A Complex Mixture of Forces

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Infant Observation

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A complex mixture of forces

Alan Shuttleworth

To cite this article: Alan Shuttleworth (2004) A complex mixture of forces, Infant Observation,7:2-3, 43-60, DOI: 10.1080/13698030408405042

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A complex mixture

of

forces

Alan Shuttleworth

e paper argues that purely psychoanalytical theory by itself

is not suflicient to understand rnany of the complex mixed

Thtates carried by many

of

the children seen by child

psychotherapists. Mixed

forms 1 f

understanding are needed.

P.sychoanalytic thinking and ‘hard’ cience are not the same as each other

but need to be brought into active dialogue. As an instance

of

this the

paper

looks

at the relationship between Kleinian thinking and attach-

ment theory and argues that a mixed inner world and environment

sensitive fomri

of

thinking that draws on both Klein and Bowlby has

become characteristic

of

Kleinian child psychotherapy today. This estab-

lished way of thinking is now being stretched in order to accornvrwdate

ne~~roscicntificpna~n~s

Key

words

Child psychotherapy; Attachment Theory; containment; holding; bio-

psycho-social.

Introduct ion

Margaret Rustin

1997,p 264) has

written about ‘the most difficult cases’

that child psychotherapists see, ‘in which there is a complex mixture of

forces at work’, interacting with each other. These are children who are

carrying more than one kind of damage, or present ‘co-morbidlty’. In

terms of

ZCDlO,

they may have problems on multiple axes. In psychoan-

alytic terms, the difficulties that have brought them to

a

child psychother-

apist are likely to have their

origm

in more than psychodynamics alone.

Where psychoanalytic child psychotherapy can be helpful, it is unlikely to

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lead to a complete cure. In order to help such children, radically differ-

ent kinds of understanding and intervention may need to be combined.

Child psychotherapists are then required to face in two different direc-

tions: they need to retain a high degree of focus on their own specialised

task, for this is the only basis on which they can be helpful; and they also

need a more panoramic point of view, to see that what they can under-

stand and help to bring about is only part of something larger.

This requires holding in mind things that have a strong natural

tendency to pull apart, to split. Child psychotherapists’ understanding of

this complexity has emerged in two main phases. Firstly, over a sustained

period of time, child psychotherapists in all theoretical schools became

substantially more sensitive to the importance of environmental factors

than they once were. In doing

so,

they risked the emergence of deep

inner world versus the environment either/or splits. But what actu-

ally gradually emerged was a both/and way of thinlung, highly sensitive

to the interaction between the inner world and the environment. This

has become fundamental to the thought and practice of child

psychotherapy as it exists today. Secondly, it is becoming apparent that,

over the last decade, child psychotherapy has entered a new phase, in

which that mixed inner world-and-environment way of thinking is begin-

ning to

be

stretched again,

so

as to come to terms with the demonstrated

importance of biologically-based processes: for instance, the role of

genetics in causing certain child mental health disorders, the helpful

role

of medication

in

the treatment of some disorders, and the important

contribution being made by neuroscience. This again brings with it the

danger of deep eitherlor splits the brain uerssus the mind, bioloffy

versus interaction sensitivity, medication versus psychological therapy.

This paper’s argument is that such splitting again needs to be resisted.

Instead, we need to work towards an expanded kind

of

mixed thinking

one built around inner world

and

environment

and

biological sensitivity

hat elsewhere I have described as a bio-psycho-social way of thinking

Shuttleworth,2003).

Double deprivation and p rimary and setondory handicap

One of the models child psychotherapists have drawn on in developing

mixed inner world-and-environment thought and practice is the theory

of

double deprivation

described by Henry 1974) in relation to Martin, a

fourteen-year-old boy in long-term foster care, presenting with increas-

ingly unmanageable behaviour. Henry suggested that it was critically

important to recognise that Martin was deprived doubly: irst ly, he was

deprived of what he really needed by

his

real, external, environmental

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A

complex mixture of fortes

circumstances, both past and present; he also,

secondly,

deprived himself

because of the defences he had developed against the pain of this. These

secondary defences made it

very

hard for anyone to get close enough to

Martin to provide the substantial help

he

truly needed, leading to further

repeated deprivations. Henry is adamant in her view that her primary

task, qua child psychotherapist, was to focus on the second of these

forms of deprivation; that is, on her patient’s defences, his

own

active

responses to the unbearable but unavoidable pain of his given circum-

stances. But she is also clear that, in order to understand Martin, it was

essential to grasp that what he was doing was

defensive;

that these were

his ways of responding to extreme circumstances that were not of his

making and were bound to affect

him

i n

some way deeply and adversely.

Therefore Martin needed more than psychotherapy alone; he also

needed active, non-psychoanalytic nterventions in an attempt to amelio-

rate his situation in external reality. The successful progress of the

psychotherapy partly depended on these attempts and on Martin’s

understanding that Henry understood that they were needed.

The same basic model was subsequently developed by Hoxter 1986)

and Sinason

1986)

as the theory of

primanj and seconda

y

handicap.

Hoxter made clear how this gave child psychotherapists a way of articu-

lating how the development of a child’s inner life might

be

profoundly

affected by the combined operation of different forces, including a)

their given environmental circumstances, which for some children

involve ‘external traumas such as extremes of deprivation, the traumas of

physical or sexual abuse, murder or incest in the family’;and

b)

their

given biological circumstances, which may include ‘the trauma of physi-

cal disabilities which often entail the risk of death and the repeated

frights and assaults of surgical interventions from infancy onwards’ and

sometimes ‘organic brain damage, with islands and lacunae of function-

ing and dysfunctioning’ Hoxter,

1986);

arid

c) the child’s own active

ways of responding, sometimes showing extraordinary resilience, some-

times involving ‘a bewilderment of complex defences’

(ibid).

This

both/and/and

way of conceptualising the combined operation of a

complex mixture of forces is also well illustrated by Judd’s 1989)work,

carried out under the influence of Hoxter’s paper. It gives child

psychotherapists the beginnings of a hio-psycho-social way of thinking

which, with respect to complex cases, allows them to entertain a number

of possibilities. 1)Some primary disorders may result very largely from

organic damage alone,

with

rather little contribution froin the social envi-

ronment, the child’s own psychodynamic responses, or any psycho-social

interaction between them. Such disorders may, therefore, not be open to

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cure

by

either psychological or social interventions or by any combination

of

them. Nevertheless, the theory suggests that, in such cases, there may

also be damaging secondary psychological and, perhaps, social)

responses to the primary damage, and that these secondary responses

may

be

making things worse than they need be and may be helped by

psychological and/or social) interventions. 2) On the other hand, some

primary disorders may largely be the products of social damage p h ~ s

psychodynamic response, with no substantial primary organic compo-

nent. Here, the primary disorder may only respond positively to inter-

ventions that are psychologically and/or socially based. 3 )Some primary

disorders may be the combined product of complex interactive processes,

involving organic and social and psychodynamic factors. In this case,

combined biological nd psychological nd social treatments may be

needed to cure or reduce the severity

of

the primary disorder. Here,

again, secondary damage that is, active defensive responses to the

primary disorder may alsobe present and may be responsive to psycho-

logical and/or social interventions. In terms of the bio-psycho-social

model being proposed, it is crucial to note that it does not make any a

priori presumptions about which of these possibilities applies in a given

case. What the model does require is that a wide range of possibilities as

to the balance in

a

particular case should be left open to empirical inquiry

both scientific and clinical. The child psychotherapist would need to

proceed knowing that it is possible that only some of what they will come

into contact with in therapy may be a product of the child’s own agency,

individual personality, or the defensive measures which they have turned

to. Only part of the child’s disorder may be open to understanding by, and

amenable to change by, psychoanalyhcdy-based work alone. Some of

what the child psychotherapist

will

get to know may not be.

The growing

impact

of

science

Developments in ‘hard’ science, that

is,

statistically based research using

experimental design, have been critical in bringing about the recently

increased understanding

of

the importance of biological factors in caus-

ing some important child mental health

disorders. Particularly influential

on practice are: a) he strong epidemiological evidence about the role of

genetic transmission in the causation of autism Szatmari and Jones,

1998);and b) the epidemiological evidence about the weaker but real)

role of genetic transmission in causing ADHD, combined with outcome

studies about

the

value of the use

of

stimulant medication in its treat-

ment Sandberg,

2002).

In relation to both autism and ADHD, there is

now the beginning of evidence about underlying brain processes. Child

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A

complex m ixtu re of

forces

psychotherapists alert to this evidence now have no intellectually defen-

sible alternative but to

be

straightforward in taking on board the signifi-

cance

of

‘hard’ science-based developments such as these. There are of

course reductionist forms of ‘nothing-but’ bio-medical thought and prac-

tice, which exclude the psychodynamic from consideration a

priori,

and

which oversimplify the experience of children with these disorders.

These need to be resisted. But there also needs to be a counter-balanc-

ing recognition that the relevant science contains things that are true,

that are different from what child psychotherapists previously thought,

that are relevant to their work, and that should change their thinking.

Hunter 2001)pertinently illustrates this in her discussion of two hyper-

active children.

Something like this is, I take it, what Rustin had in mind when she

went on from the discussion of the ‘complex mixture of forces’, cited

earlier, to suggest that child psychotherapists’ ‘approach to treatment

and research needs to be set alongside studies from other perspectives

epidemiological, organic and sociological’ (ihid, p.269). Similarly, with

respect to autism, Alvarez and Reid

1999)

state that ‘it is our firm belief

that it is only in the synthesis of findmgs from research in epidemiology,

biology, neurology and psychology with those from qualitative research

represented

by

.

detailed clinical case studies

.

that we shall gain a full

understanding of the autistic condition’ p.246).

To bring psychoanalytically-based and science-based approaches

together in this way is a very considerable challenge. The comprehen-

sive, multi-factorial view that is required needs to have the capacity to

articulate how a mixture of radically different factors the kinds of

defensive processes studied by psychoanalysis, the kinds of cognitive

processing studied

by

non-psychoanalytic psychology, the social factors

both the micro-processes of intimate relationships with which child

psychotherapists are familiar and also the macroscopic social processes

and sometimes catastrophic political events studied by the social

sciences) and the organic factors studied by the biological sciences all

operate in combination with each other in the most difficult cases.

To make progress with this task, we need to recognise that there is

something particularly challenging in it for child psychotherapists. Some

of the profession’s most fundamental attitudes were formed on a differ-

ent premise, at a time when a radical a

priori

materialism and behav-

iourism, involving an in-principle denial of the mind, and therefore of

psychoanalysis, dominated science-based approaches to psychology.

What the philosopher Charles Taylor 1985)called a kind of ‘Cold War’

existed between the ‘correlators’ and the ‘interpreters’ Shuttleworth,

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2000).Fonned in that context, the dominant way of thinking within child

psychotherapy came to involve a turning away from ‘hard science

towards the arts and the humanities and a kind of phenomenological

humanism Guntrip, 1961) leading to a near absolute

eitherlor

barrier

between science and child psychotherapy Shuttleworth, 2003). Each

became largely self-contained and exclusively self-referring. This is

represented diagrammatically in

Figure

1.

figure

I

The Cold War beween child psychotherapy and science

ild Psychotherapy

The development of the British Object Relations School has been

closely linked to

the

view that profound values are at issue here. Guntrip

1961) was an important spokesman for the view that psychoanalysis

proper began only when Freud turned away from neurology and from

what was taken to be the associated pull of a kind of scientific reduc-

tionism, and turned instead towards a much more complete focus on the

patient that involved ‘a truly psycho-dynamic theory of the personality

implying a philosophy of man that takes account of his reality as an indi-

vidual person’ 1961:

17).

Guntrip argued that this

required

a turning

away from science, for ‘when science begins to treat inan as an object of

investigation, it somehow loses him as a person’ 1961: 16). ‘Science,’he

says,

‘is

the emotionally detached study of

.

what phenomena have in

cornmon so that the isolated individual object

or

event can be grouped

with its fellows and “unders tood according to what science means

by

understanding.’

As

a consequence, ‘scientific explanation’ equals ‘the

elimination of individuality

. . .

aiming to produce theories which are

[therefore]

. . .

in principle materialistic and mechanistic’ 1961: 16).

I

take the view that there is something right in what Guntrip was seek-

ing to defend here: the importance of the ‘reality of the individual person’.

I also agree that there is something right in his characterisation of science:

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A

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it i s committed to the ‘emotionally detached study of what phenomena have

in common’. There is, therefore, a crucial difference between psychoanaly-

sis and science. But he is wrong to conclude,

as

I think he did, that

this

real

dlfference warrants a more-or-less absolute barrier between the

two.

It is

important here that developments within science have themselves been

helping to erode the ‘Cold War’ stance. Firstly,

s

already outlined, ‘hard

science has been much more successful in its exploration

of

child mental

health

than many child psychotherapists anticipated. Secondly, this intel-

lectual success has partly derived from

the

development of

the

cognitive

sciences, including cognitive psychology, in which the

a priori

commitment

to the denial of the mind has become substantially less complete, as

Gardner’s 1987) introduction illustrates. Moreover, thirdly,

s

increasingly

strong links have been formed between all the cognitive sciences and

neuroscience, cognitive psychology’s initially exclusive preoccupation with

purely cognitive processing has diminished. The cognitive sciences have

started to developan accelerating interest in the interaction between c o p -

tive and emotional processes. The work of Daniasio 1994, 1999 and 2003)

stands out in this respect but see also Lane and Nadel,

2000,

and Lewis

and Haviland-Jones, 2000, for overviews). These fundamentally important

shifts make it much more possible to set the relevant science alongside

child psychotherapists’ approaches to treatment and research and to

conceive that both psychoanalyhcally-based and science-based approaches

can be brought to bear, not as A

Venus

B, but

s

A

and

B, in conjunction

with each other and that

this

might be done without ‘the elimination of

individuality’or a sense of the reality of children as individual persons. This

possibility is represented in Figure 2.

This is a diagram in which substantial differences between child

psychotherapy and science are retained; there is nevertheless some over-

lap; and there is dialogue.

f igure 2 Dialogue between hi ld psychotherapy and science

e n s ld Psychotherapy

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Klein and Bowlby

In the rest of the paper, I

will

focus on the earlier of the two phases in

the development of ‘mixed thinking within child psychotherapy that I

outlined earlier: the heightened awareness of the importance of interac-

tion between children’s inner worlds and their external environments. I

do so partly to make clear that what the paper is proposing involves

extending this approach, not breaking with it. I will draw attention to

critically important aspects of Bowlby’s role. The example of Bowlby is

bound to be significant for any attempt to set psychoanalysis and scien-

tific theory alongside each other, since this is precisely what he

attempted. Particularly following Ainsworth’s development of his work,

attachment research has come to constitute the most sustained, influen-

tial, and empirically successful link between psychoanalysis and science.

It plays an important part in the work of some of those, such as Schore

1994,

2003a, 2003b) and Panksepp

1998)

who are active in trying to

make links today between psychoanalysis and neuro-science. It is there-

fore critically important to be clear about the current relationship

between attachment theory and child psychotherapy. If the door

between them is open, there is at least one pathway open between child

psychotherapy and ‘hard science.

There is no doubt that in the early

1960s

Bowlby’s work led to a kind

of explosion and a sense of betrayal within psychoanalysis, a sense that

there was a profound incompatibility between his project and the

psychoanalytic one. This showed itself particularly in

a

sense

of

funda-

mental difference between Bowlby’s thinking and Klein’s. Eric Rayner

1992)has summed up the feeling that the difference between them was

unbridgeable. He reports that Bowlby had marked a copy of a paper by

his analyst, Joan Riviere

1927),

a leading Kleinian of the time. The

marked passage, slightly edited, reads as follows:

Psychoanalysis

s

Freud’s

discovery

of what goes on in the imagination

.

.

[it]

has no concern with anything else: it is not concerned with the

real world, nor with the child’s or the adult’s adaptation to the real

world

. . .

It

is

concerned simply and solely with the imaginings of the

childish mind, the phantasised pleasures and the dreaded retributions.

In the margin alongside this passage, Bowlby had pencilled scornfully

‘Role of the environment

=

zero’.

Both Riviere and other Kleinians) and Bowlby had a taste for

polemic, in which provocation was given and grievance taken, and

formulations on both sides pushed to absolute extremes. Clearly, the

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A corndex mixture of forces

present paper rests on the belief that this taste should be resisted. The

subsequent development within child psychotherapy in all schools, not

least in the Kleinian, of a greatly heightened sensitivity to the interaction

between the inner world and the environment, can be said to combine

aspects of the work of both Klein and Bowlby. That is, there has been a

shift from construing the relationship between their work as an

eitherlor,

‘Cokd

War’

split towards the recognition of some common ground. This

shift is represented in

Figure 3 .

Figure 3:

Klein

and

owlby

It is not that Klein’s and Bowlby’s views are the same, nor is it the case

that they have no common ground. There are partial overlaps, some real

differences, and some complementarities.

This way of construing things is particularly supported

by

an aspect of

the middle phase of Klein’s work, from 1935 to 1940,when her thinhng

was dominated by her concern with states of grief and depression. I

believe that this was a primary source for the development in all schools

of the internal world and environment sensitive type of child psychother-

apy current today. In accounting for the overwhelming, direct and

unavoidable power of grief, Klein was led to articulate a number of funda-

mentals: the immense importance of real, ‘whole object’ relationships in

human life; the centrality in this of love and its vicissitudes; their inextri-

cable dependence on direct encounters with external reality; and the

importance of what might

be

called the ‘mixed’nature of introjection.

The word ‘love’ appears many times in Klein’s work at this period.

Commenting on Klein’s 1937) paper ‘Love, guilt and reparation’ in

Volume 1

of

her Collected Works, the editors state that she ‘rectified her

former relative neglect of love and over-emphasis of aggression’ Klein,

1975,

p

432). In ‘Love, guilt and reparation’ she refers, for instance, to

‘real and strong feelings of love’ ibid, 313);to ‘a really loving relation-

ship’

ibid,

317); and, in the later paper ‘Mourning and its relation to

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manic depressive states Klein, 1940) to ‘the poignancy of the actual

loss

of a loved person’ (ibid,p. 353). Interestingly, the word ‘attachment’ also

appears several times. In ‘Love, guilt and reparation’, for example, she

comments that ‘a satisfactory and stable relationship implies a deep

attachment’ (ibid,

p 313).

In this emphasis, the Freud-Abraham model

of the stages of infantile sexuality and aggression, and their conceptuali-

sation as instinctual appetites, has receded. In its place, in her 1935-40

papers, the set of views that subsequently became known as

object

rela-

tions

theonj substantially occupies the foreground, including a new

emphasis on the specific emotionality

of

relationship; not only love and

attachment, but also separation anxiety and grief.

In articulating what she means

by

‘love’, Klein uses the word ‘real’

repeatedly at this time. In

‘A

contribution to the psychogenesis of manic

depressive states’ 1935) she refers to ‘love for a good object, a whole

object and

. . .

a real object’

ibid,

270).

She

writes that ‘a full capacity

for love’ depends on the ‘realistic perception’ of external reality ibid,

285) involving ‘looking at it and understanding it as it really is’ ibid,

271). She begins her 1940 paper by citing Freud’s 1917) reference in

‘Mourning and melancholia’ to how ‘extraordinarily painful’ the ‘testing

of reality’

is

in mourning, ‘carrying out the behest of reality bit by bit’.

Klein 1937) also refers to interaction in a particular way, as when

she

refers to the ‘circleof reassurance’ ibid,p 314) a baby obtains ‘over and

over again in the love of the mother’

ibid,

286-7). It is in this context

that Klein

1935)

discusses what might

be

called the mixed or

compound environment and phantasy) nature of introjection, involving

‘the continuous interplay between

.

the baby’s) actual experience and

its phantasy life’ ibid,

p

285). In ‘Weaning’ Klein 1936) describes

spirals of interaction within the baby, both ‘benevolent’ and ‘vicious’,

‘based on the interplay of external or environmental and internal psychi-

cal factors’

ibid,

292).

Thus an inner world

is

being built up in the child’s unconscious mind,

corresponding to his actual experiences and the impressions he gains

from people and the external world, and yet altered by his own phan-

tasies and impulses (ibid,p

345).

Clearly, these formulations are part of where Bowlby’s subsequent work

came from. There is an important partial overlap between Attachment

Theory and this phase of Klein’s work. However, it is equdy clear

that such overlap does not apply to other phases of Klein’s work. Her

work prior to 1935

is

rooted in her account

of

psycho-sexuality and

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aggression. Bowlby 1958, 1960a, 1960b) made very explicit the nature

of his disagreement with this aspect of Klein’s earlier work. After 1940,

while it built on the 1935-40 foundations, Klein’s work took her forward

in new and markedly contrasting directions.

Klein’s later work was centrally concerned with understanding

highly

disturbed patients, particularly schizophrenic and manic-depressive

adult patients. In this, the realistic part of introjection receded from the

foreground of her attention. She was, of course, concerned with abnor-

mal forms of projection throughout her career but this came to occupy

the foreground of her late thinking more exclusively than it had between

1935 and 1940. It was here that the new developments in her thinking

occurred. These concerned persecutory anxiety and destructiveness and

how, under their aegis, phantasy, projection and splitting overwhelmed

the more realistic and more integrated kinds of awareness that she had

focused on between 1935 and 1940.

Some distinction between more and less disturbed states is critical for

the argument of this paper. In Klein’s view, in less disturbed states, love

and realism are jointly ascendant. Backward-and-forward,projective and

introjective circles and upward spirals of interaction and a repeated

constructive interplay between phantasy and reality are possible. In

more disturbed states, anxiety and aggression are in the ascendant.

When reality makes its unavoidable presence felt, but cannot be borne,

it provokes and is fought off and obscured by an increased, downward

spiralling, defensive storm of phantasy and projection.

Thus, the spirit in which objects are approached is critical for late

Klein. She had important specific theses about this he theories of the

paranoid-schizoid and depressive positions, for instance. What is more

critical here is that some theory of this general type is common to all

psychoanalytx-based schools. Psychoanalysis,as such, rests on something

like the following fundamental empirical thesis: there are major variations

in the spirit in which individuals approach their objects; what varies is

both the emotionality and the cognitive processing employed in the

approach; variations result from a constant and complex interaction

between what is inborn and what is experienced; these variations play

a

substantial part in determining outcomes of indlviduals’ nteractions with

the world, consequently generating states of mental health and ill-health;

all

individuals have both more and less disturbed forms of approach avail-

able to them internally and are in states of more and less internal conflict

in relation to them; psychoanalytic psychotherapy is helpful through

addressing these variations, thus helping individuals shift from more to

less disturbed forms of approach.

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Bowlby’s work caused the concern it did within psychoanalysis

by

significantly challenging these fundamental propositions. In contrast to

Klein’s, Bowlby’s work was always more to do with normal childhood

development and the impact made on it

by

the reality of actual environ-

mental states. What matters most throughout his work is not the motiva-

tion through which the object is approached but what its state is, what

its

approach is; for instance, how parents approach a child, including their

real comings and goings. His deepest interest was in the realism of intro-

jection, the role played by realistic perception of the object. This led him

to his characteristic lists of real environmental events the death of a

parent, prolonged separation from a parent, abusive parental care in a

variety of forms, and

so

on. The passage cited from Hoxter earlier, in

which she refers to extreme external traumas, clearly echoes Bowlby’s

lists. Bowlby repeatedly insists on the extent to which children do realis-

tically perceive and take in extreme states. Internal working inoclels in

Bowlby are primarily understood as based on realistic perception

of

the

actual environment. He insists on the therapeutic difference made when

a child’s disturbance is understood as a response to what is realistic in

their perception.

The reading of the evolution of Kleinian child psychotherapists’

thought and practice that

is

being proposed here is that it has, in effect,

turned an either-late-Klein-or-Bowlby split into a bothland comple-

mentarity; and that something equivalent has occurred in child

psychotherapy’s other theoretical schools. The suggestion is that the

undoubted difference in the main directions of Klein’s and Bowlby’s

thinking after 1940 has come to be read as difference-but-complemen-

tarity, in which part of what is at the focus

of

Klein’s late work, to do

with the spirit of the child’s approach to their objects, and part of what

was at the focus of Bowlby’s work, to do with the emotional effects on

the child of their realistic perception of their objects, are construed as

coexisting and interacting, both playing important parts. That is, a key

element in Bowlby’s challenge to fundamental features of psychoana-

lytic thinking was accepted and folded back into it. This has become

the foundation on which child psychotherapy today is built. As a conse-

quence, inquiry has become less based on

a

priori one-process-only

exclusivity; it has become more empirical. Particular situations are

considered one at a time in an attempt to

judge

what the balance is, in

this instance, as between the active contribution a child is making to

their own difficulties

by

the way they are approaching their objects and

the contribution the child’s objects are making by the way they are

approaching the child.

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A

complex mixture

of

forces

Attachment holding and con tainment

In 1958, Bowlby published ‘The nature of the child’s tie to his mother’, in

which

he

used the term

attachinant

for the first time. Over the next

two

years,

he

followed this with a closely linked series of papers, particularly

those on

separation anxiety

Bowlby, 1960a) and

grief

and

inourning

Bowlby, 1960b) in which the main elements of attachment theory were

laid out. In 1960, Winnicott published ‘The theory of the parent-infant

relationship’ Winnicott, 1960) in which

the

term

holding

emerged, a

term previously used

by

both Clare and Donald Winnicott, but less

formally. In 1962, Bion published Learningfrom Experience in which he

used the term

containment

for the first time.

If

these texts are all read in

sequence, the reality

of

at least serendipity is unmistakeable. Since then,

these terms attachment holding and cnntainrnent have been at the

centre of inner world and environment sensitive thinking within child

psychotherapy. Not withstanding the differences, some common ground,

partial overlap or convergence between them could be visualised as a seri-

ous of partially overlapping circles, as in a Venn diagram.

The crux of what is convergent can be put as follows. There is an

innate, instinctual, human impulsion to seek something vital in human

relationships that can be conceptualised as attachment or holding or

containment. The theory supposes that this need then meets whatever

human care is, in fact, available. Out of that conjunction, states of rela-

tionship develop

with

distinctive emergent properties. The development

of the internal psychological states of babies and children is highly vulner-

able to what really happens at this emergent level: either what is available

stimulates upward spirals of development and the growth of internal

states conducive to mental health or

it

stimulates downward spirals and

the growth of internal states that are damaging to mental health.

There are convergent preoccupations with the role played

by

primi-

tive traumatised states in generating downward spirals. These states are

seen as following from profound breaches in states of relationship. Such

traumatised states are construed as being primary, distinct from and not

fully caused by any other form of anxiety or by the child’s

own

aggression

or destructiveness or by any other emotion though they may be

compounded by these. Bowlby’s formulation was that, where there is a

failure to meet a child’s attachment needs, separation anxiety mounts.

Ainsworth subsequently developed this as a theory of anxious forms of

attachment. In Winnicott, when a ~einbranes breached by impinge-

ments annihilation anxiety and unthinkable anxiety may follow. In Bion,

when a contact barrier is overwhelmed, giving way to a storm of beta

elements catastrophic anxiety

and

iia~nelessdread

may follow. It is

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supposed that these states play an important part in the causal processes

that lead to serious mental health disorders in childhood.

Theories of cognitive development, concerned with how the capacity

to think emerges in response to experience, also overlap. Bowlby

referred to cognitive development and to the growth of internal working

models that is, models of what has been experienced. Attachment

theory has subsequently developed a more elaborated model in refer-

ring, for instance, to the development of a capa cityfor narrative and to

the growth of autobiographical capacity. Holding and containmmt have

a double meaning in Winnicott and Bion: not only is a baby or child held

or contained within their environment of care, but the developing mind

also comes to hold or contain experience. Both Winnicott and Bion refer

to the importance of realisation, a concept that resonates with Money

Kyrle’s 1961) account of cognitive development and Sandler’s 1960,

1962) account of representation of experience. The common theoretical

supposition is that there is a developing relationship, beginning in early

infancy, between experience and thought; with its

own

distinctive kinds

of emergent formal properties and distinct pathologies, fragmentations

and disorganisations. This affects a child’s capacity to internally repre-

sent, and thereby cope

with,

the real impact made

by

experience.

Though many child psychotherapists have a particular preference for

either Bowlbyor Winnicottor Bion,my impression is that there is a general

recognition today that, alongside real differences, the partial common

ground outlined here does exist. Its existence has brought great advantages.

It has nourished the development of roughly) similar forms of internal

world and interaction sensitive thought and practice in a l l schools and

this

has helped open dialogue between schools. It has strengthened the link

between clinical practice and infant observation, and has contributed to

the

development of subtle accounts of

transferencekounter-transference

inter-

action between child psychotherapist and child. It has helped re-establish

child psychotherapy’s link to attachment research,’ and has enabled child

psychotherapy to make important links to infant development research

Judy Shuttleworth,1989).The work of Stem, Trevarthan and Hobson, and

the concepts of attunement and priinuy intemubjectivit y,have

al l

been

important influences on child psychotherapists’ hought and practice. They

are now helping in forming links to neuroscience Green, 2003).

Conclusion

The paper has argued that child psychotherapists are starting to attempt to

develop their way of understanding ‘the most difficult cases’,since it is now

clear that these are cases in which there is ‘a complex mixture of forces’

56 Volume

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A

complex mixt ure of forces

biological, psychological and social at work. In doing so, it is necessary to

find ways to set psychoanalytically-based thinking and relevant science

alongside each other,

so

as to achieve a combined, more panoramic view.

This is a challengmg task but it is one that I have suggested there is no

evading. It presents itself in clinical practice today as much

as

it does in

theory. ‘Mixed’ theories are needed that have the capacity to bring funda-

mentdy different kinds of processes into live interplay with each other. I

have outlined three bodies of theory

widely

used in child psychotherapy

today that

I

suggest have this capacity: the combination of the theories of

dmble deprivationand prima

y

and secondary handicap so as to form

the

begmnings of a hio-psycho-social theory; the combination of Klein and

Bowlby to form

inner

world

and environinent sensitive

theory; and the

overlap that exists between the theories of attachment holding and

containnzent.Each of these ‘mixed’ heories either explicitly opens a door

between child psychotherapy and science or has the capacity to do so.

In order to develop models of the interaction of mixed forces, difer-

ence has to be articulated since the whole point is that one kind of force

is not just the same as another. But the encounter with difference read-

ily gives rise to splitting among all concerned, leading to the giving of

provocation and the taking of grievance, and the consolidation of Cold

War barriers that become disabling. But when it

is

possible to contain the

differences, bothland mixed, less a

priori,

more empirical forms

of

thought and practice may emerge, that have the capacity to be stronger

than what came before. This possibility should

be

held in mind in child

psychotherapy’s struggle to retain the strengths of its existing ways of

thinking while exploring how to extend them, in order to take account of

the important developments that are taking place in the application of

scientific discoveries in the treatment of children with mental health

disorders.

I

have suggested that this is leading child psychotherapists

towards

the

development of new

bio-psycho-social

ways of thinking.

I

have tried to indicate how,

if

real pressures towards splitting can

be

resisted, this can be done while still retaining child psychotherapy’s char-

acteristic accent on the reality of children as individual persons.

Acknowledgements

Many thanks are due to Tom and Annie Shuttleworth for their technical

assistance in preparing this paper for publication.

Notes

1. I say ‘re-establish’because chiId psychotherapy in the UK and attachment

research began life together, cheek by jowl

in

the Tavistock Clinic. Two of

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the first generation of Tavistock child psychotherapy trainees, Mary

Boston and Dina Rosenbluth, were also first generation attachment

researchers.

References

Alvarez,

A.

and

S .

Reid eds) 1999) Auti.sm and Personality. London:

Bion, W.

R.

1962)Learning fr om Experience. London: Heinemann.

Bowlby,

J.

1958) ‘The nature of the child’s tie to his mother’. Znterriational

Bowlby, J. 19604 ‘Separation anxiety’.

International Journal of Psycho-

Bowlby,

J.

1960b) ‘Grief and mourning in infancy and early childhood’.

The

Damasio,

A

1994) Descartes’ Error. New York: Grossetmutnam.

Damasio,

A

1999)

Th e Feeling of W ha t Happens.

London: Heinemann.

Damasio,

A

2003)

Lookingfor Spinom.

London: Heinemann.

Freud, S . 1917) ‘Mourning and melancholia’,

S.E.

14. London: Hogarth

Gardner, H. 1987)The Minds New Science. Basic Books.

Green,

V.

ed.) 2003)

Emotional Development in Psychoanalysis,

Attachment Theory and Neuroscience: creating connections.

Bmnner-

Routledge.

Guntrip, H.

1968)Personality Structure and Hum an Interaction.

London:

Hogarth

Hoxter,

S .

1986) ‘The significance of trauma in the difficulties encountered

by

physically disabled children’.

Journal

of

Child Psychotherapy

12,1,87

103.

Hunter,

M.

2001) Psychotherapy with Young People In Care. London:

Routledge.

Judd,

D.

2nd edition, 1995)

Give Sorrow Words.

London: Whurr.

Klein,

M.

1940) ‘Mourning and its relation to manic-depressive states’.

Klein,

M.

1975)

Love, Guilt and Reparation and Other Works.

London:

Lane, R. D. and L. Nadel eds) 2000) Cognitive Neuroscience

of

Emotion.

Lewis,

M.

and J.M. Haviland-Jones eds) 2nd emtion,

2000) Handbook

(

Money-Kyrle, R. 1961)

Man’s Picture

of

His World.

London: Duckworth.

Panksepp, J. 1998)

Afe ctiv e Neuroscience.

New York: Oxford University

Routledge.

Journal of P.sychounalysis,

39, 350-373

Analysis,

41, 89-113.

Psychoanalytic Study of the Child, XV

9-52.

International Journal

of

Psycho-Analysis, 21,

1.

Hogarth.

Oxford University Press.

Emotions. New York: Guilford Press.

Press.

58 * Volume Nos 2

8

3

D o w n l o a d e d



u a r y 2 0 1 6


18/19

A

co md ex m ixtu re of forces

Raper, E. 1992) ‘John Bowlby’s contribution, a brief survey’.

Bulletin of th e

British Psychoanalytic Society, 20-23.

Riviere, J. 1927) ‘Symposium on child analysis’.


of

Psychoanalysis,

8 :

370-377; reprinted in Riviere,

J.

1991) The Znner

World and Joa n R iviere, ed. Hughes, A., London: Karnac

Rustin, Margaret 1997) ‘Introduction’ and ‘Discussion’, in Rustin,

M.,

M.

Rhode, Dubinsky,

A ,

and Dubinsky,

H.

eds)

P.sychotic States in

Children. London: Duckworth.

Sandberg,

S.

1996, 2002)

ed) Hyperactivity

and

Attention Disorders q

Childhood.

Cambridge University Press.

Sander,

J.

1960) ‘The background of safety’. International Journal

of

Psycho-Analysis,

41:

352-365; reprinted in Sander,

J.

1987)From

Safety

to Superego.

London: Karnac.

Sander,

J.

and Rosenblatt, B. ‘The concept of the representational world’.

Psychoanalytic .study of the child, 17: 128-145; reprinted in Sander J.

1987) above.

Schore, A. N. 1994)Affect Regulation

arid

the Origin

of

the Sev. Hillsdale,

New Jersey and Hove, UK: Lawrence Erlbaum Associates.

Schore,

A. N.

2003)

Aflect D ysregulntiori and Disordem of the Self:

London

and New York: Norton.

Schore, A. N. 2003)

Affect Regulation and the Repair

of

the Self:

London

and New York: Norton.

Shuttleworth,

A.

1997) ‘Turning towards the cognitive’.

Journal of Melanie

Klein and Object Relations, 1997, 15,4 , 647 663.

Shuttleworth,

A.

1999) ‘Finding new clinical pathways in the changing

world of district child psychotherapy’.

Jounial of Child Aychotherapy,

1999, 25,

1

29-49.

Shuttleworth,

A.

2000) ‘Psychoanalysis, its connections and change’.

Soundings, 15,

Summer 2000, 104-117.

Shuttleworth,

J .

1989) ‘Psychoanalytic theory and infant development’, in

Miller. L. et a1 eds) Closely Observed Zrfants. London: Duckworth.

Sinason,

V.

1986) ‘Secondary mental handmp and its relationship to

trauma. P.sychoanalytic psychotherapy, 2: 131-154.

Szatmari, P. and

M. B.

Jones, 1998) ‘Genetic epidemiology of autism and

other pervasive developmental disorders’, in Volkmar,

F.

R. ed)

Autism

and Pervasive Developmental Disorders.


Stern,

D.

N. 1985)The Znterpersonal World

of

the Infant. New York: Basic

Books.

Taylor, C. 1985) ‘Peaceful coexistence in psychology’, in

Human Agency

and Language.


Trevarthan, C. 1979) ‘Communication and cooperation in early infancy.

A

V o l u m e 7 Nos 2 8

3

9

D o w n l o a d e d



u a r y 2 0 1 6


19/19

The

International Journal of Infant Observation

description of primary intersubjectivity.’ In

M.

Bullowa ed.) Before

Speech: The Beginnings of H u m n Comm unication.

London: Cambridge

University Press.

Winnicott,

D. W.

1960) ‘The theory of the parent-infant relationship’.


of

Psycho-Analysis, 41 , 585 595;

nd

in 1965)The

Maturational Processes

and

the Fucilitating Environment. London:

Hogarth.

6 Volume

7

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A Complex Mixture of Forces