoxification 170 developmental aberrations 76, 175, 224, 227 developmental deviations clinical manifestations 33 clinical neurological examination 126

249

diagnosis of 121 diagnostic assessment of school-age child 123 diagnostic assessment of trouble-making child 123 discussion of 42–44 effect of deviations on progression of developmental stages 73 emotional effects of 55, 64–71 interferences 84–85 physical impairments 64–71 developmental idiosyncrasy/ idiosyncrasies 22, 35, 43, 52, 123, 133, 137, 140, 144–145, 150, 187, 190, 227–228 diagnosis 137 children’s 190 developmental individuality 20–22, 36, 137, 163, 227, 229 developmental “matrix” 23–30 synchronization of development 23 developmental psychology 58 developmental stages 23 aggressive discharge 78 attachment stage 73–75 autonomy stage 75–79 Oedipal stage 79–82 developmentally informed psychoanalysis 168 psychotherapy 145, 158, 175, 178, 228 reconstruction 163 developmentally informed therapy 139, 213, 216 psychoanalytic 158 dialectic behaviour therapy 158, 167 disappearing act 28 Dror 93–94, 123, 139 dual-drive conflict theory 206 dysregulation of sensory 63

250

INDEX

early and middle childhood 122–133 early development and developmental matrix 17 developmental individuality 20–22 EEG tracing 219 ego deficiencies 48 ego difficulties, cognitive and integrative 51 ego disintegration anxiety 221 ego function, effective operation of 26, 192 ego-alien wish 62 ego-deficiency anxiety 62, 221–222 ego-dystonic identification 232 ego-ideal 81 ego-integrative functions 175 ego-syntonic identification 81, 232 emotional development 1, 17–18, 20, 28, 31, 33–34, 42, 55–57, 69–70, 73–75, 79, 101, 109, 139, 143, 147, 175, 188, 193, 232 harm done to 143–152 emotional lability of brain-injured patients 48 emotional maturation 82 emotional process 41, 158 emotional resonance 100 environmental traumatization 52 episodic dyscontrol syndrome 91 Evangelist’s injunction 70 Evelyn D. 133–135, 142 emotional immaturity and instability 135 examination-anxiety 130 excitability 21, 105 father–daughter relationship 106 feedback-reward system 75 fMRI 126, 219

Freud, S. 17, 58, 81–82, 86–88, 150, 161, 171, 174, 198–199, 203–204, 208, 211–212, 216, 222, 225, 231–233 Analysis Terminable and Interminable 35 analytic reconstruction 44 approach to symbolism 216 body ego 26 defence mechanisms 87 ego 231 groundbreaking idea 211 psychosexual development 73 retraction 162 frustrations 29, 39, 43, 55–56, 59, 96–97, 129, 153–154 GABA 222 Gaza operation 93 Georgina’s birthmark 147 Giselle academic performance 156 behaviour 154 developmental and medical history 154 Dinosaur game 156 family relationships 157 initial enthusiasm 154 parents 154 practicing motherhood 157 social skills 158 tamed dinosaurs 153 global response 78 great white hunter 167 growth-promoting effect 56 Gunderson, J. G. 167–171 neurological consultation 170 habituation 20, 37, 104 hallucinatory gratification 82 Harry Potter 96 Hawthorne, N. 146

INDEX

Hayworth, S. 112 healthy narcissism 58, 63, 111, 151 higher executive functions 58, 61, 225 human aggression 200 hyper-irritable child 108 hyperkinetic children 45, 61, 84, 91 hypersensitive infants 37 hypothyroidism 122 idealizing transference 171 idiosyncratic development 1, 33–34, 55, 99–100, 122, 190 cognitive and emotional 190 comforting 102–105 emotional resonance 100–102 raising a child with 99 idiosyncratic temperamental traits 101 impulse dyscontrol, coping with affect 88, 90 incurable psychopath 170 individual psychotherapy 95 individuation 25, 28, 59, 108 infancy and toddlerhood 121–122 infant as active agent 18–19 infant–caregiver relationship 27, 47, 53, 100, 213, 215, 220, 227 empathy 220–221 infant development (ontogenesis) 206–208 infant temperament and development 122 infant’s perceptual system 24 infant–mother relationship 73, 174 infant–parent bond 111 inferior frontal gyrus 41 integrative ego difficulties 51 intermittent explosive disorder 91 international neuropsychoanalysis congress 222

251

interpersonal relationship problems 158 intractable hypersensitivity 70 intra-psychic conflict 51, 62 Israeli air force academy 1 Italian strike 40 Kaufman assessment battery for children 126 Kenny N. 127–128 case 129 suicide attempts 128 Kernberg, O. F. 13, 15, 52, 58, 74, 154, 167, 173 psychoanalytic theory 58 theory 58 Klein, M. 221 Koester, L. S. 19, 111 Kohut, H. 57–58, 171, 200–201 lags and impairments 41–42, 166 language barrier 23 learner–teacher relationship 218 learning disability 51–52, 83, 96, 113–114, 117, 133, 136, 169 learning-disabled children 57, 60, 136, 141, 145 less-than-optimal brain development 34 libidinal energy 203 libido and aggression 205–206, 210 Lillian 22, 112 locus of internal control 217 Mahler, M. 17, 24–25, 27–28, 59, 73, 78, 110 major affective disorder 132 maladaptive behaviours 151, 158, 224 maladaptive development, coping 87–88

252

INDEX

Mann, D. 112 masculinity 8, 10, 15, 66, 68, 181 masochistic character traits 64 mastery 26, 56–57, 59, 80, 83, 97, 110, 197–205, 207–210, 214, 217, 223 “matrix” model 192 matter-antimatter theory 206 mature ego 163 Maya’s developmental history 132 McGuffin, P. 20 mental retardation 33, 128 mental-health professional 138 mentalization-based psychotherapy 167 meta-cognition 29 methylphenidate (Ritalin) 93, 128, 131–132, 156, 179 middle childhood 82–84 mild congenital encephalopathy 171, 175 minimal brain dysfunction 3 minimal encephalopathy 167 mini-RNAs 208 mock trials 170 momentary confusion 51 mother–child relationship 151 mother–infant dyadic therapy 187 motor clumsiness 70 motor coordination 25–27, 34, 39, 60, 76, 83, 111–112, 114, 117, 123, 129, 134–135, 143, 149, 164, 175, 180, 213 motor development 22, 28, 31, 35, 43, 56, 59, 75–80, 84, 130–131, 140–141, 164, 193 motor organization 21, 105 MRI 126, 219 Murphy, G. 212 narcissism 14, 26, 57–58, 63, 69–70, 91, 97, 110–111, 151, 155, 195, 197–198, 200–201, 210, 218, 232

parents as “mediators” 110 narcissistic concerns 68 narcissistic gratification 173, 210 narcissistic injury 14, 64, 69, 83, 88, 95–96, 98, 111, 114, 151, 192, 195, 200 coping with 95–98 narcissistic needs 111–115 narcissistic personality 41, 96, 154, 172 features 172 narcissistic protective devices 88, 98 narcissistic vulnerability 63, 68–69, 95, 97, 135, 147 Nazi pseudoscientific philosophy 20 negative self-representation 61, 64, 88, 98 negativism 28, 40, 44, 78–79, 150, 164–165 negativistic behaviour 28, 78, 113 neonatology 121, 188 neurobiological perspective 219 neurobiology of drives 222–223 neuro-cognitive impairments 52 neurological examination 76, 104, 126 neuromuscular system 205 neuropsychological deficiencies 48, 92 neuropsychological deficits 42, 47 of cognition 53 neuropsychological dysfunction 51, 70 neuropsychological impairment 42, 44–45, 47, 49–50, 52, 83, 85, 134–136, 149–150, 189 impulse control and affect modulation 44–48 propensity to anxiety 48–49 rigidity 49–52 neurotransmitters glutamate 222 neutral energy theory 204

INDEX

neutralized energy 203–204 “neutral” psychic energy 204 newborn’s gaze 24 non-adaptive aggression 64, 98 non-affective destructiveness 201–202 non-conventional therapies 113 non-destructive aggression 201 non-responsive to reinforcements 86 Nugent, J. K. 20 object examination protocol 27 obsessive-compulsive disorder 132 occupational therapy 139 Oedipal ambivalence 165 Oedipal challenges 80 Oedipal child 79–80 Oedipal competition 68 Oedipal component 174 Oedipal conflict 10–11, 13, 68 Oedipal fantasy 8 Oedipal love objects 84 ontogenesis 206–208 oppositional defiant disorder 48 oppositional disorder 154, 157 oppositional-defiant behaviour 29 orientation responsiveness 20, 104, 107 orthodox educational system 113 orthodox Jewish family 113, 124 overall functioning concept 124, 126 paediatric movement disorder clinic 75 panic-rages 48 Panksepp, J. 58, 156, 159, 220, 222–223 FEAR system 222 PANIC system 222 Papousek, H. 19, 25–26, 57, 74, 100, 207, 214 Papousek, M. 19, 25, 57, 74, 100

253

paralysing anxiety 51, 170, 173–174 Parens, H. 200–202 parent–child antagonism 195 bond 110 relationship 111, 116, 191 parent counselling and early intervention 185 devising parenting skills 190–192 diagnostic assessment 188–190 improving functions 192–194 promoting well-developed abilities 194–195 using “detours” 194 parent’s narcissistic investment 111 parental behaviour 56, 228 parental expectations 111, 182 parental mediation 110 parental narcissism 111 parental omnipotence 166 parenting response 18–19, 110 passive-aggressive personality 79 relationship 50, 80 resistance 51 style of defence 114 passive hostility 40 patient’s object relationships 151 patient’s temperamental idiosyncrasies 166 patient’s unconscious conflicts 165 patient–therapist relationship 218 Pavlovian conditioning 212 peek-a-boo game 76 perceptual hypersensitivity 48 perceptual-cognitive organization 56 personality development 35 personality disorders 47, 52, 90, 146, 158 personality formation 36, 136, 167

254

INDEX

pharmacotherapy 95, 139, 143, 193 rational program of 193 pharmacotherapy (clonidine) trial 92 phenylketonuria 122 phobic anxiety 61–62 phylogenesis 206, 208 of mastery 208–210 physiotherapy 75, 128, 139–140 picture arrangement subtest 125 Pine, F. 17, 24–25, 27–28, 57, 59, 73, 110 Plomin, R. 20 poor genes 116 positron emission tomography (PET) 219 post-traumatic stress disorder 94, 125 centre 94 predation 202 pre-industrial societies 207 pre-Oedipal child 80 primitive defence mechanisms 11, 13, 173 professional speech therapy 141 protobiotic systems 208 pseudobulbar paralysis 48 pseudo-narcissistic personalities 96 psychiatric symptoms 67 psychic autonomy 75 psychic energy 203–204 “neutral” 204 psychic functions 58, 87 psychic inertia 150 psychic structures 23 psychoanalysis and psychotherapy cognition in 211–212 maladaptive behaviours 224 psychoanalytic drive theory 222 psychoanalytic investigators 73 psychoanalytic metapsychology 205

psychoanalytic psychotherapy 144, 150–151, 161 psychoanalytic psychotherapy and psychoanalysis 144, 223 psychoanalytic reconstruction 166 psychoanalytic theorists 90 psychoanalytic theory 18, 58, 62, 161, 198, 220, 229 of emotional development 17 of infant development 166 of psychosexual development 30 phobic anxiety 62 psychoanalytic treatment 35, 44, 150, 211 psychological intervention 143–144 psychological reality 162 psychological separateness 75 psychological test 12, 49, 95, 117, 125–126, 131, 134, 136, 147, 183 report 126, 147 psychological theories 101 psychoneurosis 161 psychopath’s callousness 41 psychosexual development 30, 73, 233 psychotherapy of borderline child 1 Uri 1 psychotherapy works 223–225 racial inferiority 20 reality-oriented cognition 26, 82 thinking 84 reconstruction in psychoanalysis 161 relaxation 21, 39, 105, 131 remedial tutoring 139–140 Richard, King 69 Riley, B. 20 Rochlin, G. 200–201, 210 Rorschach 49, 134

INDEX

protocol 134 test 148–149 Roth, L. 112 sado-masochistic relationship 116 Sandy 130–131, 137 examination anxiety 131 scant information 20 secondary caregivers 25, 108 secondary thinking processes 82 schizo-affective disorder 132 schizophrenic nature 132 SEEK-AND-PLAY system 223 selective serotonin reuptake inhibitor (SRRI) 133 self-amplifying processes 53 self-criticism 64 self-defeating behaviour 144 self-defeating lifestyle 50 self-destructive behaviour 64 self-destructiveness 201 self-directed aggression 91 self-fulfilling prophesy 95 self-preservative instinct 198–199 self-representation 26, 29, 51, 57–61, 63–64, 75, 77, 79, 88, 98, 146–147, 150, 175, 228 child’s 63 consolidation of 77 separation-individuation 25, 28 sequential auditory memory, impairment of 42, 51, 150 severe dysregulation 175 sex-nurturance circuits 223 sexual drive sublimation of libido 199–200 sexual identification 81 sexual latency stage 82 Shahar 177–183 background 178–180 diagnostic evaluation 180 House of Darkness 181

255

psychiatric evaluation 178 The Jail 181 therapy 180 TOVA test 179 Shuttleworth 17, 36, 73 single photon emission computed tomography (SPECT) 219 slow scientist 161 snowballing effect 108 sobering realization 166 social adaptation 2, 141 social judgement 83, 148 social maladjustment 84, 183 Stern, D. N. 17, 19, 25, 73, 206 stick figures 135 subclinical encephalopathy 47 sublimation of libido 199–200 super-ego 47, 81, 177, 199, 221, 233 anxiety 221–222, 233 synchronization 23, 31 Tel Hashomer Military Hospital 127 temperamental idiosyncrasies 35–42, 82, 163, 166, 227 temperamental individuality 35, 165 temperamental variability 33, 35, 101 activity level 38 adaptability 38 clarity of communication 40 cuddliness 38 habituation 37–38 hypersensitive infants 37 perception of social cues 40–41 sensitivity 36–37 temperamental trait 36 tempo 39–40 tension-reducing urge 205 theory of mind 40–41, 158, 220

256

INDEX

therapeutic alliance 2, 53, 146, 151, 165, 188, 190, 217–218, 233 therapeutic reconstruction 137, 162–163, 166, 175 thinking in loops 49, 150 third drive theories 204–206 third instinct theory 205 TOVA test 93, 179 transference 14, 44–45, 50, 137, 150, 161, 166–167, 171–172, 174–175, 212, 216, 218, 233 transference-focused therapy 167 unconscious ego functions 87 unconscious fantasies 166 unpleasure-related destructiveness 201 Uri adjustment to reality 12 adventures in psychotherapy 4–12 aggression 14–15 complex bisexual fantasy 8 compulsive masturbation 6 defence mechanism 11 early childhood 1 grandiose aspirations 14 history and family background 2–4 inborn characteristics 13 infantile thoughts of omnipotence 11 inquisitive eyes 7 intense attachment 14

intense projective preoccupation 7 known sensitivities 8 parents 4 primitive defence mechanisms 13 reason for referral 2 recklessness and accidentproneness 13 self-concept 14 shoulders 9 therapist 1 thoughts of grandeur 5 thoughts of omnipotence 13 uncontrollable rage 14 unusual sensitivity 14 ventro-medial prefrontal area 41 verbal release 78 verbalization 79 village idiot 95 Vineland social maturity scale 106 visual–motor coordination 25–26, 76, 83, 112, 114, 117, 123, 129, 134–135, 141, 180, 213 vulnerable narcissism 189 Wechsler Adult Intelligence Scale (WAIS) 49, 134 WISC-R test 125 Wolf Man’s ambivalent relationship 44 Wolff 206 working-memory impairment 113