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Article Excerpt
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...
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