Selected Observations of an Infant With Clinical Implications for Adult Psychotherapy

The following extracts consist of my observations of a new-born infant, Imogen, in interaction with her mother, Bernie, as well as with myself as a participant observer. The observations were on a weekly basis for 18 months, each observation lasting an hour.

In addition to recording the key phases/domains in Imogen’s development, and the organisation of a secure pattern of attachment, several of the observations include my spontaneous subjective responses and idiomatic theorising of work with adults to which the experience of observing Imogen gave rise. The latter have been left unreferenced, but the discerning reader will have no difficulty in identifying their source.

My chosen method of observing is participant observation. This methodology is consonant with theoretical and philosophical assumptions deriving from systems theory, interactionism, phenomenology and social constructivism. Systems theory holds that the observer ineluctably becomes an interrelated and interconnected element of the system as a whole, both influencing and being influenced by the mutual interactions of the system and its environment. Interactionism, phenomenology and social constructivism emphasise, in their respective ways, the sociability of subjective experience and behaviour, the situated, context-bound nature of human existence, and the socially constructed nature of knowledge and the self. It will readily be appreciated that such theoretical and philosophical assumptions inform both developmental studies and contemporary relational models of adult psychotherapy.

Observations

Observation No 13. Age: 15 weeks.

Imogen was in an alert state when I arrived, avidly sucking her fingers. Her mother, Bernie sat her on her lap sideways on so that she was face-to-face with me. Imogen smiled and engaged me with her gaze. I accompanied my gaze and facial mirroring with vocalisations. Imogen did not employ any vocalisations but responded to this modality by increasing the intensity of her gaze and widening her smile and the fullness of her mouth opening, thereby matching my vocalisations cross-modally. The affective intensity of our engagement gradually increased, with Imogen displaying a gape smile and prolonging her visual regard of me.

After intense periods of mutual engagement, Imogen would look away every so often, while staying oriented en face. She seemed to be using gaze aversion to regulate the exchange and thus her state of arousal. At such times, I lowered the intensity of my stimulation so as to allow her the time and the space to re-regulate her affective state. After a while, Imogen would signal her readiness for more social play, and a similar mutual exchange would take place. This developed into something of a pattern, occurring four or five times.

If I were to make an inference from my observation of Imogen’s actions and behaviour, I would say that she was experiencing pleasure from this interaction. Reflecting on my own feelings, I, too, was experiencing a heightened psycho-physiological state consisting of joy and pleasure. Thus, it would seem that the matching of Imogen’s and my own varied behavioural display, and the sense of self-agency deriving from such mutual influence, reflected a shared inner subjective state consisting of pleasurable feelings.

Later, I held Imogen face-to-face while Bernie made coffee. Initially, Imogen showed a clear preference for interaction with Bernie. Although she was sat en face to me, she kept her head turned to the right so that she could exchange gaze and facial expressions with Bernie. It was almost as if their mutual gaze consisted of an invisible umbilical cord keeping them connected, despite their physical separation. After a while Imogen withdrew from interaction with Bernie, turning her head to face me. I stood her up so that she could flex her legs and kick against me, and I occasionally lifted her into the air. The dominant modalities on Imogen’s part during this exchange were again kinesic rather than vocal, in that she used physical movement and changes in direction of gaze and facial expressions.

I became aware that I was matching and tracking Imogen’s movements and expressive display cross-modally through the nuances of my vocalisations. Again, she regulated the intensity of the exchange by averting her gaze, looking slightly to my left every so often, though staying engaged, albeit on a decreased level of affective intensity. I was sensitive to these changes, anticipating and tracking her moves and responding by affectively matching the timing and duration of the interaction. Thus, when Imogen was behaviourally active, I would become behaviourally “silent” and also decrease the frequency and tone of my vocalisations; when she was “silent” behaviourally, I would respond in a somewhat more stimulating way. We seemed able to match the timing and rhythm of our exchanges, taking turns in the movements of this “dialogue”, anticipating and responding to each other’s behaviour and affective display on a moment-to-moment basis.

At one point, Imogen looked away to her left. Her gaze took on a dreamy, trance-like quality as if she were looking inwards rather than seeing anything in the environment. Almost automatically, my vocalisations became rhythmically slower and more measured with a soft-toned inflection. Even my choice of words seemed to mirror Imogen’s facial expression, in that I said “There’s a dreamy look”. This phrase was intoned in a dreamy sort of way and with a modulated descending musical pitch. The very fact of observing Imogen’s change of mood affected my own subjective state which became calm, peaceful and reflective. I felt drawn to mirror Imogen’s mood and behaviour with my own soft-focused gaze and gentle musical vocalisations. This was a beautiful moment which Bernie took pleasure in as well. Again, it seemed to demonstrate the extent to which Imogen was regulating both her own self-states and influencing the quality of the affective exchanges with Bernie and with me.

Some moments after this quiet interlude our social play gradually broke down. Imogen started to frown and became fretful, averting her gaze and then turning her head away from me towards Bernie, who was sitting on my right. I handed Imogen to Bernie who instinctively realised that she was both hungry and tired. She put Imogen to the breast and stroked her arm gently from shoulder to hand several times. All of this seemed to have a calming, mesmeric effect on Imogen who kept her eyes closed and soon fell into a deep sleep. As well as being tired, perhaps part of the reason why Imogen avoided mutual gaze with Bernie whilst feeding was because she needed to re-regulate her state of arousal after having engaged in a fairly long and intense period of social play.

Imogen awoke just before I was due to leave and was soon in an alert state signalling her readiness for more social play by smiling. I felt quite torn at having to leave at this point, feeling drawn to engage in further play with her.

In terms of work with adults, today’s observation would seem to emphasise the importance of mirroring or matching between therapist and patient, as such symmetry in behaviour appears to provide a behavioural basis for insight into each other’s rhythm, perception and feeling state. By these means, the therapist’s psychophysiological state (countertransference) becomes an additional source of information about the patient’s subjective experience that cannot be accessed or known directly.

On a behavioural level, then, turn-taking would appear to be an important aspect of positive affective matching and to be associated with a congruence of feeling states. In adult work, such positive matching or affective congruence may be manifested verbally through the taking of turns in the analytic dialogue during which the therapist and the patient come to match the rhythm and duration of each other’s vocalisations and pauses on a moment-to-moment basis, largely out of conscious awareness. On the other hand, should the participants talk over one another, or misread an intrapersonal pause for a “switching”, interpersonal pause, thereby taking the speaker’s role out of turn, this is likely to be experienced as an impingement. Derailment of contingency or attuned responsivity is likely to follow, together with the loss of mutual influence.

Should such ways of relating prove characteristic of the patient, causing the therapist to respond in uncharacteristic ways, this may indicate that the encounter consists of a re-enactment of an implicitly encoded troubled object relationship. Not only will such mutual enactments and consequent ruptures to the working alliance need repair, but also provide important countertransferential information about the patient’s formative experiences, in terms of security of attachment and quality of object relations.

Just as with the infant, gaze aversion in the adult patient may indicate that the interaction has become too intense, arousing and anxiety-provoking. At such times, therefore, it is likely that the patient will need the time and space to self-regulate his or her anxiety or state of arousal before engaging in more active work. Sensitivity of this kind by the therapist may, in itself, prove therapeutic, helping the patient to feel known, understood, and on the same wavelength as the therapist. Thus, it would seem that the therapist’s attuned, non-verbal response or contingent “style of being and relating” in the implicit domain of relatedness is instrumental in establishing trust and a “holding” environment or good enough secure base from which to explore and regulate painful affect and unresolved trauma. This, in turn, may assist in generating a therapeutic alliance. Within a safe, benign setting the therapeutic relationship may develop into a truly collaborative one in which both transferential and developmental issues can productively be re-organised, modified and integrated.

Observation No 14. Age: 16 weeks.

Imogen was asleep on my arrival but awoke shortly afterwards. As usual, Bernie sat Imogen facing outwards towards me. Although Bernie was in the process of telling me something very interesting about her work, I found my attention ineluctably drawn to Imogen who was signalling her readiness for social play by gazing at me and smiling. Bernie continued to talk to me and I found myself trying to divide my attention between her and Imogen. As a consequence, I failed to engage fully with either of them, being unable to concentrate on what Bernie was saying or to interact with Imogen at a level of intensity that seemed appropriate to the cues she was expressing. Seemingly as a result of my lack of a contingent response, Imogen became subdued and started to fret and intermittently cry.

Imogen’s cry and vocalisations had a rather pathetic, pitiful, “poor me” quality to them and seemed expressive of a general sense of discontent. She displayed a good deal of half-hearted grimacing, accompanied by some frowning, and seemed not to know what to do with herself or be able to self-regulate her fractious state. Bernie thought she had not slept for long enough and was still tired. She employed various strategies in an attempt to comfort her, including vocalisations, rocking, sitting her face-to-face, holding her close and patting her back. None of these methods was effective in helping Imogen to regulate her fretful state. It seemed to me that something of a battle of wills was taking place over the issue of control, in that Imogen, as had become customary, wanted to be put to the breast for comfort, whereas Bernie wanted Imogen to settle without the breast. This struggle had a familiar feel to it, seemingly characteristic of a pattern of interaction that had developed between Bernie and Imogen almost from the word go. Throughout the several weeks that I had been observing, I had never known Imogen lose this particular battle, and, sure enough, she eventually triumphed!

The quality of Imogen’s interaction with Bernie over this issue appeared to have changed in subtle ways during the course of her development. Whereas in the first weeks of life Imogen’s fretting and crying had seemed involuntary. Now, however, her expressive display appeared to be under her voluntary control and, moreover, employed in an instrumental way so as to elicit from Bernie the expected contingent response. In this instance, to be put to the breast.

In a similar way, Imogen now seemed adept at using her smile for the specific purpose of eliciting social interaction, whereas in the early weeks of life her smile appeared to lack this aspect of voluntary control. These developmental changes, particularly Imogen’s readiness for interaction and seeming anticipation of being able to influence and regulate social exchanges in self-agentic ways, would appear to indicate that she was beginning to acquire a rudimentary, but durable, sense of herself as physically separate and distinct from Bernie.

Whilst at the breast, Imogen sucked intermittently, pausing every so often to pull away and look about her in a drowsy state. She would then turn towards Bernie and seek out the breast. A delightful interaction developed between Bernie and Imogen as she fed, with each taking turns to push against the other’s open palm, grasp one another’s hand, and then gently pull away from the other’s hold. The two of them seemed to be matching their movements, with first one and then the other taking the lead in a push/grasp/release rhythmic pattern that had spontaneously arisen. All of this appeared to be happening out of Bernie’s conscious awareness, but nevertheless to take on something of a behavioural “conversation”, the timing and rhythm of which seemed to resonate with Imogen’s affective state and way of being at the breast on this particular occasion. Far from feeling controlled or resentful at having given in to Imogen, Bernie seemed to take pleasure, both in Imogen’s ability to be soothed and by her playful interaction whilst feeding. These exchanges appeared to act as a powerful “hook” for Bernie, eliciting her continued positive attention to Imogen’s needs, as well as strengthening the bonds of attachment and love between the two of them.

Bernie remained seated with Imogen on her lap as I stood up to leave. I loomed over Imogen, inadvertently bringing my face too close to hers. Imogen’s eyes grew serious and her facial expression took on a look that I interpreted as fearful. I adjusted the proximity between us by a short distance, whilst at the same time smiling and vocalising. Imogen’s fleeting fearful look changed and, instead of breaking into a cry, as had seemed likely, she recovered her equilibrium and smiled in response.

My subjective responses during this observation ranged from a keen sense of disappointment at the lost opportunity to engage with Imogen in social play at the start of the observation, to a degree of guilt for giving neither Imogen nor Bernie the attention that each seemed to require. In identification with Imogen, I experienced a sense of relief, tinged with omnipotence, when Bernie finally succumbed in the battle of wills that had developed between them and gave Imogen the breast. Observing Imogen’s and Bernie’s gentle, rhythmic social play with their hands generated a sense of pleasure and contentment within me. Moreover, I became aware that the timing and tonal quality of my own conversation with Bernie had adapted to the rhythm and affective quality of their interchange. Thus, it seemed to me that my feeling state and behaviour were being influenced by the touching expressive display I was observing.

The fact that Imogen felt able to cease sucking the breast and look outwards before returning to suck, would seem to indicate both a sense of trust in the continuing availability of Bernie, and a sense of an emerging core self. From these observations, it may be inferred that Imogen was beginning to experience herself as distinct and separate from Bernie and, therefore, as having the capacity to relate to her as other. Furthermore, Imogen’s pulling away and returning behaviour whilst at the breast may be seen as her testing out this developmental leap.

On considering what lessons this observation may have for work with adults, it struck me that my failure to respond adequately to Imogen’s signals, and her subsequent querulous reaction, demonstrated the importance on the part of the therapist of maintaining the frame by keeping external distractions to a minimum, thereby providing the patient with one’s undivided attention within a safe setting. Moreover, the way in which Bernie and Imogen negotiated the developmental issue of control seemed instructive, showing that a flexible, sensitive response by the therapist may prevent a potentially confrontational situation from arising and, instead, lead to a gradual build-up of trust and attachment between therapist and patient.

Furthermore, should developmental issues such as trust, mastery and control take centre stage in the therapeutic relationship, this may alert the therapist to the possibility that the patient’s relationship with his or her caregiver had been problematic in these respects. Indeed, such issues may be tested out by the patient with the therapist in ways not too dissimilar to those employed by Imogen whilst she was at the breast, in that, following a successful encounter or moment of meeting, the patient may disengage. Successful disengagement leading to a mutual restructuring of intersubjective experience will depend on the patient being sufficiently confident of the continuing emotional availability of the therapist. Such repeated experiences may, in turn, enhance the patient’s “capacity to be alone” in the presence of the other. Awareness of these issues and implicitly encoded relational dynamics may help the therapist to affectively attune to the patient, thereby avoiding getting stuck in repetitive transferential re-enactments, and, instead, to become available as a new developmental object, different from the original pathogenic caregiver.

On reflecting on Imogen’s fearful reaction to my looming over her, this incident graphically illustrated for me the importance of the therapist maintaining an optimal distance from the patient, both in physical and psychological terms. With regard to the latter, the therapist should guard against pursuing the patient with intrusive interpretations or questions. Sensitivity of this kind will particularly apply in cases where the patient’s personal integrity has been violated, such as trauma arising from abuse of one form or another. Here, a delicate balance will need to be achieved in which the therapist is neither excessively emotionally detached from the patient nor excessively intimate and intrusive. That said, regardless of how sensitive and empathetic the therapist may be in general terms, ruptures to the therapeutic alliance are bound to occur, given that the therapist, like the mother, may only be “good enough”. The therapeutic task will then become one of repairing ruptures on a moment-to-moment basis. How this is accomplished will vitally affect the therapeutic relationship, acting either to facilitate or forestall the development of the patient’s true self and validate his or her subjective experience.

Observation No 15. Age: 18 weeks.

Imogen was in her baby-seat on the kitchen table on my arrival. She was being fed solids by her 14-year- old sister, Louise. Imogen had been started on solids a few days earlier and seemed to have taken to them quite readily. She ate avidly and was adept at taking food from the spoon. All the while Imogen vocalised in an intense way and “cycled” her arms and legs. The intensity and positive expressive quality of Imogen’s responses to being spoon-fed led me to infer that she was experiencing a state of pleasure and contentment. Imogen did not engage Louise with her gaze a great deal but, instead, looked around in an all-embracing way without focusing on anything or anyone in particular.

This interaction developed into a pattern, in that after taking a spoonful of food, Imogen would allow Louise to spoon off excess food from her mouth and chin. She would then turn her head to her left away from Louise and survey the surroundings whilst eating contentedly. When ready for more food, she would turn her head to her right towards Louise. If this movement met with the expected contingent response from Louise, Imogen’s affect remained positive and the mutual pattern of interaction continued its smooth, uninterrupted course. However, whenever Louise was slow in having the spoon re-charged with food and appropriately poised in response to Imogen’s head turn, Imogen was quick to signal her displeasure, frowning, grimacing and changing the quality of her vocalisations from contentment to disgruntlement. This influenced Louise to respond by quickening her own pace in an attempt to keep up with the rapidity of Imogen’s feeding behaviour.

On having consumed the fruit and yogurt mixture, Imogen appeared satiated. Nevertheless, she broke into a state of crying when no further food was available, seemingly unable to regulate her evident distress. Bernie responded by putting Imogen to the breast, more for comfort and to help her settle than because she was still hungry. Within moments she fell into a deep sleep.

In terms of temperament, Imogen’s readiness to take solids, and the skill with which she managed spoon-feeding, demonstrated a good capacity for adaptability to new experiences. Her vocalisations and motor activity whilst feeding showed a characteristic intensity of response. The rapidity and persistence of her feeding behaviour would also seem to be characteristic features of her temperament. The change in Imogen’s positive affective display when Louise failed to match her rhythm and contingent expectations (being too slow to re-charge the spoon with food) again illustrates the way in which developmental issues of control, mastery and trust in the early months of life often centre on interpersonal interactions during feeding.

As I observed Imogen spoon-feeding, I experienced a mixture of amusement, amazement, admiration and something akin to awe, not only at the new skill she was demonstrating, but also because of the intensity of her pleasure and, most of all, at the way in which she was using a range of positive and negative expressive displays to influence Louise’s behaviour. The inference I made from these observations was that Imogen was employing these displays in instrumental, self-agentic ways so as to ensure that a spoonful of food was available on demand. Thus, Louise felt constrained to adapt her leisurely pace to the more urgent rhythm of Imogen’s pattern of feeding behaviour. Delay and deferred gratification were clearly not on Imogen’s agenda at this stage in her development!

The interaction between Imogen and Louise, as well as Bernie’s subsequent response when Imogen began to cry, brought to mind technical dilemmas concerning how to distinguish an instinctual wish from an “ego need”, and whether to gratify or frustrate a patient’s desires and requests. The latter may take the form of direct questions about the therapist’s personal life, or requests to borrow a book, use the telephone or schedule an extra session. For those patients who have suffered deficits and developmental failures in early life, desires may more helpfully be construed as representing ego needs rather than instinctual wishes. In certain instances, meeting a demand or a need may prove beneficial, helping to heal a patient’s “basic fault”, forge an emotional connection, and, thereby, overcome a therapeutic impasse. On the other hand, granting a wish may amount to infantilising the patient and thus engender familiar unhelpful feelings of dependency and lack of control, mastery and self-regulation. Gratification may also lead a patient to escalate his or her demands with greater intensity (rather as Imogen seemed to be doing with Louise and Bernie). Not being drawn into a familiar gambit for rescue may therefore be powerfully reassuring for a patient and enhance his or her sense of separateness and individuation.

Decisions about how to respond to a patient’s requests and desires are informed by the countertransference and the affective tone and context of the therapeutic relationship. Accepting that countertransference responses carry important information about the meaning a patient attributes to a desire, subtle differences in the countertransference may enable the therapist to decide how best to respond.

Observation No 16. Age: 23 weeks.

Imogen was in her baby-seat on the kitchen table engaged in interaction with her 18-year-old sister, Madeleine, when I arrived. Because of Bernie’s and my own respective holiday arrangements, three weeks had elapsed since I had last observed Imogen. She had grown and rounded out considerably.

Imogen had just had a breakfast of solids and seemed content to survey her surroundings with a steady gaze. She gazed at me in this way, vocalising in a rather measured way, but otherwise not responding to my attempts to engage her in social play. In the meantime, Madeleine was busy preparing a packed lunch. Each time she passed Imogen, she (Madeleine) would playfully tickle her or tousle her hair. Imogen responded by gurgling with delight and eagerly turning her head to follow Madeleine until she was out of her line of vision.

Bernie shifted the angle of the baby seat so that Imogen faced more into the kitchen, rather than outwards towards the French windows and the garden. This seemed to unsettle Imogen, who immediately started to fret. Bernie responded by lifting her out of the chair and sitting with her face-to-face.

Imogen’s mood seemed labile, in that she fluctuated rapidly between engagement in social play and fretting. Her plaintive vocalisations were expressive of this indeterminate, betwixt and between state. Several times, Imogen burrowed her head into Bernie’s body, flexing her legs and arching her back. She then put three fingers in her mouth to suck. After a while, Imogen turned towards Bernie and started to root for the breast. Bernie responded to this cue.

While feeding, Imogen gazed intensely at Bernie for short periods, interspersed by closing her eyes. All the while she kept moving her free left arm, often holding it in the air with open palm. Each time Imogen did this, Bernie took hold of her hand. Imogen would then wrest herself free from Bernie’s hold and grasp one of her fingers. This interaction continued until Imogen dropped off to sleep.

Although appearing to be asleep, Imogen continued to suck intermittently. Bernie stimulated Imogen to suck by gently stroking the corners of her mouth with her forefinger. At one point, Bernie withdrew the breast. Without opening her eyes or seeming to wake up, Imogen signalled that she still wanted the breast by a display of urgent rooting behaviour. Bernie continued to make the breast available and Imogen soon fell into a deep sleep.

A little later, Imogen was suddenly awoken when Bernie shifted her position. She looked dazed and disoriented. At the same time that this happened, there was a knock at the front door. Bernie unceremoniously handed Imogen to me to hold while she answered the door. Because of the abruptness of all this, and the fact that Imogen had not seen me for some almost a month, I fully expected her to break into a state of crying. I sat her in the crook of my left arm facing outwards, rather that face-to-face, thinking this would be less intrusive for her. To my surprise, Imogen tilted her head back, looking over her right shoulder and engaging me with her gaze.

Her expression was solemn and she continued to gaze at my face steadily and intensely with large, serious eyes. I vocalised and smiled, but my expressive display did not elicit an active response from her, merely more of the same intense gazing. I started to feel disconcerted and, after a while, felt constrained to avert my gaze, looking up the hallway and saying somewhat desperately and plaintively “Where’s mummy, then?”

Whereas generally I experience great pleasure when holding Imogen, on this occasion I found myself hoping that Bernie would return sooner rather than later to free me from Imogen’s relentless gaze, and from the discomfort that this, and my failure to engage her, was generating in me. My strongest feeling at this point was of a lack of emotional connection or intersubjective relatedness between the two of us. For whatever reason, I was failing to match her mood, and I felt acutely aware of a lack of spontaneity and authenticity in my responses to her.

Almost intuitively, I stopped being so busy with my vocalisations and facial expressions. Instead, I held Imogen’s feet, gently stroking them with my thumb. After a while, I slowly pushed the palm of my hand against her feet. Imogen responded by kicking against my hand. At the same time, her facial expression lifted and her eyes brightened. Soon she was smiling, seemingly taking pleasure in this game of push and kick. After each kick, she would look at me eagerly with wide, bright eyes in anticipation and expectation. I duly obliged with a push against her feet, making a whooshing sound as she kicked my hand away whilst matching her wide-eyed expression. I experienced tremendous relief, as well as pleasure and exhilaration at having found a way to connect with her. Previously, I had not felt on the same wavelength as her. Indeed, I felt as though I was floundering like a man drowning at sea. I also felt distinctly out of sorts and at odds with myself. Now, however, I felt both at one with myself and attuned to Imogen. Our shared, intersubjective feeling states and “ways of being together” seemed well-matched. In the event, therefore, I was glad that Bernie had been delayed at the front door for so long!

Relating this observation to psychotherapy with adults, I was left pondering on the powerful and disturbing impact my initial inability to communicate with Imogen had had on me. Was Imogen, even at the tender age of five months, communicating to me in a non-verbal way that my overly busy mode of being with her was ill-matched to her needs at that moment? In any event, my interaction with her brought to mind the proposition that at times the most important communication from a patient may be unspoken; that patients may behave in ways that stir up painful and distressing countertransferential feelings in the therapist because they are unable to communicate such feeling verbally. The initial task then becomes one of distinguishing between what belongs to the therapist, in terms of past or current unresolved issues, and what belongs to the patient.

Reflecting on my interaction with Imogen with these points in mind, I was aware of feeling uncharacteristically anxious when Bernie handed her to me because I fully expected her to become distressed. I was vaguely conscious that I would experience this as a failure. As a consequence of this anxiety, I sat Imogen facing outwards instead of towards me, rationalising this defensive deflection as meeting her need for me not to be overly intrusive. Imogen, however, signalled her wish to see me by arching backwards and looking upwards. Continuing to feel anxious, I then tried too hard to engage Imogen in social play. Despite my misattuned response to her subdued cues, Imogen stayed with me by means of her gaze, albeit in a largely non-responsive way. My failure to elicit a response from her, or to forge an emotional connection, increased my anxiety, stirring up uncomfortable feelings. Primarily, these were to do with feeling false, inauthentic and disconnected. I felt at a complete loss and all at sea, partly, I think, because I was unable to detect of infer how Imogen was feeling. If she was giving out cues, I was failing to pick up on them, except, perhaps, for a countertransference response consisting of feeling a lack of emotional connection.

The important lesson of all this in clinical work with adults would seem to be that the therapist can only know the patient to the extent that he or she provides clues. Such clues or signals, conscious and unconscious, verbal and non-verbal, are used to guide the therapist towards understanding the interaction and attuning to the patient’s needs at such times. Should the patient give little or no clues, there is not much the therapist can do, except tolerate or contain the anxiety of not knowing and reflect on what aspect of his or her own interaction may have led to a disruption to the therapeutic alliance or attachment relationship.

Just as an infant uses gaze aversion and playing possum to avoid over-stimulation by an impinging caregiver, so an adult patient may fail to collaborate and give clues in order to limit the actual or dreaded power of an intrusive therapist. This may reflect the activation of a particular internal working model or relational configuration, together with a set of implicitly encoded, non-conscious expectancies and predictions. Such archaic mental models tend to distort the current relationship with the therapist. The patient’s reluctance to provide clues may, in itself, be read as an unconscious prompt, indicating that something is awry. Such unconscious or implicit prompts may also be made in the hope that the therapist will pick up on them and examine the quality of his or her interaction with the patient. If the therapist is able to do this via the countertransference and a mentalising stance, he or she may act to validate the patient’s subjective experience thereby becoming a potential new developmental object rather than the expected familiar toxic transferential object.

Only after monitoring and reflecting on my subjective responses (countertransference) was I able to contain my anxiety and find a different way of being with Imogen, one that facilitated a sense of being emotionally connected with her through the medium of spontaneous social play.

Following this, it seems to me that what a “good enough” caregiver does intuitively in interaction with their infant is similar to the optimal therapeutic process in work with adults. Unconscious forms of communication are invaluable tools in this process, as is the therapist’s ability to monitor, self-analyse and reflect on his or her countertransferential responses so as to engender a safe space within which to play and be curious about the meaning of any disruptions to the therapeutic relationship.

Observation No 17. Age: 24 weeks.

Imogen had not long been awake when I arrived. Bernie laid her on a changing mat on the floor to change her nappy. I was sat on Imogen’s left. She turned her head in my direction and engaged me with her gaze, occasionally looking at my mouth expectantly and protruding her tongue. I dutifully followed suit. This exchange seemed sufficient to re-establish intersubjective relatedness.

Following this, we went to the kitchen so that Imogen could be fed her breakfast. She is now on three feeds of solids a day and is sleeping throughout the night. Bernie sat Imogen in her baby-seat on the table, tying a linen bib round her neck. Imogen responded with increased motor activity and vocalisations, and she followed Bernie’s every move as she prepared a bowl of cereal. From Imogen’s responses, I inferred that she had recognised various cues and that these had caused her to anticipate being fed. The intensity of Imogen’s behaviour in this situation seemed to reach a peak of excitement on her hearing and seeing Bernie stir the breakfast mixture with the feeding spoon.

On having prepared the meal, Bernie asked if I would like to feed Imogen while she made coffee for the two of us, as well as for workmen who were converting her loft. I last spoon-fed a baby (my own daughter) some 30 years ago, so I felt rather out of practice! It soon became apparent just how rusty I was at this skill. Indeed, I was not making anything like as competent a job of it as I had observed Louise do a month previously. Fortunately, Imogen knew what she was doing, guiding me as to how best to angle the spoon, and giving me a clear signal when she was ready for more food by looking at me directly and opening her mouth. Her vocalisations were wide-ranging and, in the main, seemed to indicate pleasurable affect. However, at times she appeared to be on the verge of breaking into a state of crying. I wondered whether her response was linked to my ineptness with the spoon, as well as to her wariness at being fed by a relative stranger with mum nowhere to be seen. This notwithstanding, Imogen ate avidly until all of the food was gone. She then vocalised in a by now familiar half-hearted way that seems to be characteristic of a betwixt and between state.

Imogen continued in this manner after being picked up by Bernie, seeming unable to self-regulate her state. A familiar battle of wills ensued over the developmental issue of control. As ever, this culminated in Bernie capitulating and giving Imogen the breast. There was a good deal of intense mutual gazing between the two of them whilst Imogen fed. At one point, she suddenly pulled away from the breast, throwing her head back, arching her back, and crying out, seemingly in pain. She did this again a little later. Bernie thought that Imogen’s distress was caused either by her teething or being constipated. In the event, Imogen let out an explosive burp later on, indicating that wind had been the problem all along!

My subjective feelings during this observation varied widely, changing in direct response to Imogen’s expressive behavioural display. I became acutely aware of this process of mutual reciprocal influence whilst feeding her. Whenever Imogen expressed positive affect by means of her motor activity and vocalisations, I felt competent and conscious that I was matching her positive affect vocally and through my facial expressions. When her affect took on a negative connotation, I felt anxious and de-skilled. Once again, my subjective feelings were expressed by and reflected in the quality of my vocalisations and facial expressions.

On Bernie asking me to feed Imogen, I felt a surge of pleasure, verging on excitement, being quite thrilled by the prospect. These feelings were quickly followed by ones of trepidation and inadequacy as I began to question whether I had the skill for the task in hand. My anxieties and doubts were heightened initially as I splodged food liberally round Imogen’s mouth, angled the spoon awkwardly, making it difficult for her to take the food, and either gave her more food than she could manage comfortably, or less than she needed to feel satisfied. Gradually, however, I became more adept at this task, charging the spoon with just the right amount of food and finding the optimal angle for Imogen to receive it.

Translating aspects of this observation into clinical work with adults, several thoughts and associations came to mind. For example, just as I had had to learn from Imogen a way of spoon-feeding her with which she was comfortable, similarly, therapists need to learn from each patient his or her unique way of using the therapist in the therapeutic situation. By being responsive to the patient’s cues and clues, as well as to his or her own subjective feelings (countertransference/mentalisation), the therapist may be able to appropriately match his or her personal idiom and interventions to the patient’s needs and personal style. Thus, as seemed to happen in my interaction with Imogen, the therapist may come to adjust his or her way of being with the patient so as to match his or her personal idiom or style of relating (hold the spoon less awkwardly). Likewise, the therapist may use this reflective process (internal supervision and trial identification) to become aware of when he or she is being either inappropriately impinging or frustrating (putting too much or too little food on the spoon to meet Imogen’s needs).

The fact that Bernie misread the cause of Imogen’s pain and distress when at the breast, believing this to be the consequence of her teething or being constipated, rather than needing to be winded, would seem to constitute a cautionary tale for psychotherapists. The lesson here is not to presume to know what the patient is experiencing, as such knowledge may lead to a premature interpretation and invalidation of the patient’s subjective experience. This way of relating to the patient may, in itself, amount to a transferential re-enactment of entrenched patterns of interaction. Better by far, then, to wait, to be patient and allow the patient the time and the space to discover his or her true self or authentic experience in a spontaneous, non-compliant way. Similarly, though an interpretation may be “correct”, it may be woefully mistimed. In Imogen’s case, she informed us in no uncertain terms that the actual cause of her distress was wind by letting out a resounding belch!

Over and above these thoughts, I was struck by the way in which Imogen responded with eager anticipation to the preparations Bernie was making to feed her. To this extent, Imogen seemed to be drawing on a rudimentary implicitly encoded working model that had been built up from previous experience of characteristic patterns of interaction with Bernie around this particular activity. Imogen’s excited anticipation of being spoon-fed would seem to demonstrate how quickly she is able to store characteristic interaction structures internally, thereby creating models against which to compare and match her own and the other’s behaviour. It would seem clear from my observations of Imogen’s behaviour that she has come to recognise, remember and expect a particular event to follow from a specific pattern of activity and interaction. This by now characteristic pattern of interpersonal interaction (being spoon-fed) may, therefore, be thought of as acting to organise Imogen’s subjective experience in this specific context.

A similar pattern of reciprocal mutual influence and concomitant construction of working models would appear to be evident in our game of protruding tongues and, more significantly, in the interaction surrounding breast feeding. Here, Imogen seems to have learnt to expect that her expressive behaviour will produce a contingent response from Bernie. From my observations, when Imogen’s expectancy is confirmed, it produces positive affect in her. However, the cessation or loss of such expected contingent responses caused her to become distressed, as was the case during today’s observation when there was no more breakfast cereal left, and when the breast was withdrawn precipitously. Imogen displayed similar negative affective responses to the loss of self-agency during a previous observation on when she failed to influence me to follow her signals and cues and engage her in social play.

In terms of work with adults, my observations of Imogen in these respects indicate that patients, too, will quickly build up implicitly encoded internal working models of characteristic patterns of mutual influence during interactive relational processes with their therapist. Given this, trust, security and a sense of safety, together with the self-agentic experience of being able to influence the therapist, will vitally depend on the therapist’s capacity to respond to the patient’s cues and behaviours in ways experienced by the patient as contingent and expectable. This may lead to an enhanced differentiation between self and other and to a more accurate appraisal and understanding that what is being procedurally enacted in the interpersonal present is often a transferential version of earlier implicitly encoded sub optimal relationships.

Observation No 22. Age: 6.5 months.

Bernie opened the front door to me with Imogen in her arms. Imogen smiled at me but seemed somewhat wary. I recalled that she had cried on seeing me last week. Although this had occurred in the context of noise and commotion from having builders in the house, and of being physically separated from Bernie, I again wondered whether Imogen was experiencing a degree of stranger anxiety that develops around the age six to eight months.

We sat on the couch in the sitting room with Bernie on my left. She sat Imogen on her lap sideways on so that she was facing me. My supposition about Imogen’s wariness appeared to be confirmed by her behaviour at this point, in that she would look at me, smile briefly, but then turn away to look up at Bernie’s face before looking at me again. Imogen did this two or three times, seemingly using Bernie’s expressive behavioural display to gauge whether or not it was safe to interact with me. Each time Imogen looked at Bernie, she (Bernie) smiled and vocalised and then looked at me. Imogen followed Bernie’s gaze back to me and I then smiled, vocalised and “talked” to her, uttering phrases like, “You know me, don’t you?”, and “You’re not going to cry, are you?”, with appropriate facial expressions and tone of voice.

Observing Imogen’s social referencing behaviour led me to infer that she and Bernie had established a shared focus of attention. I concluded that Imogen’s backwards looks up at Bernie were being made to validate the achievement of joint attention, and to confirm that they were focusing on the same target of attention, that is on me. After a few such exchanges, Bernie stood Imogen up between us, gently impelling her towards me. I took over her support by holding her under her arms, but I sensed that bringing her on to my lap at that point may have caused her distress, being experienced as an impingement or intrusion. Indeed, whilst stood in no-man’s land, or the transitional space between Bernie and me, Imogen glanced back at her once or twice. Bernie responded by again looking at me, imperceptibly inclining her head in my direction whilst, ever so slightly, ushering Imogen towards me and asking with a smile, “Are you going then?” I experienced Bernie’s rhetorical question as a cue to me as much as to Imogen. I responded by gently lifting Imogen to stand on my lap. As I did so, Bernie stood up and, on seeing Imogen beginning to engage in interaction with me, went to the kitchen to make coffee.

This was the first occasion that I had observed Imogen employ social referencing to attain a shared focus of attention or state of interattentionality. Observing this new-found capacity led me to infer that she is developing a sense of a subjective self, together with a capacity to share subjective experiences with significant others in an intersubjective domain of relatedness. From Imogen’s response to my initiating behaviour at the beginning of today’s observation, I surmised that she was feeling uncertain (if not actually fearful) about engaging with me, in that, despite her having smiled at me, she clearly felt the need to check back to Bernie several times before deciding whether to allow the engagement with me to intensify. Bernie’s positive expressive display appeared to signal to Imogen that it was safe to do so.

From my observations of these subtle interactions, I inferred that Bernie and Imogen were, in some intangible way, able to read each other’s feeling states from their overt behavioural display, with the latter constituting both a shared framework of meaning and a means of communication. Their capacity to communicate by such means would seem to indicate that implicit or procedural memories of repeated micro-events had become internalised, being represented as generalised patterns of interactive behaviours or pre-symbolic emotion schemas.

Having successfully read Bernie’s positive affective state from her contingently attuned behaviour, Imogen seemed able to bring her own wary emotional state into alignment with that of Bernie’s. Thus, it would appear that Imogen’s state of consciousness had been socially negotiated in the domain of intersubjective relatedness. Thus, Bernie’s emotions in some way became part of Imogen’s emotional experience, thereby supplying the tone and contours of her internal state at this particular moment. The psychic intimacy or emotional connectedness of this exchange seemed to have been achieved through a mutual process of affect attunement, with Bernie first reading and then mirroring and marking Imogen’s uncertain mood and wary behaviour. Attunement, or interaffectivity, was accomplished by Bernie sensitively matching the shape, intensity and timing of Imogen’s behaviour during her approach/withdrawal activity in relation to me. From my observations, it seemed that the primary modalities that Bernie had brought into play during this intuitive interactive process were gaze, facial expressions, vocalisations, posture and gesture. Bernie’s attuned, cross-modal responsiveness appeared to resonate with Imogen’s subjective experience, thereby creating a match between her own and Imogen’s inner affective states.

I concluded, therefore, that Bernie’s emotional availability for use as a social referent enabled Imogen to self-regulate her cautious, wary state, and, in turn, to restructure her subjective experience in relation to Bernie and, by extension, to me, since I was the precipitating cause of her anxiety in the first place. As a result of this process of mutual influence, Imogen seemed to feel sufficiently safe and secure to separate from Bernie and engage with me in social play. Moreover, she was able to sustain playful interaction even after Bernie had left the room. I therefore surmised that the intersubjective process of affect regulation that had occurred during this particular encounter or “being with” experience had facilitated Imogen’s sense of agency and coherence as a developing subjective self. As a consequence, she was able to self-regulate her affective state and subjective experience with regard to clinical issues of trust, separation, exploration and autonomy. Curiosity may also have been a developmental issue here, in that Imogen seemed to be testing out and exploring aspects both of her sense of subjective and core self in relation to me, a relatively unfamiliar person in her interpersonal world. The capacity to self-regulate affective states and playfully explore her interpersonal world indicated the development of a secure pattern of attachment organisation.

Conclusion

From the foregoing observations, it may be seen that in many respects the “good enough” caregiver-infant relationship constitutes the prototype of a therapeutic model in work with adults, and that aspects of the analytic process is redolent of the subtle intersubjective, communicative and regulatory processes that take place between caregiver and child, as argued by Stephen Mitchell . Indeed, from a relational perspective, the inner world is viewed as developing through these mutually reciprocal influences, and the mind as being composed of relational configurations developed in the context of interaction with others. In consequence, the therapeutic process is perceived as being inherently interactive, and as requiring the active participation of both therapist and patient in a collaborative endeavour. More generally, the empirical data from the work of Daniel Stern and Beatrice Beebe and their respective colleagues indicate that the observation of the micro-processes that characterise optimal caregiver-infant interaction can be used to understand the therapeutic process and thus helpfully inform clinical work with adults.