Early childhood experience and the therapeutic relationship.
Subject: Physician and patient (Management)
Psychotherapy (Methods)
Psychotherapy (Management)
Author: Young, Barbara
Pub Date: 09/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2009 Source Volume: 12 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 208639917
Full Text: The author uses examples from her caseload of 57 years of doing analytically oriented psychotherapy to explore what similarity existed between the various ways the patients had connected with the therapist in the therapeutic relationship and their earliest experiences with their mother or mothering persons. A number of former patients cooperated with her study by comparing the reconstruction of their early childhood life with the memory of the relationship they once had with the therapist. When these data were drawn together, it was possible to conclude that the more secure the mother/infant bond, the more solid had been the therapeutic alliance. Likewise, the degrees of insecurity existing in that crucial period of life had affected the manner in which the patients had related to the therapist and had determined what adaptations the therapist had needed to make in the analytically oriented psychotherapy.

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In the process of psychiatric treatment, we therapist are so busy working on what went wrong in the patients' lives, we tend to take for granted that something must have gone right because they have the capacity to form a therapeutic alliance. Recently, as I sat silently in the presence of the simple wooden casket that contained the body of my friend Ed, my thoughts rushed back forty years to our 12-year struggle to free him from the icy casing in which he had concealed himself so that no one could ever humiliate and hurt him again as had his father. For five years I listened to his narcissistic ramblings with increasing impatience. When the icy casing finally gave way, he was astounded to realize that, unconsciously, he had perceived me as his Father. He gradually learned to trust that I would not hurt him and the analysis proceeded to a most satisfactory conclusion.

Only now am I asking what was it that made it possible for him to sustain the therapeutic relationship with me through all those years? What good had happened to him that had given him the strength to keep going, and the hope that things could get better? At the funeral, I found my answer. His nephew described Ed's warm relationship with his mother: though they were poor, she was determined her children were going to have an education; she would deposit her spare change in a bottle for that purpose. Ed had always cried when he told this story. These were not feelings I had heard about from the couch. He was 13 months-old when his first sister was born, and 29 months-old when his second sister was born. By the time he could remember, his mother had been overburdened by little children and a frustrated, angry, and abusive husband. But those 13 months that Ed had obviously enjoyed with a loving mother had given him a strong foundation, making it possible for him to survive his father's attacks and, 30 years later, to sustain the therapeutic relationship with me that eventually freed him from his icy prison.

In a previous paper (2007) surveying my 56 years of practice, I stressed that all psychotherapy and psychoanalysis moves forward on the connection the patient is able to establish with the therapist, which includes the therapeutic alliance, the transference relationships, and the real relationship. Each patient relates to the therapist in his or her unique way. In my survey, I divided my patients' manner of connecting with me into five different categories. The majority of patients who made what I perceived to be a solid working connection had a success rate of 97%. Those who made a solid connection but needed to maintain a certain reserve had a success rate of 91%. Those who made a solid working relationship but kept their contact with me as a person to a minimum because of their early life experiences, had a success rate of 54%. The therapies of those who "entangled" with me, living out in the treatment their transference pathologies, were long and extremely challenging for both therapist and patient but the success rate was 60%. Those sicker people who perceived the relationship as dangerous had a success rate of only 19%.

When I presented the paper, which is made up of clinical vignettes including reports by a number of former patients on how they view themselves using the internalized therapeutic relationship in their personal and professional lives today, child analyst Silvia Bell (2006) brought to our attention that these classifications of the patients' ways of relating closely resemble those used in the 1960s by Mary Ainsworth in her study of mother/infant bonding. After a year of observation of mother/infant pairs, the children were tested for the degree of security present in the attachment they had developed to their mothers. To what degree had the child been able to retain the presence of the mother in his mind when she was absent? The secure babies wanted to interact with the mother when she returned; they had continued to remain connected with her. The insecure babies were classified as:

1. Avoidant: These babies tended not to show distress at separation. They avoided the mother upon reunion and tried to remain engrossed in play.

2. Ambivalent/distressed: These infants might cry, but did not find comfort in the mother; they both wanted something from her and rejected her, pushing away or ignoring her.

3. Disorganized/disoriented: These children could not explore even in the mother's presence, were undone by the separation and were not able to use her to obtain comfort. Their response was characterized by undirected, misdirected, incomplete bizarre stereotypic actions. (Bell, 2006)

Ainsworth (Karen, R.) concluded that secure babies had mothers who were sensitive in their responsiveness to their infant's signals. Mothers of avoidant babies tended to be rejecting, angry, and irritable. Mothers of ambivalent/distressed babies seemed inept or depressed, and tended not to hold their babies except when necessary. The disorganized/disoriented babies (which was a classification that was appended later) had been subjected to chaotic and bizarre interactions with their mothers and, it was felt, would continue to show the same behavior as they grew. The others had more ego strength to deal with future challenges and would be more amenable to the positive influences from other loving people who came their way.

How the less damaged insecure babies fared in the future would vary, of course, depending on many factors. Though it is essential that good mothering be present at the very beginning of life--at the time when the beam of love in the mother's eye is most essential for the development of the part of the brain which makes possible interpersonal relationships--her continued attunement to the shifting needs of the infant is crucially important. Illnesses of either the mother or child can be disruptive; unexpected absences or serious losses can be devastating, as can prolonged stress in the family situation. Occasionally, early signs of hereditary or familial psychiatric illness or personality disorders disrupt the normal development.

Some mothers are able to bond well with their infants for six months, only to become depressed and withdraw when the child pushes away from them in order to explore the world. As you will see in the case studies that follow, these ingenious little children had good ego strength--a stronger fundamental foundation to stand on--and discovered ways of extracting attention from their mothers and fathers, aunts or neighbors, in order to survive. Of course, adaptations that were lifesaving at the time got them into trouble as adults, for which they sought out the service of a psychiatrist. However, there was a small group of patients who had received enough love to survive, yet were seriously damaged by their mothers' periodic episodes of desperation, at which time the children's lives had actually been in danger. Not having been helped to reach the state of object constancy, they were not able to hang on to the love they felt for their mothers in the presence of their fear, rage, and hate. These patients formed a working relationship with me that eventually brought positive lasting results and yet, at the time of termination, they needed to part from me with an anger that could not shift back to love.

Prompted by Bell's observation, I looked more closely at the information available on my patients' early mother/infant bonding and compared that early relationship with the therapeutic relationship they made with me. I asked a number of former patients if they would construct a picture of their early lives through photographs, family stories, early memories, and their own imaginings. Fourteen people were stimulated to serious reflection and wrote back, sometimes copiously. Their responses make up the body of this paper. Enough information on 23 others existed to include them in my informal statistics, which appear in the chart to the left. My hypothesis was that there might well be a correlation between the type of parent/infant interaction and the later ability to form a therapeutic relationship.

Ainsworth's testing of the mother/infant pairs was done when the children were one year old. Since we know the manner of mothering can change remarkably, I have estimated the child's relationship with the family members both before and after six months. I have joined Ainsworth's two categories of insecure relationships--avoidant and ambivalent--to cover the multitude of ways in which events in the family constellation can turn a secure child into an insecure one. Specific traumatic events complicated even further a child's sense of security.

The therapy was considered successful in 35 of this select group of 37 patients. Although the treatment of one young woman who related to me in an "entangling" way was judged marginally successful, she has often made contact with me in the ensuing years and recently contributed to this attachment study. The one patient whose therapy was not successful perceived her therapy as dangerous and eventually committed suicide some years after terminating treatment by moving away.

The treatment modality of these 37 patients ranged from classical analysis to the essentially supportive therapy with a seriously impaired man with bipolar I disorder. The majority were treated psychotherapeutically, making use of as much psychoanalytic work as was needed and the patient was strong enough to undertake. The reader will note that Bell's supposition was correct. The pictures my patients and I assembled of their early mother/child relations did indeed closely resemble the manner in which they, as adults, related to their intimates, and how they, in treatment, related to me.

Several clinical observations drawn from my total patient population validate Ainsworth's prediction that only those children who had a seriously disorganized, insecure early relationship with their mothers would continue to live out this disturbance in their attempts at interpersonal relations. The vast majority of my patients had been fortunate to have secure early months with their mother or mother substitutes--fathers, grandparents, nannies, maids--giving them the firm foundation that made it possible for them to surmount the later complications to their lives. When things went wrong--when they were "stuck" in their growth--they had been able to face the fact that they needed help and to profit from it.

The reader will witness a variety of coping mechanisms the patients used as children in order to survive, and see how those mechanisms revealed themselves in their relationship with me. In several instances, relatives and neighbors had appreciated the children's unique gifts in ways in which their parents had not been able. The good fortune of a caring teacher or a special friend added both richness and possibility to a sagging life. However, despite the effectiveness of mother-substitutes, the early mother's disinterest or unavailability had left scars of hurt and narcissistic injury.

Patients Not Able to Make a Therapeutic Connection

I worked for two years in a hospital with psychotic veterans shortly after World War II. All of them had been functioning young men at one time, only to be assaulted by a psychotic illness triggered either by their experience in the service or the return to their home towns. I surmise that those few who found their way to my office and were capable of making a tenuous relationship with me must have had a good enough beginning with their mothers, only to be assailed by severe problems after those early months.

I had a brief window into the world of those who were inaccessible to psychotherapy. I was monitoring Gus and Bill as they regressed under insulin shock treatment, standing ready to administer a life-returning feeding by gastric tube. In this primitive state, Gus gnashed his teeth, wildly throwing his head back and forth like a ferocious animal, while Bill lay curled up in the fetal position with a blissful expression on his face. I thought: Bill is so merged with his mother, I doubt he will ever recover, but Gus has a chance of improving for he is fighting to live. I was not surprised when several years later I saw Gus walking down Charles Street in Baltimore. He was mumbling to himself, but he was at least functioning in the outside world.

If Gus and Bill had undergone Ainsworth's separation situation examination at the age of one, they would probably have been classified as disorganized/disoriented. Though their diagnosis was schizophrenia, and they may have had a biological propensity for that disorder, I believe it is fair to assume that the nature of their earliest relationship with their mothers played some part in their illness, for they had been functioning adults before entering the service.

Patients who Made an Entangling Therapeutic Connection or Perceived the Relationship as Dangerous

Though Miriam's therapeutic alliance was fundamentally solid, her intense transference relationship shifted as she lived out her many pathological dilemmas. During the first phase of treatment, her transference relationship was definitely "entangling" as she connected with me in the only way she had been able to reach her depressed mother after six months of age. Her verbal attacks on me were repetitions of the violent verbal engagements with her mother. In the second phase, when four times a week on the couch was suggested, the therapeutic relationship was perceived as so dangerous she became physically ill with a mysterious thyroid condition and was hospitalized for three months. In the third phase, the relationship was again entangling, as she gradually lived through her confused identifications with the various members of her family in her shifting identifications with me. She often made use of an unconscious avoidance technique--a blank expression would take over her face. We later learned that this was to avoid and deflect the danger of her wish to be close to me for that meant to lose her identity and dissolve into her early mother. Ainsworth would have characterized her childhood as ambivalent/distressed and avoidant.

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Miriam was the first girl in a large family of a seriously depressed mother. The brothers on either side of her became schizophrenic. It appears that the mother's depression was relieved by having a small baby. Miriam had her mother's love for six months, but when she began to push away from her mother's lap in order to explore the world, the mother became depressed and conceived another child. Miriam was ingenious. She discovered that she could get her mother's attention if she engaged in vituperative arguments. And she got her father's attention by putting on a seductive mask while she sat on the front steps waiting for him to come home.

A gifted artist, she had to leave school and was confined to the house by her phobias. Rescued by two psychotherapists, she was able to obtain a job, but when she found herself verbally attacking her female boss as if she were her mother, she was referred to me. She immediately began attacking me, criticizing my clothes and my office: "How could I help her if I was not married?" This was made less difficult for me to bear because of the look she gave me as she walked out the door which seemed to say, "I am sorry to treat you this way but I have to do it in order to get better." After several months, I called a halt to the attacks and suggested we try to understand what they meant. Cautiously, we shifted to increasingly analytic work. We discovered that the attacks were not only a repetition of her relationship with her mother but another way of protecting herself from the primitive longing to be reunited with her early mother, which would mean losing her precious but precarious autonomy.

She finished treatment without tackling her problem with men, later to return with the old anxiety. Sitting face to face was essential in clarifying this. She had gone from assuming I was sexless and identifying with that "me," to assuming I was promiscuous, and was on the verge of acting out that fantasized identification. In the midst of these shifting mirrors, it was unnerving to be in the room with her and hang on to the real me! She gradually gave up her identifications with the psychologically disabled members of her family and said goodbye to the "irresistible" mask with which she had seduced men--the mask of enticing beauty she had assumed as a child to both cover her feelings of worthlessness and to preserve her sanity.

For 26 years, Miriam lived a full active life with many friends. Nearing death, she called me to her and made the final interpretation of her therapy. She had had a dream: "You know how I have always kept my distance from you. I was afraid you would get too close, that you would swallow me up. In the dream I realized that I was afraid of my feelings for you, and of my desire to engulf you. For the first time I could feel how much I love you and I started to cry."

Miriam's story was published in 2005 under the title "The Golden Hand of Creativity," in the International Journal of Applied Psychoanalytic Studies.

Jane was a brilliant college student interested in a career as a writer. All her life she had suffered with an almost unbearable longing, which was somewhat assuaged by an attachment to a former teacher. Occasionally in our sessions, she would be in such pain she crawled on her knees across the floor toward me. She appreciated my being there for her, but resented the dependence on me.

I have referred to Jane's connection with me as entangling in the sense that she was living out with me both her primitive longing and her need to escape its entanglements, but we made no exploration of the underpinnings of this complicated problem because Jane's personal and professional life was moving forward. However, in the memoir she wrote for me recently, it is possible to understand both the origin of her agony and her strength to fight back against the ominous tide of "insanity."

When I wrote Jane asking her to imagine what it was like as an infant to gaze into her mother's eyes, she wrote:

We must question how much of that essential life-giving gaze Jane had actually received from her mother's eyes? She continued:

Jane and her mother lived with her grandparents when she was young because her father was in the service. Later, the family moved to many places throughout the world where he was stationed. Who was this mother who at least for a few months must have gazed with love at her first-born infant? She was considered not quite "with it." There were episodes of "nervous breakdowns" with repeated hospitalizations and many diagnoses including schizophrenia and manic-depression. We can hear Jane's determination to free herself from her dismal childhood:

For Ainsworth, Jane, at the age of one, probably would have tested as a seriously distressed baby or even disorganized. But the grandfather's love helped her climb out of what could have been a difficult fate and, in her teens, the rich sustenance from an uncle and aunt helped consolidate her ego strength.

Solid Connection with Minimal Relationship with Me as a Person

Clarissa's early childhood experience and her way of relating to me may well parallel Ainsworth's insecure babies who used avoidance to deal with their pain and loss.

She had been able to form a solid, straightforward working alliance with me, but seemed to pay little attention to me as a person, almost as though I did not exist. (As she told me recently, this could not have been further from the truth. At the time I had been the most important person in her life, but she could not let me now that. She said that appearing to not exist herself had been her most important defense in getting through life.) When I asked about her mother, she acknowledged that they had no contact with each other. Her parents had separated early in her life. During the one visit in which Clarissa had initiated to have lunch with her distant mother, she learned with great pain that she had actually concealed her existence from the children of her second marriage, but that she had thought about her daughter every day. To avoid the unbearable pain of this lifetime of rejection, Clarissa had protected herself by essentially wiping her mother out of her mind. I did not understand how she had achieved her determination to succeed, her ability to relate to her husband and the son who was born during therapy, and to participate so successfully in the therapeutic alliance, until I met with her 15 years later as part of the survey of my practice.

She explained to me that her mother had been deprived of the instinctive bonding with her first-born infant because she had developed a post-partum psychosis and received electric shock treatment. The role of mother had been filled by her father and the grandparents who lived in the home. For years her absent mother had existed in her fantasies as a beautiful, unreachable, almost fairytale woman until that moment at lunch when she had to face the fact that her mother had protected herself from both her guilt and her feelings of loss at "abandoning" her child by denying the child's very existence.

Clarissa's story raises an interesting question: If an infant receives good enough care from mother substitutes from the very beginning, what effect does the mother's "abandonment" have on the infant? It is unlikely that it weakens the fundamental foundations of the child. As little Clarissa became more aware that her mother had left her, she created a fantasy about her as a desirable fairy godmother who would return. But in real life, being wary of any human attachment had become a permanent part of her character.

Is there any lasting repercussion on the character of a child from being raised by a composite of mothers, as happens to almost all children today? I know of quite secure little children who go from mother, to father, to two sets of grandparents, and spend the day with a loving aunt while the mother works. These transitions seem to go more smoothly with less separation anxiety than when the child goes to a day care center. Donald Rosenblitt (personal communication), child analyst at the Lucy Daniels Center in Raleigh, suggests that if the mother must return to work when the baby is young, the infant should see the caregiver and the mother together, loving each other for at least two weeks. This makes possible the transferring of the maternal bond.

Solid but Reserved Therapeutic Connection

Mr. Stewart had sought me out because he was having episodes of uncontrollable anger since the death of one of his children in an auto accident. He feels that the year we worked together helped him handle his anger and frustration better, and led him out of his "cycles of despair." I will quote from the long letter he sent in response to my request:

It is apparent that I stepped right into his mother's shoes and he was able to make use of my assistance in getting himself back under control as she had done for him. That there was some reserve in his relationship may reflect the need of every adolescent to get free from the mother, especially one who has been so close. Ainsworth would have said of this mother/infant relationship: "Secure!"

Solid Connection

As we move to the patients who made a solid therapeutic connection with me, we must look beyond the earliest months when the initial mother/infant bonding was solidified and the fundamental groundwork laid down, to how well the mother was able to support the growing independence of the child, and how the child, with the instinct of self-preservation, developed skills to make contact with the mother when she strayed. Let me cite two brief examples.

Teresa's mother was busy taking care of the older brother who suffered with congenital heart disease. Teresa has the distinct awareness that at 11 months, while lying in her bed, she made up her mind that she had to begin to talk and to walk in order to go to where her mother was hanging up the clothes. Apple's mother could not tolerate her screaming and would disappear down the hall to the neighbor's apartment. She remembers practicing over and over how to modulate her voice before she called enticingly, "Mamma!" Think of the strength Teresa and Apple must have gained in those crucial early months that they were able to control their urgent need and their anger and figure out a way to maintain contact with their life-giving mothers.

Corinne's story illustrates how the good enough mothering of the first months of life gives the child the strength to overcome serious adversity, whether as a child or a 46-year-old woman. When she came to me at 27, she was a very unhappy young woman despite her success as a poet and college professor. Her solid relationship with me enabled her to move forward, to marry, and to have a rich, contented life. Then one day, 19 years later, she stepped on an insecure stepping stone and went plummeting down into the abyss. She had just enough strength to hang on to my hand for the three weeks it took to ease her out of the abyss to safety. We worked an entire year to help her understand her extraordinary vulnerability to "betrayal" so she could pick up the pieces of her life and move on.

Corinne responded to my request to picture what her earliest relationship with her mother was like:

In her therapy, Corinne described how she learned to deal with her depressed mother's ambivalent feelings toward her. She would come home from school with the need to run to mother to check in, but her mother was in bed with back pain. Corinne knew that her mother needed her nearby but she must not ask for closeness. Thanks to her inherent will to survive and the anticipation of the arrival of her father in the evening, she was able to control her urgency for attention by playing repetitive games in her room. She endured a difficult life but had the coping skills to move on, leaving home as soon as she could. And when she was 27 and unhappy in her personal life, she had had the strength to undertake analysis.

Obviously six weeks or six months of good enough mothering is not enough. The mother must be there for the child, supporting him/her in his/her adventures into the world, even when his/her feelings are hurt when he/she turns his/her face away from her to protect himself/herself from the pain he/she felt at her absence--even if it was just a trip to the grocery store--or pushes her away and reaches eagerly for his/ her father when he arrives home from work. I've always said being a mother is the hardest job in the world, unless it is the job of a one-year-old child who is struggling to survive the loss of his/her mother's attention. The extraordinary efforts Teresa, Apple, and Corinne had made to retain contact with their mothers had been successful. They not only survived, but as adults were able to relate well to loved ones and to make a solid therapeutic relationship with me.

The importance of being present to assist a child in developing his/her own autonomy is built into the African-American culture. A friend said to me as I was preparing my patients for my forthcoming vacation, "My grandmother always used to say 'A tub has to learn to sit on its own bottom." I added, "But the tub better be full, or a strong wind can blow it over."

Mario's first year of life in a secure relationship with his mother had given him a firm foundation, but the tragedy of the change in his mother's personality when he was a year old shook that security seriously and left him with a lifetime of anxiety. When he first came for help at the age of 68, he had a look of chronic terror in his eyes. His chief complaint was nightmares in which he suffered severe frustration in attempting to fit two pieces of something together. I felt he was trying to make sense of what had happened to his life since his abrupt retirement. Friends were dying. Mario was terrified of dying, yet he weighed so much he was endangering his life.

Though he was an intelligent man, all his life he had blanketed over many of his feelings, living under the illusion that his childhood had been totally happy. We cautiously explored what his life had been like since the age of one or two when his mother had suddenly become stone deaf and depressed. This was the terror that was pushing its way out from under the blanket in his nightmares. There appeared a terrifying mask-like face that would bite and burn, which seemed to represent both his mother's face of rage and resentment at him who had "caused" her deafness, and his own face toward her for disappearing from his life.

He was astounded when he began to remember words he must have said to her: "I won't!" And later, "You're a rat!" And he remembered seeing the hurt on her face and feeling guilty. When he was very small, the two of them were together all day long struggling to control their anger, living in a state of tension. Each evening they stood at the window waiting impatiently for his father to come home so they could relax.

For the first time, Mario realized that he had begun to gain weight at the age of 50, at the time of his father's death. Apparently, all his life his father's actual existence had kept the little boy inside him safe. With his death, he developed an uncontrollable hunger that he tried to assuage with food. As his weight increased alarmingly, it seemed he was throwing himself on a bomb that might explode if he no longer had his father to protect him from his unresolved aggression toward his mother and toward his grown children who were not as attentive to their parents as he felt appropriate.

When a child loses his/her mother before he/she is a separate person from her, he/she is unable to grieve and experiences the loss as a loss of part of himself/herself. Before his good mother had "disappeared," young Mario had no doubt just begun the process of controlling his emotions out of his love for her. His happy companionship with his father and his friends in his small community had saved his life, but with no further assistance from her, his only recourse had been to blanket over his raw primitive terror and rage and live a life devoid of self-reflection, wiping out all feeling as soon as it appeared. When he no longer had his work to keep him busy, the primitive feelings had begun to surface in his nightmares.

Thus far, the paralleling of the mother/ infant relationship with the kind of therapeutic connection made with me appears valid. By adjusting and adapting the treatment to these different ways of relating, most therapy proceeded to a satisfactory conclusion, in some cases even when the relationship was an entangling one in which the patient lived out the pathology in the transference as with Miriam and Jane. Let me close with three patients whose stories possibly put my hypothesis to the test.

What appeared to be a solid therapeutic relationship with Edna proved to be a facade. Her eventual death by suicide confirmed that the episode of severe anxiety at the age of three had been a momentary exposure of a serious defect in the mother/ infant bonding. In sharp contrast are the stories of Dennis and Una. Despite severe impairment of the mother/infant bond by illness and prematurity, they had cobbled together a solid bond that was later reflected in the solid therapeutic relationship with me.

I had judged Edna's therapeutic relationship as solid, but, in retrospect, I should have been alerted to the fact that I was dealing with a charming facade of a woman who was in deep trouble and terrified of what she might uncover in therapy, by her initial resistance to being a patient. Almost 50 years my junior, she immediately called me Barbara and debated whether to use me as a supervisor or therapist. She was anxious and depressed, and suffered with an insatiable hunger. Nothing could make her feel better for any period of time. When her little boy was very young, she had the feeling of being valuable as a person and found some satisfaction of her need for intimacy. But when he began to grow into a separate person, her symbiotic partner was gone. She began to drink more heavily. After she lost her child, she left the city. She occasionally wrote, thanking me for the difference I had made in her life, but questioning how much love she had actually received, questioning whether her life had made any difference to anyone else. I am told that after a period of disorganized living she found a job in her profession, only to commit suicide. Apparently nothing, not even success, could fill that agonizing hole.

We know little about her childhood, but there was one indication of serious anxiety at age three which had been hidden under her pretty exterior. Something must have occurred in her earliest days that deprived her of the essential mother/infant bonding. Perhaps there was no one there to nurture her mother during those difficult postpartum weeks that would have left her free to respond to nature's strong instinctual push to bond with her infant? Whatever fundamental anchorage Edna had had in her earliest months was not secure enough to hold when the tide went out. Though her facade was deceptive, it would not have escaped Ainsworth's test. She would have been labeled "Disorganized." Needless to say, I was left with the question of whether there was more I could have done if I had read beneath the facade sooner? But I must accept that there are patients whose problems are beyond our help.

It is remarkable what 18 hours of excellent maternal/infant bonding can do. Dennis had been welcomed with great love. Eighteen hours after his birth, he was dying from paratyphoid fever. His mother sat beside his comatose body. Because of his strong constitution, he was one of the six babies out of 23 who survived. For some time, the family took turns carrying him on a pillow at a 30-degree angle in order to keep his food down. The life-giving bond his mother had formed with him in those first 18 hours carried over and was resumed despite the impediment of the pillow. Dennis writes:

However, at age six, he no longer wanted to be touched:

When Dennis had started treatment, his life was in serious disarray because of his somewhat frantic escape from the suffocating bond with his mother. When he was not racing cars or riding a bucking bronco, he was telling endless stories. It was necessary for me to play an active role in his therapy by being firm about our financial arrangements, and stopping his stories to bring him back to what he was running from. Dennis carries on the story:

It was amazing to watch this man grow from a somewhat irresponsible, daring, out-of-control guy to a responsible, gentle, delightful man. Dennis worked through his rage at his mother to break free from his entanglement with her and they became dear friends with many mutual artistic interests. Today he is happy in his marriage and more productive than he has ever been. He continues to have interior dialogues with me in order to avoid taking a road that would lead to his undoing.

It is remarkable that the life-giving gleam in Dennis's mother's eyes survived those days of his unconsciousness. Despite his catastrophic beginning to life, this baby absorbed and maintained the strong bond his mother supplied. At age one, Dennis would probably have passed Ainsworth's test as "Secure."

Una came into the world weighing three pounds four ounces and spent the first two months of her life in an incubator. In 1930, the medical world was not yet aware of the essential importance of establishing the mother/infant bonding for premature babies. And her mother--by character an aloof person, daughter of an aloof mother--did not have the inherent knowledge to insist on seeing her infant every day because Una was her first-born and only child. Una came home to be mothered by Martha, the family maid. Where did Una get the strength to escape from a world where she lived in fear of being abducted and longed for eternity that would free her, to become the vital person whom I know today? From where, and how, did she as an infant absorb enough security to eventually be able to make intimate friends and to seek and profit from psychiatric help? My recently recorded interview with Una will help to answer these questions.

It is not surprising that she has lived with more than her share of anxiety and depression, but she became a well-educated professional woman dedicated to the needs of children and to world peace. Prior to coming to me at age 46, she had made a serious suicide attempt set off by her pervasive sense of insecurity: in this case, that Blue Cross would cut off her medical coverage. She accomplished a great deal in her analytically oriented psychotherapy. I remember her joy the first day she put A and B together to make C. After treatment she was able to lead an independent life for a period of about seven years. With the sudden death of her male companion, her depression developed into a bipolar II illness. In the last few years, this extraordinary woman has pulled herself back from the edge of death three times, slowly recovering to regain her mental alertness, her curiosity, and her enjoyment of dear friends. Let's look at what she has to say in order to try to understand how she escaped from such a dire beginning to become a woman capable of loving deeply.

Una tells me that she has been depressed all her life. I asked her what she did when she was depressed as a child. "I played with the kitten. I want a kitten now. I would be less lonely. But I would trip over it with my walker .... Scarlet was loving." When I asked what Scarlet saw in her face, she responded: "Depression. She would curl up in my lap to comfort me." When you were an infant, what did you see in your mother's gaze? "Nothing." What did she see in yours? "Nothing." What do you think you saw in your father's face? "Disappointment. He wanted a boy." What did you see in Martha's face? "Kindness." And she in yours? "Nothing."

We look at a photograph taken by her father when she was four. There is the beginning of a smile, but she notes her anxiety in the way her foot is turned. When she was young, there was more warmth coming from her father than her mother, who was occupied with her "clubs and bridge." She and Martha ate together in the butler's pantry. There was little conversation, so she entertained herself by reading a book. But Martha was sensitive and wise. She once told her, "Miss Una, it's your little red wagon. You can push it or pull it." Taking Martha's advice, she made friends with the neighbors, and spent much time with her cousins in their country home, garnering attention and love wherever possible. As college approached, she packed up her things and left the isolation of her home.

The life force in this tiny baby was strong. I believe that she must have pulled the nurses toward her with that beguiling smile; that they may well have slipped into the nursery and given her extra time. I suspect this, for today I notice how thoughtful and considerate she is of the women and men who care for her. What would Ainsworth have found when Una was one? An "Insecure" baby? Yes. However, I believe we need to add a new category to Ainsworth's list. I suggest "Stalwart." If Una had been separated from Martha-mother in Ainsworth's laboratory, she would have coped. If it had been her mother who disappeared and reappeared, she would have been disorganized.

Summary

It is awesome and terrifying to recognize how the future of our lives rests on those foundation stones laid down by the consistent beam of love in our mother's eye--for me personally, to realize that my life would have been totally different if my brothers had not had the whooping cough when I was born. Since my mother could not go home, she remained with her parents and her younger brother and was nurtured by them, leaving her free to nurture me. I have pictures of my beady eyes gazing up into her loving face as we sat before the blazing fireplace. I waited the required four hours to be fed, but there were many hands to comfort me. By the time we returned home and my mother resumed her busy life of caring for her husband and children--cooking, washing, scrubbing floors--I was secure enough to know that she would come.

When my sister was born, I witnessed what my fate might well have been. I could not tolerate her crying and was found with my finger in her mouth, because when I took it out she resumed her screams. No doubt I too would have suffered with the same depressive feelings and the unquenchable hole inside that led to my sister's incessant smoking and possibly to her premature death.

When I was in high school, imagine my astonishment when I opened the Ladies Home Journal to find an article "The Rights of Infants" by Margaret Ribble. Infants have rights? Thank heavens, someone is finally paying attention! Rend Spitz found babies dying in foundling homes from lack of mothering. Harry Harlow with his monkeys and Konrad Lorenz with his goslings showed us that animals too need consistent mothering to survive.

I remember vividly hearing Eleanor Galenson speak of the emergency assistance they were giving the babies of depressed mothers at the Albert Einstein Clinic. Substitute mothers were quickly moved into place. Then came John Bowlby and Mary Ainsworth and their work on attachment. I can hear Margaret Mahler today describing her infants and their mothers. The tantalizing toys were on the other side of the room; the infants started crawling toward them. When they looked back at Mom, if her face was encouraging, they kept going. If she was anxious and picked up a book, or unconcerned and started a conversation with her neighbor, they came crawling back. We need that extended arm to crawl along even when we go off to college. We carry that supportive, encouraging arm, safely internalized, inside our head for as long as we live.

It is said that we learn to mother from our own mother. How far back do we need to go to break the cycle of deficient mothering that has such serious consequences for the future of each individual and of society? The Educating Children for Parenting Program at the Germantown Friends School, which was started by the psychoanalyst Henri Parens and his colleagues, has expanded to many classrooms across the country. In grades from pre-school to high school, children learn parenting skills by directly observing a mother and her infant who visit their classroom frequently. They share in the baby's delight in new accomplishments, and learn what the baby needs by observing and participating. They ask questions of the mother about "their" baby, with whom they have bonded. The goal of the program is for the children to realize that they have all the skills necessary to be successful, thoughtful, and empathetic parents. Another goal is to reduce the incidence of child abuse and premature pregnancy by learning firsthand the awesome responsibilities of parenting as well as the values of caring and nurturing. The researchers feel that they can see in the responses of the children the degree to which their capacity to care and feel empathy has grown, providing hope for the future.

I have wandered far a field, but there is the hope that what we learn with individual patients can have a broader applicability. Reparative therapy, even with these relatively healthy, well-functioning people who were my patients, takes years. Donald Rosenblitt spoke to us of the incredible amount of time required by several people to make any progress with children who fit Mary Ainsworth's disorganized classification.

But let us look at the positive. With the exception of Edna, who eventually committed suicide, all of these patients were given lives that would not have been possible without therapy. In the vignettes written for the paper, the reader can hear the degree to which the process of creative self-reflection has become an integral part of their lives. And the benefits expanded like a ring upon the surface of the water to the patient's spouse, children, friends, students, and patients.

We come to the end with a thanks to mothers for their dedication to their children and to the fathers, relatives, and communities who have supported the mothers in this increasingly complex and more difficult task. And an awesome appreciation for the indomitable spirit, the instinct of self-preservation, and the ingenuity of young children to adapt to their mother's needs in order to obtain what they need to grow.

This article is approved by the following for continuing education credit:

The American Psychotherapy Association provides this continuing education credit for Diplomates and certified member s whom we recommend obtain I S CEs per year to maintain their status

The American College of Forensic Examiners International is an approved pr o rider of the California Board of Behavioral Sciences (CBBS), approval PCE 1896 Course meets the qualifications for g hours of continuing education credit for MFTs and/or LCSWs as required by the CBBS

This activity is co-sponsored by the American College of Forensic Examiners (ACFEI) ACFEI is an NBCC Approved Continuing Education Provider (ACEP) and may offer NBCC approved clock hours for events chat meet NBCC requirements The ACEP solely is responsible for all aspects of the program and its content

This organization, American College of Forensic Examiners International Approval Number 1052, is approved as a provider for continuing education by the Association of Social Work Boards 400 South Ridge Parkway, Suite B, Culpeper, VA 22701. www.aswb.org ASWB Approval Period: 8/20/2007 to 8/20/2010. Social workers should contact their regulatory board to determine course approval Social workers will receive 2 continuing education clock hours in participating in this course.

After studying this article, participants will learn the following:

1. Recognize that patients vary widely in the way they relate to the therapist.

2 Discuss the need co adapt the analytically-oriented psychotherapy to meet the needs of the patients in their unique ways of connecting with the therapist.

3. Explain the direct correlation between the security and insecurity that had existed in the patients' early mother/infant bonding and the solidity, or lack therof, in the therapeutic relationship.

4 Recognize the ingenuity, resilience, and coping mechanisms that patients had used as children in order to survive by maintaining at least minimal contact with their avoidant mothers.

KEY WORDS: mother/infant bonding, attachment, therapeutic relationship, analytically oriented psychotherapy

TARGET AUDIENCE: mental health professionals

PROGRAM LEVEL: Basic

DISCLOSURE: The author has nothing to disclose.

PREREQUISITES: None

POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages (60-69)

1. Is there any relationship between a patient's early months of life and the relationship he/she is able to create with the therapist?

a) Yes

b) No

c) Sometimes

2. Is it possible for mother substitutes in the early months of life to be as effective as the actual mother in establishing a firm foundation for the child?

a) Yes

b) No

c) Rarely

3. What is the percentage of success in treatment of patients who perceive the therapeutic relationship as dangerous?

a) 54%

b) 19%

c) 60%

4. Can a baby with an insecure attachment to a seriously disturbed or withdrawn mother ever overcome the deficit?

a) No

b) Yes

c) Rarely

5. What do you do when a patient is living out anger transferred from a parent in the treatment?

a) Tell them to stop

b) Argue with them

c) Observe for a time & note your own feelings

6. What do you do when, early in treatment, you sense a patient is on the verge of disintegrating or of abruptly leaving treatment?

a) Remain the silent listener

b) Loan them some reality by becoming more interactive

c) Make a deep interpretation

7. How long can the results of a successful treatment expect to last?

a) For a lifetime

b) For a year or two

c) For 6 months

8. How long is psychotherapy usually necessary to achieve lasting results?

a) 6 weeks

b) 6 months

c) 3 or more years

9. At what age is it too late for a patient to profit from insight-oriented therapy?

a) 25 years

b) 50 years

c) Never

10. How do the mechanisms a child uses to cope with adversity serve useful functions in adulthood?

a) In their interactions with others

b) In their creative endeavors

c) In coping with future catastrophes

References

Bell, S.M.V. Infant research, attachment theory, and psychoanalysis (2006). The Betty Huse Memorial Lecture and personal communication.

Bowlby, J. (1951). Maternal Care and Mental Health, World Health Organization.

Galenson, E. personal communication.

Harlow, H.F. (1959, June). Love in infant monkeys, Scientific American, 200(6): 68-74.

Karen, R. (1990, Feb.). Becoming attached: What children need. The Atlantic Monthly, 35-70.

Lorenz, K. (1979). The year of the greylag goose. New York: Harcourt Brace Jovanovich.

Mahler, M.S, Pine, E & Bergman, A. (2000). The psychological birth of the human infant. New York: Basic Books.

Parens, H. (2004). Renewal of life. Rockville, MD: Schreiber Publishing.

Puriefoy-Brinkley, J. & Bardige, B. (January 2004). Learning from babies: Vital lessons for school children. Zero to Three, 24(3), 22-28.

Ribble, M. (1943). The rights of infants. New York: Columbia University Press.

Rosenblitt, D. personal communication.

Spitz, R. (1965). The first year of life. Madison, CT: International Universities Press.

Winnicott, D.W. (1987). Babies and their mothers. Reading, NY: Addison-Wesley Publishing Co, Inc.

Young, Barbara (2005). The golden hand of creativity. The International Journal of Applied Psychoanalytic Studies, 2(1) 2, 22-39.

Young, Barbara (2007). The efficacy of psychoanalysis and the analytic therapies: Reflections of a psychoanalyst and her former patients. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(2), 313-334.

Earn CE Credit

To earn CE credit, complete the exam for this article on page 70 or complete the exam online at www.americanpsychotherapy.com (select "Online CE").

Dr. Young grew up in a minister's family in the Midwest during the years of the Great Depression. In 1942, she traveled east to attend Johns Hopkins Medical School. She received her psychiatric and psychoanalytic training in Baltimore and has remained in practice there from 1951 to the present. Most of her" patients have been treated with some form of analytically oriented psychotherapy. In 1958 she discovered her creative eye and began to "paint" with a camera. She is recognized today as one of the pioneers in the acceptance of color photography as art by the important museums in the country and is listed among the Modernist photographers of the past 50 years. In her semi-retirement, she has been speaking and writing about the role creativity plays in self-integration and self-fulfillment, and the intertwining of her two professions (See Re-birth at Forty: Photographs as Transitional Objects, (International Journal of Applied Psychoanalysis, 2004). Recently she has done an informal survey of all the patients she has treated during 56 years of practice that contains vignettes written by a number of former patients on how they continue to use today in their personal and professional lives what they had learned in their psychotherapy or psychoanalysis.
I felt very defensive about you asking me
   to do this, but then ... I realized how
   that's what I really live for ... to be held
   by Andrea's gaze.... It is the only time I
   feel complete .... Love for me has probably
   always meant pining for the inaccessible,
   so that I can hardly imagine what it
   would be like to love someone accessible.
   You are teaching me so much.


In the pictures of me with my mother
   as a baby, she was always holding me
   away from her toward the camera as
   though showing off a doll. She posed
   with a big lipsticked smile and seemed
   happy. The pictures are rather inscrutable
   save for how clearly posed they are,
   and she is not posing as madonna and
   child, that's for sure. She wanted my
   face and her face in the camera: "Smile
   and look pretty." I know I was very attached
   to her and pined for her when
   I was put to bed upstairs and she was
   sleeping downstairs in the guest room.
   Even with knowing she was in the same
   house, she still seemed so far away. My
   memories of going to bed during that
   time are of lying upstairs terrified. I had
   two grandmothers and Emy, the cook,
   and Hazel, the maid, also mothering me
   at that time. I don't recall any of them
   being particularly loving or warm. I do
   remember sitting on my grandfather's
   lap; that was my favorite place on earth.
   So often I do feel just like that little
   girl in the upstairs bedroom, waiting,
   waiting, waiting and hoping that tonight
   will be the night that the beautiful
   angel mother will climb the steps to
   check on me, to give me another kiss.
   Yes, that sums up how I feel about my
   entire life and just about every woman
   I have loved.


God forbid the wastrel creature of my
   mother would fix her Medusa stare on
   me and turn my heart--and ambition--to
   stone.... At 13, I lived in a world
   of frightful echoes and fearful symmetries
   I thought could be madness. I was
   prone to virulent temper tantrums and
   cathartic crying fits, triggered by nothing
   that made sense. I would often reel with
   paranoia or helplessness and a desperate
   passion for women who could mother
   me. An almost demonic undertow in
   my psyche sucked me into an early marriage,
   into motherhood when I was still
   fighting for the good grades that would
   prove I was not insane.


I think my parents were worried and
   protective of their first child, [but] not
   so compulsive with me. They thought
   I was lively and enchanting and treated
   me as an entertainment in their lives. In
   most of my memories of pictures with
   my mother, she's smiling at me, as if I'd
   done something amusing. Looking back,
   I think of that mother as my protector.
   She kept me from trouble as she battled
   my teachers (I was in constant minor
   trouble at school and always disappointingly
   underperforming). She also kept my
   older brother from bullying me when she
   found out about it. More than my father,
   whom I admired and wanted to be like,
   she's the one who paid attention to what
   was going on in my life, and that of my
   brothers and sister, a fulltime presence.

      I battled with her non-stop during
   pre-teen years, and was anxious to get
   out from under her shadow as soon as I
   could. My mother was a force! She was
   fierce in her love and her scorn. She was
   solid in her advice, but very strong in advancing
   and defending it, which, unfortunately,
   is a style I've adopted.


My favorite photograph from when I was
   a baby is a picture of my mother and me
   when I was three months old. It's summer,
   and my mother is sitting outdoors
   in a lawn chair with me on her lap. My
   head is resting on her knees, my chubby
   legs are curled up against her chest, and
   she and I are totally absorbed in each
   other. She is smiling down at me with
   absolute adoration, and I am smiling
   up at her with pure delight. Both of our
   mouths are open; perhaps she is cooing
   at me, and perhaps I'm gurgling back in
   glee. I love the photograph because it reminds
   me that my mother once took real
   pleasure in my being.

     Another photograph, which I keep
   tacked over my desk at home, shows me
   in my crib; I'm wearing pale blue, footed
   pajamas, and I must be at least eighteen
   months old. I'm gazing--quite somberly--at
   the person behind the camera. My
   pensive facial expression always strikes me
   as having a melancholy cast. It's certainly
   in direct contrast to the joyful, chuckling
   baby's face in the earlier photograph.
   Why am I not smiling?

      Another memory of my mother and
   me is not captured in a photograph, but
   it's just as vivid in my mind. I must be
   at least four years old. I'm sitting in the
   bathtub, and my mother is kneeling beside
   the tub, giving me a bath. She is attempting
   to sing me a song. I remember
   gazing up at my mother as she ran the
   soapy washcloth over me and struggled
   to sing the song in a cheerful, maternal
   way. It was clear to me--even at age four
   or five--that her performance was an
   act. On some deeper level I realized that
   she was trying to be the happy mother
   who sang to her child as she bathed
   her. I remember feeling a mixture of
   puzzlement and pity as in a detached
   way--I observed her attempt to be the
   'good mother.' Neither of us could enjoy
   this ritual--or so many other motherchild
   interactions throughout my childhood--in
   a spontaneously pleasurable
   way.


Right from the very beginning there
   was an unbreakable bond between
   mother and child which was so interpenetrated
   between their beings that
   neither needed or wanted to speak
   about it later in life.... My earliest
   memories of my mother are of a blob of
   soft pillowy warmth. I was something
   like a bean-bag in her arms, completely
   adapting my contours to hers, folding
   into her totally.


Something had changed. What had
   changed was the awareness that only by
   pushing away could one breathe more
   easily, could one begin to distinguish a
   self apart from this inter-active bonding.
   It was simply impossible to continue being
   too much in her to be out of her. And
   one had to be out of her in order to connect
   to the world which buzzed closer
   and closer and had to be experienced.


This prompted some pretty dramatic
   interchanges between us. I held my
   ground. So did you. Occasionally, you
   would let me carry the day. You provided
   me the safe and secure viewpoint from
   which to see myself as other than essentially
   a forsaken wretch who deserved
   far worse from life than what had been
   meted out to him.... I adored the fact
   that you could stand up to me.... When
   I am determined, I'm pretty formidable
   with words, and I certainly pulled no
   punches with you. And you endured.
   We endured. If it were a war situation, I
   would be proud to pin on your chest a
   medal for valor.


No. of Patients   Re with Therapist   Early re with Mother

1                 Solid               Secure
12                Solid               Secure
5                 Solid               Secure

6                 Solid               Secure substitutes
1                 Solid-reserved      Secure
3                 Solid-reserved      Secure
2                 Solid-reserved      Secure substitute
1                 Minimal             Secure
4                 Entangling          Avoidant/ambivalent
1                 Dangerous           Avoidant/ambivalent

No. of Patients   Re with parents after 6   Catastrophes
                  months

1                 Secure                    X
12                Avoidant/ambivalent       0
5                 Secure avoidant/
                  ambivalent tense
6                 Secure substitutes        X
1                 Avoidant/ambivalent       X
3                 Avoidant/ambivalent       0
2                 Secure substitute         X
1                 Avoidant/ambivalent       X
4                 Avoidant/ambivalent       0
1                 Avoidant/distressed       X
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