Abstract: Specific treatment modalities, such as dyadic psychotherapies, have emerged, based on the notion that in cases of very early relational disorders, the patient is the parent-infant relationship. The aim of this paper is to present a case study of such a relational disorder which took place as the result of a complex interplay between the infant's biological risk factors and the parents' psychological risk factors. The emphasis is on the technique and the course of the dyadic psychotherapy of the mother and her three-year-old child, where the main goal was to change some of the intrapsychic and interpersonal processes specifically related to pathological motherhood. The theoretical background is briefly presented, while emphasizing the criteria for choosing one approach among the different kinds of dyadic psychotherapy.
Winnicott's famous sentence (1), "There is not such a thing as a baby," set the process of viewing the maternal fantasies about her infant as one of the major building blocks for the infant's construction of a sense of identity. Mannoni (2) emphasized the need to understand the role of the young child's psychotic symptom(s) in the individual myth of his parents; for doing so, she argues for a conjoint child-parent psychoanalytic cure. Fraiberg (3, 4), a psychoanalytically-oriented social worker, worked mainly with mothers of babies coming from disadvantaged backgrounds with disturbed patterns of parenting, went further by placing the maternal representations at the core of the parent-infant clinical situation and emphasized the catalysator role of the infant's presence; she suggested viewing the baby as the object of parental transference. Soon after, Lebovici (5) was a pioneer in breaking the "anti-behavior" psychoanalytic approach, arguing that the observation of the real interactions is not an obstacle to the unfolding of the unconscious representations. Lebovici introduced the notion of the dialectic between the real and the fantasied interactions, between the interpersonal and the intrapsychic. He defined the role of the therapist as the one who makes the bridge between these two.These conceptualizations marked the beginning of "infant psychiatry" of a psychoanalytic inspiration. From then on, dyadic psychotherapy became the main therapeutic approach for early parent-infant relationship disorders. In the following years, various trends developed within this approach, both in Europe and in the United States, as a combined result of having to face different types of psychopathology by therapists with different theoretical approaches. Stern, both a psychodynamically-oriented clinician and a observational researcher, did not introduce a new therapeutic approach, but rather proposed a unified view of parent-infant psychotherapy, which stems from his conceptualization of the dyadic (or triadic) psychotherapeutic setting (6). Stern argues that when a child is born, the mother (and to some extent, the father) undergoes a unique developmental stage characterized by a new intrapsychic organization with emotions, fantasies, anxieties and wishes specific to the state of motherhood, called "the motherhood constellation." This intrapsychic material impacts on the quality of the representations she forms of her infant; these, in turn, reflect in her interactions with the baby, who experiences these interactions as satisfying or frustrating, and develops an affective and cognitive representation of "being with Mom"; this representation expresses itself in the baby's (non-verbal) behavior, which in turn is understood by the mother according to her internal representations. Each of them develops cognitive and affective representations of the interactions ("schemas-ofbeing-with"). The sum of these representations will finally define the overall quality of the relationship. The therapeutic setting is diagrammed as following:
The triangle symbolizes the setting in which verbal and non-verbal interactions take place between therapist, parent and child. These interactions are interpreted by each of them on the basis of internal representations. The mother has two types of representations: her self-representation as a mother when she is alone with her child (Mrepl) and when she is in the presence of the therapist (Mrep2). This conceptualization of the therapeutic setting of the dyadic psychotherapy implies that one component influences the other. Consequently, a therapeutic intervention that changes one element may change the whole interactional situation. Stern views the different therapeutic approaches for early parent-infant relationship disorders as different "ports of entry" to the common target being the parent-infant relationship. The therapist may choose between four basic ports of entry, according to the level of organization of the mother's personality, the nature of her "motherhood constellation," the infant's characteristics, and the severity of the relational disorder:
1. The parents' representations as both port of entry and theoretical target
Lebovici, Cramer and their psychoanalytically-oriented colleagues (7) focus on the mother's transference toward the child (Mrep2). This type of dyadic psychotherapy tends to be brief and fits quite highly organized maternal personalities. Differently from them, Lieberman and Pawl (8) work with severe parent-infant relationship disorders mainly due to maternal psychopathology, such as personality disorders and depression. The establishment of a positive working alliance with the therapeutic recognition of the mother's psychological needs is then the first requisite; the mother hopefully experiences a corrective attachment experience (Mrep2) which then permits entry into the mother-child attachment process (Mrep1). These therapies are often long and tortuous, almost by definition. The case we present below tries to illustrate this.
2. The infant's representations (as imagined) as port of entry
This is a technique used by Dolto's school in France (9) and is for the therapist to assume the infant's "voice," as if she were speaking from inside the infant's mind and with the infant's words, if he had them. The dramatization of the infant's conceivable inner experience is usually intended for the parents' ears and is aimed at their representations of their infant. The use of this technique can be effective in claiming more representational space in the parents' minds, provided they are not threatened by the therapist's identification with their baby.
3. The infant's behavior as port of entry
This approach, described by Brazelton and his colleagues (10), aims ultimately to change a mother's representation of her infant and of herself as a mother (Mrep) by focusing clinically on the overt behavior of the infant (B act). It is especially valuable when the infant was born constitutionally weak, and the source of the relational problem is more the mother's difficulty in perceiving her infant's strengths in spite of his weaknesses and to read its cues than psychopathology of her own.
4. The parent-infant interaction as port of entry
Though the use of the actual interactions that take place in the dyadic psychotherapeutic setting is common to all the approaches, Stern (6) suggests focusing on the microanalysis of the videotaped interaction in order to access the mother's representations. Stern does not explicitly mention the clinical criteria for using such a port of entry, though it can be inferred to be useful in cases where a high level of defensiveness and repression impair the mother's ability to bring up her emotion-laden representations. The joint videotaped microanalysis of the interaction works as an effective activator of these.
In the following pages, we present the dyadic therapeutic process of an extremely disturbed early mother-child relationship, while trying to show the port of entry we chose to access the heavily distorted representations the mother had of her baby.
Description of the Case
N., a three-year-old girl, was referred for the psychiatric evaluation of a complex clinical picture including refusal to eat, failure to thrive with severe motor, cognitive and verbal developmental delay, refusal to be toilet trained, and aggressive behavior towards peers.
N.'s Past History
N. was born in the thirtieth week of pregnancy, the smaller of identical twin girls (900gr versus 1600gr), in a family of four. A previous child had died of SIDS at the age of seven months. At first, the mother wanted the pregnancy, but then she violently rejected the idea of twins: "I wanted only one child, not two. I don't want them!" The pregnancy was difficult, and at the thirtieth week, one of the fetuses showed signs of distress, which necessitated caesarean section. Three years after, the mother was still emotionally laden about it, as reflected in her remark "I wasn't prepared for that kind of birth. They [the doctors and her husband] decided on the operation without taking me into consideration. It was only the twins who mattered." Both twins stayed at the neonatal intensive care unit. S., the larger one, was healthy. The smaller one, N., was in critical condition. Both parents recall the moment they were told that N.'s chances of survival were almost nil: The mother turned away from N., saying: "She'll die anyway," and went to the healthy twin; the father said nothing and went over to the sick one. S. was released home after a month. N. stayed there for seven months because of resistant tachypnea of unclear etiology. The mother barely visited the Unit; the staff, assuming she had to take care of S., did not worry about her absence. The father stayed at N.'s bedside. The long hospitalization had its known psychological side effects, such as the presence of multiple figures, the lack of stimulation, the experiencing of painful procedures - all of which were connected to seven-month-old N.'s general developmental delay. The fact that N.'s mother had given her up and was behaving as if she had given birth to only one baby (as was her original plan) had not been recognized. The father was N.'s main attachment figure. N. was discharged home at the age of seven months. The mother was unwilling to accept the fact that her daughter had survived. The father worked long hours. The mother recalled her difficulty in physically approaching N. and explained: "They kept telling me she would die, and here she is, at home!" Indeed, N. spent most of the day lying in bed, not playing, not crying and not asking for anything. Three months later, N. was rehospitalized, because of respiratory distress and active refusal to eat. She looked sad, had no interest in playing. A gastrostomy feeding tube was inserted, but N. did not gain weight or height. No specific organic etiology was found. The medical staff, and the parents in its wake, took the position of "let's wait and see." Follow-up became irregular. N. took her first steps at the age of three. Contact with the family was broken off until they were referred for psychiatric evaluation by the nursery school teacher.
At the evaluation, N. looked much smaller than her age and her speech was equivalent to that of a one-and-a-half-yearold child. She had big, black eyes in her tiny face, eyes that seemed to still be waiting for answers to unspoken questions. Her behavior was excessively sociable and she did not differentiate between strangers and people familiar to her. She smiled a great deal, a smile that transmitted a blend of both stubbornness and responsiveness to adults. N. gave one the feeling that she understood more than she appeared to. Her physical stance was marked by tension, as if she were in a state of constant alert. Her attention span was quite limited, and she barely touched one game before moving on to the next. N.'s play content was poor but significant: "There's no mommy in this house. Daddy's working." To the question "Where's mommy?" she replied, "There is no mommy. A secret." Her drawings were no more than scribbles. N.'s observed cognitive functioning was appropriate to that of a two-and-ahalf-year-old child. The curiosity and learning ability she demonstrated during the psychological tests raised doubts regarding the diagnosis of mental retardation, indicated by the formal results. N's mother, C., directly and uninhibitedly expressed anger and hostility towards N. who "doesn't eat and doesn't grow." She expressed great distrust in the medical system, declaring that she was absolutely not a partner in N.'s therapy and placing all the responsibility on her husband. While N. continued to glance at her mother, she did not approach her. Her mother mocked her: "Here's our monster." N. retreated even further. N's father, A., seemed to be a secure base for N., although he missed several of her non-verbal appeals.
N. was diagnosed as suffering from a disorder of attachment and feeding disorder, with severe physical, cognitive and socioemotional sequelae, to which contributed her difficult past medical history. Indeed, the combination of pathogenic biological factors of the child, such as severe prematurity, and psychological factors of the mother, such as narcissistic personality disorder, totally disrupted the process of attachment. The mother's unconscious wish that the sick premature infant would disappear - since in any case she only wanted one child - was given legitimacy and substance when N. was defined at birth as a hopeless case. Her gesture of turning her back on N. in the premature nursery reflected the final step of the detachment process. Still, thanks to the father's presence, N. was able to experience a continuous affective relationship throughout her long hospitalization. His presence had the effect of protecting and supplying her with primary narcissism, the grounds for survival. When she came home, she lost that anchor of the father, who returned to work; she was then exposed to the rejection, this time active, of her mother. Two months later, N. was refusing food, as an active protest, parallel to the mother's refusal to accept her, as well as a depressive symptom, an unconscious fulfillment of the mother's wish for her extinction. N.'s refusal to eat had not been understood by the medical staff as an active distress signal, but rather as a "symptom without a specific etiology." This position led the doctors to carry out a gastrostomy that impaired all areas of N.'s functioning without solving the problem. The eating disorder turned into a persistent symptom, including secondary gains (like bringing the mother to the kindergarten at mealtime). At this stage, the medical staff was at an impasse, and in a way, left N. to her fate, which in the mother's fantasy was death.
Having concluded that N.'s major problem was a disorder in her primary relationship with her mother, we chose the therapeutic modality of dyadic therapy. The extent of N.'s developmental arrest, the risk of having it become irreversible, the extreme negative perception the mother had of this child, conveyed to us a sense of urgency; the mother was extremely resistant to the idea of starting a psychotherapy of her own, which anyway would have been a long-term one, taking into account the narcissistic structure of her personality. She did seem to have some capacity for insight, though her own needs for nurturance and mirroring were obvious. We therefore opted for a psychodynamic dyadic psychotherapy. Our main goal was to change the mother's and the child's reciprocal representations, so that the process of attachment could take place. This therapy lasted for two years.
The Course of the Therapy
During the first three months of therapy, C. came to the therapist like someone in need of narcissistic refueling, and made clear this was a precondition for her cooperation. Only once her primary narcissistic needs had been fulfilled was she ready to hear the therapist reflecting on the non-verbal interactions that were taking place between her and her daughter. She gradually became aware of N. trying to reach her, to catch her look, and of herself not responding to her. N. sensed this slight change, and encouraged by the therapist's presence, drew closer, and without looking at her or saying anything, laid her head on her mother's knees. The mother denied the meaning of this gesture, saying, "She's just tired," and did not touch her. The therapist's suggestion of an alternative explanation of N.'s gesture brought up the mother's representation of N. as "a tiny baby made of crystal that you cannot touch," which dated from the Neonatal Unit period. Interestingly, while describing this vivid representation, C. inadvertently touched N. lightly on the head. N. looked at the therapist, who "answered" both of them: "Since then, you've grown, and you're not made of crystal, and no one has to be afraid to touch you." The mother picked up the word "afraid" and told how threatening the experience of the premature infant unit was for her: "It was frightful to look at N. in the NICU unit," an expression that linked up with her turning her head during the assessment session.
For months, C. expressed her ambivalent concept of N. as fragile and in need of protection (at the expense of the experience of growing and learning), on the one hand, and as a threatening, monstrous object to which one cannot become attached, on the other. C. still was not ready to give up this image, but her facial expression gradually became less angry and suspicious. The child, on the other hand, smiled a lot, hardly spoke, and looked for the therapist's approval to explore the room.
A turning point occurred around the material raised by N.'s play with a big teddy bear attached to a smaller one. The mother exclaimed "See, you're connected to Mommy in the stomach!" and went on freely associating "I wanted them...after all, I could have had an abortion...This week, I went to my gynecologist for a checkup. I don't know why he asked me how N. is doing. I replied cynically that she's in an institution, and he said: 'I knew it!' I asked him what he meant, and he said, `Yes, it was clear that you didn't want her!' C. looked at the therapist with contempt, saying "You, doctors, you don't understand anything...No one ever understands me." A long silence followed. N. was playing very quietly with clay, as if she sensed her mother was about to say something important. Indeed, she did: "That birth...they should have prepared me... it's impossible to give birth in such a brutal manner...and when she was born, it was obvious that she wouldn't live. How can such a small thing live? ... Look, I already had one infant who died. And he was healthy, big, beautiful..." The therapist just added "and that pain has still not gone away until today," and C's eyes filled with tears. N. lifted her head, and this time turned her glance at her mother. "Even my husband doesn't know that all these years I've kept a picture of that baby in my bag...he was seven months old (the same age N. was when she came home for the first time). A week ago, I threw away all the pictures, enough, I can't do anything about it." N. came closer to her, C. gently patted her head. The therapist added, "and now you can make room for her and start from the beginning..." N. climbed onto her mother's lap, and snuggled in her arms. C., thinking aloud, murmured "how much she has lost." They remained hugging each other silently, like the two teddy bears. N. made the gesture of wanting to give the therapist a kiss. The therapist told her: "This is a kiss that has waited and waited until Mommy could accept it...it's a kiss for your Mom." N. smiled. C. asked hesitantly: "It's for me? A kiss?" N. kissed her.
Touching the pain, while feeling she was understood and not criticized, had enabled the mother to touch her daughter. Indeed, the attachment process was taking place, and the next developmental step for the child was to dare ask and say "no" (other than by refusing food). The parents reported that N. had started to compulsively kiss her mother's feet, but still avoided her face, and would repeatedly ask whether they love her. C. understood this behavior as a fear of seeing rejection in her eyes. The level of the mother's insights improved, and she began to create a representational space for N. The child dared, for the first time, to compare herself with her twin sister, asking "Why not me?" or "If I can't climb the ladder like S., will you love me?" N. started to feel confident enough to say "no" to her mother, first in the therapist's presence, then at home. As taking a further step towards self-identity, N. started to ask about the reason of her being half the size of her twin sister. Her questioning reactivated the "monstrous" representation C. had of her child, as soon as she was reminded of N.'s sick parts. She would try to minimize the problem: "You only need to eat more, and then you'll grow and be like your sister." C. reacted to the therapist's remark of looking tired by disclosing another past representation: "I'm tired of trying so hard...you know, I used to pray I'd find her dead, I didn't buy her any toys or clothes, only for her sister I would; her sister used to say: 'N. will get my hand-me-downs."' While her mother was disclosing this threatening fantasy, N. took a syringe-toy and put it in her mouth, as if eating from it. C. reacted strongly: "No, no, you put a syringe in your bottom to take your temperature." Therapist: "Correct, but maybe N. remembers eating from a syringe and she just heard how important it is for you that she grows fast, to be like everyone else." At the end of the session, for the first time, N. had a hard time separating from her mother. C. noticed the change and said: "You know, her twin apparently feels the change. A few days ago, she said to me: 'I love you, even though you're also N's mother!"'
After a year and a half of therapy, a reevaluation of the situation was conducted in a multiprofessional psychiatric/pediatric meeting with both parents (for the first time C. had agreed to join such a meeting). The areas of improvement were noted, such as the quality of the mother-child relationship (appearance of separation anxiety), the eating behavior (closure of the gastrostomy, N. ate orally both at home and in the nursery school, although not enough), the socialization behavior (N. has stopped biting other children and shouting, became well-accepted by the other children, and her play had become more "sharing"), the language development (complete and clear sentences), and toilet training had been achieved. However, despite this progress, there had still not been a significant gain in weight or height. It was therefore decided to add a nightime feeding tube. This decision had a double psychological significance: for the mother, it was experienced as a new narcissistic injury, with a retreat to the "days of sickness and medical treatments"; to the child, it meant punishment for not having eaten and grown enough. During the first weeks of the night feeding, C. did not touch the instrument, leaving all the responsibility to her husband and older daughter. The two of them "rebelled" and C. had no choice other than starting to be involved in the treatment. She needed almost daily support from the therapist. Gradually, she began to accept the sick - to her, repulsive - part of N., through the necessity to handle the feeding instrument. N., for her part, gave her mother an enormous reinforcement, when one morning she called out to her father in a shout of joy: "Mommy learned, Mommy learned!" Nonetheless, the process of re-acceptance turned out to be very slow. There was frequently a need for reaching out: C. would not come to the joint meetings with N., giving various excuses for her absence. It was interesting to see that N. "covered" for her, as if she were telling the therapist: "Don't be angry with her, it's hard for her, don't give up on her..." Slowly, N.'s weight and height increased, and her cognitive level literally jumped.
This dyadic therapy ended at the close of its second year. At the last session before parting, N., holding the small teddy bear, said to it: "Mommy will look after you when the doctor goes away." C. understood what she meant and after a long silence, said: "Maybe this is for the best" (she herself was having a hard time with the pending separation).
Already at the very beginning, the mother brought up her distorted and negative representation of N.: "our monster." N. also gave us a hint of her representation of the absent mother. The port of entry we chose was the mother's and the child's respective representations of "being-one-with-the-other." The process of changing C.'s inner negative image as a mother to N. was slow and necessitated first a gradual change in the therapist's image of her as a mother, from a monstrous mother who rejects her child (the same monstrousness that is projected on N.) to a desirable mother despite her "bad parts," enabled her to create a positive transference towards the therapist. Only then did C. expose the pain associated with the loss of the-healthy-infant-who-died. Freud wrote after the death of his daughter: "It is an unbearable narcissistic blow, the grief comes only later"(11). It seems that in our case the sudden death of the "perfect" baby caused an irreversible fracture in C.'s intrapsychic maternal structure. C. was unable to become attached to N., who was identified with death. This differs from what Stern wrote about the very small premature baby: "The 28-week premature baby is doubly disadvantaged, being hit with a developmental lag in his own functions and unfinished representations in his/her mother's mind." N. was linked to a world of images in her mother's mind, but these were images of death and loss. We may understand N.'s lengthy depressive picture as a result of projective identification with these images. C. did become attached, albeit in an ambivalent manner, to the second twin, since she was healthy and, as such, did not constitute a narcissistic wound for her. By relating to the loss of the infant, it became possible to gradually separate the dead infant from N., until the latter could be seen as a "living being" (in C.'s words). Moreover, touching on the pain of losing the healthy infant "connected" C. to her long-lasting distress. To the extent that distress is necessary for a therapeutic change to occur, this stage was necessary to form a working alliance. C.'s question, "The kiss, for me?" reflected her negative parental self-image, which began to change under the impact of the interactions taking place in the room: N., who kisses her mother, thus pointing to the existence of some parts of good motherhood. Then, and only then, C. could touch her negative feelings towards N., i.e., the death wish, as reflected in her saying "I used to pray I'd find her dead..." In parallel, N. started with a striking representation, reflected in her only sentence: "There's no mommy, a secret," Did the "secret" relate to the dead infant who "hovered" over her and whose photograph had remained for years in her mother's purse? Perhaps. The experience of the "look that did not succeed in meeting the mother's glance" was apparently also a schema-of-being-with-mother. The stages of change in the schema-of-being-with-mother were reflected in the development of attachment behaviors: first the transfer of the glance from the therapist to the mother, the transfer of the kiss from the therapist to the mother, first by kissing her feet, and later her face, and finally asking if she is loved (allowing herself to draw closer when she senses that the level of rejection has been reduced). The last stage, the passage from the therapeutic triad to the father-mother-child triad, was reflected in the child's exclamation: "Mommy learned, Mommy learned," and was made possible when in parallel, the mother accepted the child's sick and threatening parts.
Dynamic dyadic psychotherapy is not a substitute for "classical" psychotherapy; rather it is a form of therapy specific to early mother-very-young-child (up to the age of three) relationship disorders. The difference does not lie in the nature of the topics that are worked through (basic trust, dependence, independence, control, separation, selfregulation, etc.), but in the way in which they come up, and in the specific context of parenting an infant: the parent-infant interactions play a key role in the therapeutic situation since they reflect the unconscious and pre-conscious parts of parenting, on the one hand, and the contribution of the infant, with his/her strengths and weaknesses, as a partner in the "dialogue," on the other.
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Miri Keren, MD,1 Sarah Spitzer, MD,2 and Samuel Tyano, MD3
1 Community Baby Clinic, Day Child Dept., Geha Psychiatric Hospital, Petah Tikvah
2 Day Child Department, Geha Psychiatric Hospital, Petah Tikvah
3 Geha Psychiatric Hospital, Petah Tikvah
Address for correspondence: Dr. Miri Keren, Geha Hospital, P.O.B. 102, Petah Tikvah 49100, Israel…