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Infant-Caregiver Interactions and the Developmental, ...Greenspan, Stanley I, MDJournal of Infant, Child, and Adolescent Psychotherapy; Summer 2007; 6, 3; ProQuest Centralpg. 211

JournalofInfant, Child, and Adolescent Psychotherapy, 6(3): 211-244, 2007

Infant .. Caregiver Interactions and the Developmental, Individual .. Difference,

Relationship .. Based (D IR) Model

Implications for Psychopathology and the Psychotherapeutic Process

Stanley I. Greenspan, M.D.

Observing and working with infants and young children with a range of clinical challenges, as well as adaptive patterns, has provided an opportunity to further understand early developmental pathways. From observations of early infant/caregiver affective interactions, we constructed the Developmental, Individual-Difference, Relationship-Based (DIR) model, a framework which delineates functional emotional developmental capacities, individual biologically based motor and sensory processing differences, and formative relationship patterns. We have employed this model to describe early developmental pathways associated with anxiety disorders and depression, bipolar, obsessive/compulsive, and narcissistic patterns, as well as autistic spectrum disorders, borderline conditions, and personality disorders. The DIR model also provides insights into the therapeutic process. It describes different levels of prerepresentational experience and enables the psychotherapeutic process to address these levels as well as individual constitutional and maturational differences. Understanding early developmen-

Stanley Greenspan, M.D., is Clinical Professor of Psychiatry, Behavioral Sciences, and Pediatrics at George Washington University Medical Center, Chairman of the Interdisciplinary Council on Developmental and Learning Disorders, and Supervising Child Psychoanalyst at the Washington Psychoanalytic Institute. He is a recipient of the 2003 Mary S. Sigourney award, a founder and former president of the ZERO TO THREE: National Center for Infants, Toddlers, and Families, and former director of the National Institute of Mental Health's Clinical Infant Development Program and Mental Health Study Center. Dr. Greenspan is the author or editor of more than 100 articles and 40 books.

211 © 2007 The Analytic Press, Inc.


212 Stanley 1. Greenspan

tal pathways broadens the scope of the psychotherapeutic process to include patients with a large range of personality organizations.

Co,Regulated, Infant,Caregiver, Affective Interactions: Implications for Psychopathology and the

Psychotherapeutic Process

OBSERVATIONS OF INFANT-CAREGIVER INTERACTIONS REVEAL

developmental processes that further understanding of psychopathology and the psychotherapeutic process. In an earlier paper,

we explored the relationship between early affective interactions between infants and caregivers and the capacity to regulate mood and behavior; form a prerepresentational sense of self; construct signal affects, defenses, and character structure; and create internal representations and symbols.

In this paper we apply our DIR model-a developmental, biopsychosocial framework that conceptualizes early affective interactions, the factors that influence them, and the developmental pathways they form-to psychopathology and the therapeutic process. Observations of early developmental processes inform our understanding, however, not through a direct translation from infancy to childhood or adulthood but through a fuller description of early developmental pathways. Developmental pathways will be described for depression, anxiety, obsessive/compulsive and narcissistic patterns, bipolar patterns, attachment problems, autism, thought disorder (schizophrenia), borderline syndromes, and severe personality disorders. In addition, developmentally informed psychotherapeutic principles will be described.

The opportunity to observe and engage in clinical work with infants, children, and families evidencing many different types of difficulties, has been helpful in understanding early developmental pathways (Greenspan and Lourie, 1981). This effort further develops the work of a number of infant-caregiver observers such as Emde, Stem, Beebe, Lichtenberg, Provence, Fraiberg, Sander, Brazelton, Ainsworth, Mahler, Chess, Sroufe, and Yarrow (Emde, Gaensbauer, and Harmon, 1976; Stem, 1974b; Stem, 1974a; Beebe, Jaffe, and Lachmann, 1992; Beebe, Lachmann, and Jaffe, 1997; Stem, 1983; Provence and Lipton, 1962; Fraiberg, 1979; Sander, 1962; Brazelton and Cramer, 1990; Ainsworth, Bell, and Stayton, 1974; Mahler, Pine, and Bergman, 1975; Thomas, Chess, and Birch, 1968; Sroufe, 1979; Yarrow, 1975).


Infant-Caregiver Interactions and the DIR Model

Developmental, Individual~Difference, Relationship~Based (DIR) Model: Observations of Early Affective Interactions in the Developmental Pathways to

Selected Mental Health Disorders

213

In the first paper in this series, we described the DIR model. Its focus on different prerepresentationallevels of early affective interactions, individual differences in sensory processing, sensory modulation, and motor planning, as well as formative relationship patterns, provides a framework for understanding aspects of the developmental pathways involved in a number of mental health disorders.

To illustrate this developmental model and some insights it is generating, brief observations will be presented on the early affective interactions and biologically based sensory processing patterns that are part of the developmental pathways associated with anxiety, depression, obsessivelcompulsive and narcissistic patterns, bipolar patterns, thought disorders (schizophrenia), borderline conditions, personality disorder, and autism. These brief discussions are only intended to illustrate individual differences in selected aspects of early dyadic, affective interactions and sensory processing in relationship to the developmental pathways leading to different disorders. These are complex disorders with many contributing factors. The following will not include discussions of many relevant biological, family, psychodynamic, and social factors.

Depression

While there is a general consensus that depression has genetic and biological origins, it also involves environmental or experiential factors. The challenge has been to understand how all these factors interact. We observed that children at risk for depression express aspects of their biological patterns with increased sensitivity to sensations such as sound and touch and, as a consequence, evidence a great deal of emotional reactivity.

We have also observed a specific pattern of co-regulated, reciprocal, emotional interaction that tends to lead to a vulnerability toward depression. When the toddler or preschooler evidences emotional reactivity due to his sensory differences, and expresses strong affects, the adaptive reciprocal partner pattern is to modulate up or down to help keep the child regulated and in an even mood. As the toddler speeds up and intensifies


214 Stanley I. Greenspan

his affective interactions, the adaptive partner soothes, engages, and attempts to calm and slow down the rhythm of affective energy. As the toddler begins to be overly subdued or self-absorbed, the adaptive caregiver might increase the saliency of his emotional cues, energize up, and increase the rhythm of affective interactions. This process of co-regulating is often a subtle one where both partners are "up" and "down" regulating each other, even before there are obvious extremes. The result is a relatively well-modulated mood. If, instead of up or down regulating, however, the reciprocal partner tends to either withdraw (even temporarily), or slow down significantly in their own responses, it may be experienced by the child as a withdrawal. The reciprocal partner may also overreact and intrude, disrupting a calm sense of relating. In these instances, instead of a pattern of modulation where the caregiver up- or down-regulates to help the child's mood stay regulated, there is a temporary rupture in the co-regulated pattern of emotional interaction. This results in dysphoric or unpleasant affects, often a sense of loss, and sometimes humiliation or anger. For example, a caregiver may personalize a toddler's intense affective responses. Instead of providing extra soothing, she may feel "He doesn't want to play with me" and, therefore, withdraw for a moment. In this situation, rather than modulated emotional interactions, the child experiences a sense of loss or catastrophic affects. The child can come to experience these dysphoric or catastrophic affects anytime feelings become intense. Dysphoric affects often then lead to expectations that go along with them (e.g., loss, humiliation, or other depressive ideation). In contrast, the child who has experienced soothing regulating affects when feelings become intense may come to have expectations that go along with adaptive interactions (e.g., optimism that one can feel better).

As the child moves into the representational and symbolic realm (assuming co-regulated interactions have not been severely disrupted), dysregulated patterns make it difficult for the child to construct a nurturing image of a caregiver that can be represented and felt in times ofloss, stress, or anger. An internal representation characterized by nurturing images and affects can serve as a type of internal security blanket that a person can call on when needed. When this type of internal security blanket is not constructed, however, the child may also come to expect that intense feelings of any type will lead to loss of soothing and nurturing. In this context, object constancy (Mahler et al., 1975) can be viewed in terms of the internal representations of the regulating affective qualities of prerepresentational experiences with primary caregivers.


Infant-Caregiver Interactions and the DIR Model 215

We have seen these patterns frequently in adults with depression. Often an event in their lives may involve loss, which routinely would precipitate some feelings of sadness. However, they can't call on a nurturing internal image (or internal representation) to help them feel better. Therefore, they feel either "empty," "alone," "despondent," or self-critical. In addition, they don't have enough mastery of co-regulated emotional interactions to engage with their current relationships in a soothing and modulating manner.

More analytic types of depressive feelings tend to be associated with expectations of loss. Self-critical feelings are often associated with anger at the affectively dysregulating caregiver.

Consider the following highlights from a case illustration of a woman who was very bright and a talented professional. She talked about being in a meeting and experiencing some competition from a peer. She felt like she was being put down and had a feeling ofloss. She got depressed and couldn't function for the rest of the meeting. This sequence occurred routinely when she experienced competition. As she described a profound sense of "being all alone" during these moments, I asked her if she could bring to mind an image of her husband, who tended to nurture her, and picture him nurturing her at these times. She said, "You know what's interesting? I can't picture him at all in that way, even though he's a very caring person." She couldn't create a nurturing internal image. I later learned that she had a mother who could not nurture her through strong affects. Whenever she had strong feelings, her mother would "shut down" and "become stone-faced."

A clue to this pattern was this patient's reaction to her therapist's periodic temporary loss of empathy and relatedness. If, for example, the therapist moved in his seat or looked out the window for a second, she would immediately look quite sad. Instead of trying to pull the therapist back in, she would look down and her voice would go into more of a monotone, as though she were giving up.

It wasn't sufficient, however, to just verbally point out this pattern. Rather, it was necessary to create a different type of affective interaction and rhythm as well. The therapist needed to pull her back in with animated affective gestures and literally challenge her with his affective gestures to take the initiative. He did this with very distinct "expectant" looks, which communicated "Can you keep the affective rhythm going or are you going to intensify my momentary lapse with an even bigger one?" Eventually, they were able to verbally explore this pattern as well.

Initially, this patient didn't have the basis for recreating a multi-sensory, affective experience of nurturing in her own imagination. She didn't have



the internal affective image or feelings to get her through a tough time. Instead, she would get depressed because there would be no internal, representational "security blanket" for her to fall back on. The missing security blanket was absent at two levels-at the presymbolic affective interactive level and the symbolic level. As she learned to initiate affective interactions at times ofloss, she also gradually became able to imagine and symbolize an internal representational security blanket (of images). She could feel and picture her husband or children in nurturing interactions.

This patient was also much stronger in her verbal processing capacities than her visual-spatial processing-a pattern we have observed in many individuals prone to depression. She was much better with details than big-picture thinking. Because of these processing patterns, she took a long time to progress to the level of feeling and "picturing" nurturing interactions, first describing them, and then gradually feeling and picturing them. This emerging capacity evolved in the context of transference, explorations, and related considerations of past and present experiences.

As her explorations broadened, she was able to deal with many additional conflicts. For example, she was very competitive with her "stone-faced" mother and had sought out her father as an "ally" in the family triangles. Only after she was able to construct internal, nurturing images, however, was she able to explore her own competitiveness, triangular relationship, and other conflicts.

One goal, then, for working with the child or adult with depressive tendencies is for the therapist to work on the flow of interaction, up-regulating with the person when necessary and, at the same time, help the person understand what might have happened in his or her own background to bring on these tendencies. As this capacity becomes established, the patient is often able to experience, express, and verbally explore a broad range of affects, including feelings of anger, entitlement, and fear of loss. The patient is often also able to organize pre-oedipal and oedipal fantasies into a more integrated narrative, which is then able to serve as a basis for further self-exploration.

In summary, individuals vulnerable to depression may tend to express their biological differences in being sensory and affectively hypersensitive. They need modulating, soothing, co-regulating emotional interactions even more than would otherwise be the case. When the care-giving environment has a hard time providing it and/or the caregiver engages in withdrawal, slowing down or rigidity, we tend to see a tendency toward associating needs and strong feelings with loss and other depressive affects and ideation, which, in tum, influences subsequent stages of development.



Anxiety

Anxiety, like depression, also has important biological components. Individuals prone to anxiety also tend to be overreactive to sensations and experience and express affect intensely. During early development, however, individuals vulnerable to anxiety, in contrast to depression, evidence different types of co-regulated emotional interaction patterns with their caregivers. In a child at risk for anxiety patterns, the caregiver overreacts to the child's emotional communications. As a consequence, the child feels overwhelmed and dysregulated. Instead of experiencing a loss or rupture in the relationship, as was the case for depression, the child constantly feels overwhelmed and experiences dysphoric or unpleasant affects associated with being overwhelmed. For example, when the toddler shows strong emotions, such as crying to be held or fed, the caregiver overreacts as though this routine communication is a major catastrophe. The caregiver may vocalize loudly, speed up the affective rhythm ofinteraction and intrude into the child's physical space by quickly picking him up (before he gestures his wishes). The child prone to anxiety requires long chains of especially soothing, reciprocal emotional interactions, rather than this type of overreactive response.

As this child progresses into the symbolic realm, she may internalize expectations for being overwhelmed and is often unable to use affects as a symbolic signal for various coping strategies because she is constantly experiencing affects in an overwhelming manner. Instead of serving as a signal, such as "I better do something about this aggressive partner I have," the individual feels overwhelmed. What for another person is a signal, for this person is the first step in an escalating feeling of anxiety, sometimes leading to panic. Later relationships also tend to be more difficult because, based on the earlier patterns, the individual expects to be intruded on or overwhelmed. Especially soothing relationships in therapy and in life can be very helpful. Along with verbal awareness of these patterns, the individual needs to experience new ways of engaging in interactive, affective exchanges and signaling.

Obsessive/Compulsive Patterns

Obsessive/compulsive patterns tend to share many features with anxiety patterns. The early sensory processing patterns and affective interaction patterns tend to be similar as those described for anxiety patterns. The individual, instead of becoming overloaded and overwhelmed, however, at-



tempts to retain internal regulation and control through evidencing a great deal of control over his relationships and environment. In other words, the individual tries to keep from becoming overloaded. Specific mechanisms used for this purpose include defiance, stubbornness, and power struggles. They also include obsessive thought patterns, which overfocus on certain ideas and avoid others, and compulsive rituals, which attempt to bring an extreme sense of order to the world.

Narcissistic Patterns

Narcissistic disorders often have their own unique pattern of early affective (prerepresentational) interactions. These include affective exchanges within which a caregiver is unable to enter into an empathetic rhythm with the child when the child evidences strong affects. The caregiver, however, doesn't withdraw or shut down, as with depression, or overwhelm the child, as with anxiety. Instead, the caregiver tends to evidence a rigid response pattern to the child's feelings. As a consequence, the toddler pulls in or constricts some of his emotional depth. He goes through the motions of social interaction, often becoming quite skillful at a superficial social level, but protects his more intimate feelings, loss, disappointment, anger, or assertiveness. He especially avoids or constricts the affective thematic areas surrounding true intimacy and compassion and later on, empathy, not having experienced these himself.

This proposed pathway is consistent with the observations of both Kernberg and Kohut (Kernberg, 1975; Kohut, 1971) regarding the origins of narcissism. Kohut focuses more on the child's feeling of a lack of empathy for his dependency needs (Le., not being a "gleam in his parents' eyes"). Kernberg, in contrast, focuses more on challenges with aggression. In our experience, the caregiver tends to have difficulty with a variety of the child's intense feelings. In addition, children have different constitutional maturational patterns that may contribute to whether or not they experience more rage or more a feeling ofloss, even though most experience some degree of both. For example, some narcissistic individuals are somewhat sensory- and affective-craving and will evidence aggression when there is a lack of soothing empathy. Other narcissistic individuals are more sensory overreactive will experience a sense of loss or vulnerability to a lack of empathy for their basic dependency needs. Therefore, the clinical insights of both Kernberg and Kohut need to be considered in working with such individuals.



Bipolar Mood Patterns

More and more children are being diagnosed with bipolar patterns. Infants and toddlers at risk for bipolar patterns tend to exchange gestures and affective signals in extreme "all-or-nothing" patterns. They go from one emotional extreme to another (Le., 0 to 60 miles an hour in a few seconds). Infants and toddlers with this pattern also tend to be very sensory hypersensitive. They are, therefore, very reactive to their caregivers' interaction patterns. If their caregivers have difficulty engaging in modulated emotional interactions, if may intensify this pattern. Furthermore, because these children are sensory sensitive, it's especially hard for their caregivers to soothe and comfort them.

These young children evidence another feature, however, that may be unique to children at risk for bipolar patterns. Typically, when children who are overreactive to sensations become overloaded with too much noise, they try to avoid the overload. They may become cautious or retreat. However, children with bipolar patterns, when overwhelmed with too much sound or other sensations, have a different response. Instead of becoming cautious or retreating, they seek out more sensations and become active and agitated. They may hit or scream or engage in risk-taking behavior. Being very oversensitive, after such an episode, they may become sad or depressed, especially if they have been criticized for their behavior. This cycle then repeats itself.

The clue to their tendency to seek sensation and become overly active and/or agitated with sensory overload resides in another characteristic of these children. In addition to being sensory oversensitive, they crave movement. They are underreactive to vestibular patterns and, therefore, crave vestibular stimulation, which occurs in part through movement and activity. Typically, we observe a seven or eight-year-old with this sensory profile becoming overloaded by his or her siblings and then becoming impulsive and hitting his siblings. He may also get sent home from school for the same kind of behavior. Therefore, rather than becoming cautious when overloaded, as the hypersensitive, fearful child does, the child at risk for bipolar patterns seeks out sensory input when overloaded. As a consequence, this type of child overloads himself even more.

The goal is to help this child learn to self-soothe and calm when overloaded, rather than further escalate out of control. With a toddler evidencing such patterns, lots of soothing and long chains co-regulated interaction may help him regulate the mood. It is important to help the toddler down-regulate quickly before he gets overloaded. For example, when the



child starts getting excited, a caregiver can begin by calming her voice instead of using more excited tones. Then the caregiver works on soothing and slowing down the affective rhythm until the child is calm. Preschoolers and older children can also be engaged in slow-motion games, moving from fast movement, to slow, to super-slow, to real slow motion.

Once calm, soothed, and down-regulated, preschoolers and toddlers also need much work at the symbolic level. They need to learn to represent their experiences. Because they are so pressured by intense affect, the intense affect tends to determine what they think. An eight-year-old child is likely to get suspicious, "My sister did that on purpose. She just wants to be mean to me and I have to get back at her."

Clinicians working with such children need to work on the symbolic content through empathy and warmth-again, down-regulating, soothing, calming, and then helping the child reformulate the experience. However, it's vital to calm the child down first at the affective, experiential level in order to help him reformulate what's happening symbolically.

In addition, because they are governed by all-or-nothing, catastrophic, emotional patterns children with this pattern need to learn to experience their emotional world-all of its terrain-in modulated, more subtle, emotional shades.

This requires both prerepresentational and representational work. At the prerepresentationallevel, they need more long chains of co-regulated, affective exchange in all the different affective areas such as dependency, assertiveness, and anger. At the representational level they need more verbal and play elaborations of the full range of emotional themes with a focus on gray-area, differentiated, reflective thinking on a range of feelings (e.g., "I feel a little angry" or "I feel a lot angry").

Children with these patterns are easily humiliated and shamed, so it's important to help in a very respectful and gradual way. Also, they tend to be polarized (all-or-nothing) in their use of symbols, as well as feelings. Therefore, a gradual, long-term approach is essential. A successful program often requires an entire team, including family members, therapists, and teachers working on both the pre symbolic and symbolic levels. For some older children, biomedical interventions also need to be explored. Adults often evidence similar patterns, often intensified by the adult equivalent of agitated and sensory-seeking behavior. Nonetheless, work at the basic gestural levels of soothing, regulating interactions and the symbolic level with representing and reflecting on experiences and affects.



Attachment Problems

Attachment problems include a range of challenges-from infants and young children who are not able to engage in any type of intimacy and may be either very withdrawn or diffusely aggressive and promiscuous in their relationships to subtle variations in degrees and qualities of intimacy, empathy, and the capacities for negotiating and sustaining relationships.

Challenges in forming relationships, however, can also lead to challenges in sensory modulation, sensory processing, and motor planning, which can appear to have a biological origin, even when they are secondary to interactive challenges. For example, in our observations of infants in multi-risk families (Greenspan et al., 1987), we observed that infants who were born with very competent nervous systems, including good muscle tone and abilities to focus, attend, and respond to visual and auditory sensations, lost these competencies during the first two to three months of life if their environments were either very chaotic or un-engaging(Greenspan and Wieder, 1999). Infants developed low muscle tone, underreactivity to touch and sound, as well as difficulties in auditory and visual-spatial processing and (in the more chaotic, hyper-stimulating environments) sensory hypersensitivity and patterns of avoidance. Even though these patterns were secondary to interactive difficulties, on physical examination they were indistinguishable from infants who were born with these processing challenges.

An extensive literature on attachment disordered behavior includes the work of Helga Fischer-Mamblona (Fischer-Mamblona, 2000). She describes the difficulties of geese that grow up in conditions of isolation for forming new attachments, and the conflicts between an urge for attachment and a fear of it. She further describes displacement activities and apathy as part of the attachment disordered behaviors. She explores how reducing the escape motivation can facilitate acceptance and attachment and discusses the gradualness and the steps in this process, as well as its therapeutic implications for working with humans with attachment disordered behavior.

In our therapeutic work with multi-problem infants and families-as well as in our work with infants and young children with autistic spectrum disorders (ASD) who had biologically based sensory processing and motor planning challenges-we employed a developmental, biopsychosocial approach (the DIR model) (Greenspan and Wieder, 1999; 1998; Interdisciplinary Council on Developmental and Learning Disorders Clinical Practice Guidelines Workgroup, 2000). In this approach, we attempt to create



nurturing relationships and interactions that are tailored to the child's unique pattern of individual processing differences. Multi-risk families, however, require a great deal of family support and outreach to facilitate nurturing interactions as part of a comprehensive program (Greenspan et al., 1987), whereas families of children with ASD are often very available and nurturing.

The parents in multi-problem families often experienced severe deprivation themselves and then were unable to form intimate attachments with their own infants. Over a period of a number of years, we were often able to help such individuals form their first intimate relationships with a skilled therapist who was able to reach out and maintain a positive relationship through a series of challenges. From this work, we formulated a therapeutic relationship scale which identified the steps such individuals went through in forming, what was for many, their first intimate relationship (Greenspan et al., 1987). At the later stages (higher steps) of their therapeutic relationship, they were often able to verbalize their fear of intimacy as well as their anger and deep despair. In a number of cases, as the mother's ability to form a relationship with her therapist developed, her ability to form a relationship with her growing infant improved. She was then able to form a pattern of intimacy with her next baby from the beginning. She was also able to learn to read and respond to the subtle emotional cues of her new infant.

The pathways to helping the infants and young children included tailoring nurturing interactions to the child's individual processing differences and working with individual processing differences, however, at each of six early levels of affective organization, including the level that deals with co-regulated affective signaling, which can be exceedingly challenging for these children to master. Co-regulated, affective interactions tailored to the child's processing differences often enabled the child to negotiate "intimacy" on his own terms (e.g., to change global approach-avoidance interactions to more and more finely regulated affective negotiations). Caregivers worked through their conflicts as well via affective signaling, often coupled with verbal explorations.

Understanding the child's sensory over- or underreactivity and the way he or she processes auditory and visual-spatial information and plans motor actions provided a range of therapeutic strategies to facilitate relationships for even the most challenging children. One of the first areas to improve, even among children with severe autistic patterns, was their quality of relating and engaging and affective signaling. In a significant number of the children, this has led to the capacity to form symbols, use language creatively and meaningfully, form peer relationships, and relate to others with



a high degree of empathy and reflectiveness. A comprehensive, developmental therapeutic model that focuses both on relationships and individual processing differences has made it possible for many of these children to achieve developmental competencies thought unattainable for children who have had severe emotional deprivation or evidence autistic spectrum disorders (Greenspan and Wieder, 1997; Greenspan and Wieder, 1998; Greenspan, 1992).

Autistic Spectrum Disorders

Children with autism, even those who develop verbal abilities and score above average on IQ tests and do well on school-based academic work, often have difficulties with making inferences, using high-level abstract reflective thinking, empathizing with others, and dealing with their own and other people's emotions (Frith, 1993; Baron-Cohen, Frith, and Leslie, 1988; Baron-Cohen, Tager-Flusberg, and Cohen, 1993). In studying such children over time and exploring their histories and videotapes of their interactions during their formative years, we have found that the vast majority, including those who "regressed" at age two or later, did not fully master co-regulated affective interactions and the capacities that are based on them during the second year of life, such as joint attention (Mundy, 1993) and reading and comprehending the intentions of others (early stages in the theory of mind) (Baron-Cohen, 1994). In other words, while some of the children could engage with caregivers and signal with emotions in a limited manner, they did not get to the point where they could take a caregiver to find a toy (Le., "open and close 50 to 60 circles" of affective interaction to regulate their behavior and mood).

Without this critical foundation, we believe, they were unable to develop the full range of higher-level symbolic capacities. For example, using symbols meaningfully and negotiating emotional and social challenges requires investing symbols with regulated emotions ("Mom" is understood as the total of one's emotional experiences with mother) (Greenspan and Shanker, 2003; 2004). This can only occur through co-regulated, affective interchanges with the mother. Similarly, empathy requires a full sense of another as an emotional "other" that can only be learned through co-regulated, emotional interactions with others. In contrast, math or history facts can be learned largely via memory exercises.

The Affect Diathesis Hypothesis (Greenspan, 2001) is a new theory we have proposed that describes the developmental pathways associated with



autistic spectrum disorders (ASD). It postulates that co-regulated affect signaling is difficult because of a unique biological challenge. The biological challenge is in connecting affect or emotion to the capacity to plan and sequence actions. This biological challenge begins with the difficulty in connecting sensations, affects, and motor responses together early in the first year.

The Sensory-Affeet-Motor Connection

In healthy development, as the infant progresses through the first year of life, she's continually connecting the sensory system to the motor system. As this occurs, the sensory system provides direction and purpose to the motor system. For example, an infant sees his caregiver's face and turns toward it. Even early in infancy, however, these sensory-motor patterns have a special sensory component, however: affect. As indicated earlier, affect operates like an additional extra sensory capacity. A person touches a surface and it feels cold, but also aversive or scary or pleasurable. As we have shown, all sensation or perception is double-coded according to its physical and affective qualities (Greenspan, 1997b; Greenspan & Shanker, 2004). There are infinite variations to the affective coloring of sensation. For example, there many subtle variations in the experience of pleasure, excitement, joy, rage, and fear. This degree of variation enables us to use affect to code and store a near infinite amount of information as well as retrieve it later.

As infants progress during the first year, the capacity to create links between the physical and affect qualities of sensation, and motor behavior enables the infant to go beyond basic sensory-motor reflexes and operate more and more in terms of patterns. He can perceive patterns, as well as organize his own behavior into patterns. For example, the baby perceives the pacifier sitting on his mommy's head. She experiences interest and pleasure in this sight and the novelty of its location. She reaches for it. We now have a purposeful motor pattern. As the infant develops, he is able to bring together one or two purposeful units into larger patterns. He sees a toy, experiences delight, points to it, and takes his father by the hand and, through multiple back-and-forth interactions involving perception, affect, and action, persuades his dad to pick him up so that he can reach for the toy. By the second year of life, these patterns lead to a sense of self (the affective, intentional agent of the pattern), a sense of others (the perception, expectation, and associated affects of the "others"). As we have discussed, this developmen-



tal progression enables the child ultimately to form and give meaning to symbols as well as develop higher levels of thinking.

What happens, however, when biological factors (or severe deprivation or abuse) interfere with the formation of a primary connection between the sensory system and the motor system? In such a case, motor behavior is not tightly linked either to the physical or the affective qualities of sensation. When this happens, we observe that infants evidence more aimless motor behavior. Instead of hearing or seeing the caregiver (i.e., a perception) and turning toward her (a motor behavior), the infant may move his head aimlessly. There is more or less no perception or sensation guiding motor behavior. Similarly, instead of hearing his mother's voice and kicking his legs in a rhythmic movement (in synchrony), the child may move his legs more randomly. The relative lack of a connection between sensation and motor behavior interferes with connections forming between affect and motor behavior. Therefore, as the infant perceives the pacifier on his mommy's head and experiences pleasure in the sight, he is unable to connect it to a motor action, such as reaching for the pacifier. If the infant could reach for the pacifier, this behavior would let the caregiver know of the baby's perception and pleasurable interest and create the first step in a back-and-forth pattern of communication. The caregiver would likely hold the pacifier closer and, after the infant took it, gesture for it back with an outstretched hand, a big smile, and a welcoming sound.

When a baby is unable to create a back-and-forth pattern of communication, she is unable to fully participate in the primary units of purposeful interaction that give rise to complex interactive patterns. Complex interactive patterns (Le., a continuous flow of back-and-forth communication) are necessary if a child is to understand the world's social, language, and physical patterns. Such complex interactions enable problem solving, the construction of a sense of self, symbol-formation, and higher levels of thinking.

When biological factors interfere with the formation of the critical sensory-affect motor connection, the infant and child has difficulty in successfully negotiating the developmental pathways leading to these emotional and intellectual capacities. Our observations suggest that this is what happens in many children with autistic spectrum disorders. In children with autistic spectrum disorders, there may not be a total lack of connection between the sensory-affect and motor system but a relative one. This relative lack of sensory-affect-motor connections makes it difficult for affect to guide motor actions; therefore, we observe a compromised ability for complex, purposeful, meaningful behavior. For example, an infant with this challenge may evidence some purposeful and even reciprocal interactions,



but often will not progress to initiating and sustaining complex, continuing, reciprocal interactions and shared purposeful problem-solving behavior.

As indicated, we call the model, which formulates the role of affect and sensation in creating purposeful, meaningful behavior (and then symbols), the Affect Diathesis Hypothesis. In this model we formulate a number of stages through which the relationship between sensation, affect, and motor behavior progresses (Greenspan and Shanker, 2004). Understanding these stages has enabled us to identify infants at risk for developmental problems and autistic spectrum disorders early when interventions are likely to be more successful. At each stage in the sensory-affect-motor connection, we are able to look for the presence, absence, or compromise in this critical capacity. For example, in the first six months, we look for different types and degrees of aimless rather than purposeful, coordinated or synchronous motor activity. We also look for aimless rather than synchronous or purposeful interactions between infants and caregivers. In the second half of the first year, we look for a lack of initiative and multiple reciprocal affective interactions in a row (Le., back-and-forth patterns of perception, affect, and action). In the first half of the second year of life, we look for a toddler demonstrating a lack of initiating and sustaining a continuous flow of back-and-forth complex social problem-solving. Then we look for the lack of the meaningful use of emerging symbols and a lack of progression to the meaningful and creative use of symbols (Le., affect-directed conversations) as well as a continuation of the earlier pre symbolic difficulties.

This developmental model also informs an approach for early intervention and preventive work. Because the sensory-affect-motor connection in children at risk of autism and related developmental problems is not an all-or-nothing phenomenon (Le., involves relative degrees of interference in the connection), there is potential for interventions to strengthen the sensory-affect-motor connections. The main "highways" may be relatively blocked, but the side roads are often available to be developed. The way to develop the side roads is to strengthen the connection between sensation, affect and motor action.

As we have discussed, to strengthen this connection we have found that creating heightened affect states is especially helpful. As heightened affects are connected to simple motor actions, infants and young children can often become more purposeful. For example, a toddler is moving a little train back and forth repetitively. If the caregiver puts the train on his head, the child may reach for it and vocalize with delight. As affect connects more and more to motor actions, it also connects motor patterns to sensations (affect is part of the double coding of sensations). As the sensation-affect-motor connection is strengthened, we observe more and more pur-



poseful affective behavior. Purposeful affective interactions and motor patterns, in tum, lead to reciprocal affect signaling, a sense of self, symbolic functioning, and higher-level thinking skills.

To function in the ways described above, affect must be relatively pleasurable and regulated (a little annoyance can be helpful, but a disorganized tantrum is not). With pleasurable, regulated affect, there's an opportunity for many purposeful interactions in a row, such as when a baby takes a pacifier, hands it back, takes it again, and so forth. An overwhelming and fearful response, on the other hand, will tend to lead to a one-step action, an avoidance response, and, in all likelihood, if the fear were great enough, to fragmented or aimless behavior. Overwhelming negative affects, while leading initially to a purposeful behavior, often overwhelm the infant and child and leads to more disorganized patterns.

Therefore, heightened affect is required to create the connection between sensation and action and help the child move into complex interactive patterns. As indicated, when we have been able to create emotional interactions involving heightened pleasurable affect with infants and children evidencing the early symptoms of ASD, we've observed enormous progress in the most essential capacities-relating and responding to emotional signals and creating meaningful ideas (Greenspan and Wieder, 1997).

The goal of creating the sensation-affect-motor connection is usually approached through a comprehensive, intensive intervention program that tailors pleasurable, regulated interactions to the child's individual processing differences (including sensory over- or underreactivity, auditory processing and language challenges, and visual-spatial and motor planning and sequencing difficulties).

In summary, the difficulty in connecting affect to motor planning and sequencing begins with a challenge in connecting sensory and motor patterns and, as the infant develops, includes creating the sensory-affect-motor linkages that make complex interactive patterns possible. If affect is unable to provide direction and meaning to motor patterns, the child's capacity to engage in a continuous flow of reciprocal affect cueing as part of social problem solving is severely compromised. Because complex affective cueing is a critical step in symbol formation, the creation of meaningful symbols (Le., symbols invested with affect) also becomes compromised. The steps in this process are summarized below:

• Compromises in simple sensory-motor connections; seen in a baby who is having difficulty moving to the rhythm of his caregiver's voice and with other synchronous rhythmic activities;



• Compromises in purposeful emotional interactions and complex sensory-affect-motor linkages; seen in a baby who is having difficulties in vocalizing to a caregiver's vocalization or in his reaching for a caregiver's nose;

• Compromises in reciprocal affect cueing (circles of communication) and complex sensory-affect-motor linkages that enable complex interactive and perceptual patterns;

• Compromises in the continuous flow of affect signaling, shared social problem solving, and the complex sensory-affective-motor planning linkages that make an early, organized sense of self and the early meaningful use of symbols possible; and

• Compromises in the formation and use of meaningful complex symbols because of compromises in linkages between affect, action, and emerging images.

There are many children who do not evidence autism but have developmental problems, for example, severe motor problems, in which intentionality or purposeful action is difficult in its own right. Such problems result in less practice at using intentional behavior and in participating in intentional interactions. In these circumstances, creating purposeful interactions around any motor skill (even head or tongue movements) may strengthen the intent-motor connection and reduce aimless, repetitive behavior. Recent magnetic resonance imaging (MRI) studies suggest that practicing and improving motor skills may enhance the developmental plasticity of neuronal connections (Zimmerman and Gordon, 2000).

In a chart review of 200 children, we found that with a comprehensive program that worked with the different levels of relating and affect signaling and individual processing and family differences, we were able to help a significant subgroup of children with autistic spectrum disorders become related, interactive, verbal, empathetic, creative, and reflective, and participate in regular classes and enjoy peer relationships (Greenspan and Wieder, 1997).

Thought Disorders (Schizophrenia)

In comparison to bipolar patterns and autism, thought disorders appear to have their own developmental pathway and organization. In individuals with thought disorders, in contrast to autism, affects are able to invest and guide motor planning and sequencing and symbol formation. However,



both pre symbolic and symbolic organizations do not undergo adaptive differentiation. In other words, the affective differentiation leading to an organized sense of self and other, and an integrated sense of self and other do not occur in the expectable way. This is often due to a combination of both biological and experiential factors.

From the biological perspective, individuals at risk for schizophrenia often have motor planning and sequencing challenges and sensory processing (Le., especially modulation) difficulties. For example, they tend to be either extremely overreactive to sensations or underreactive (e.g., paranoid and schizo-affective disorders tend to be overreactive; undifferentiated, withdrawn, primary-symptom types tend to be underreactive). In addition, there is often severe visual-spatial processing difficulties and selected perceptual motor difficulties making sequencing and cohesive, integrated big-picture thinking very difficult.

In terms of mastering the functional emotional developmental capacities, there appears to be problems at two levels. For the more severely impacted, the differentiation which stems from a pre symbolic capacity to organize and differentiate the affective patterns associated with a sense of the self and the nonself (Le., 9-18 months) is not fully achieved. We see this in individuals who have a vulnerability in their fundamental sense of where experience is coming from (inside them or outside them). For these individuals it's not so much a matter of confusing thoughts or having encapsulated delusions, but a fundamental confusion over what emotions and intentions are part of the self and the nonself. They're unable to organize experiences and categorize them as a basis for a presymbolic sense of self and reality. These individuals have difficulty in behaving realistically as well as thinking realistically. For example, they may evidence very inappropriate behavior.

Another group of individuals has their primary difficulty at a more advanced stage. For this group, internal representations or symbols are not organized according to self and nons elf (Le., the level where logical bridges are being built between different ideas or symbols). This group has a fundamental sense of where experiences are coming from. They have a sense of self and nons elf that suggests some degree of mastery of early presymbolic stages. The capacity for building logical bridges between internal representations (ideas) is, however, compromised. Ideas, therefore, may be imbued with magical power or reified to delusional realms. These individuals tend to have a better sense of how to behave than the first group. Their problems are more in how they think.

For both these types, environments that are tailored to individual processing differences and are more regulating, differentiated, nurturing, and



soothing without being overloading, tend to be helpful. Environments that do the reverse tend to be unhelpful. The hypersensitive type who's overly reactive and is likely to distort intrusive experience in paranoid ways may be particularly vulnerable to an intrusive or overloading environment and needs a great deal of back-and-forth interaction that's very soothing and regulating. In contrast, the individual who is underreactive to sensation and loses touch with reality through self-absorption requires a great deal of pursuit and wooing. This individual needs more points of reality contact through longer chains of back-and-forth emotional gesturing with key others in her environment. Individuals such as this have lost their reality sense, in part, because of their lack of a rhythm of back-and-forth communication with the other who can represent a reality that's outside themselves. In addition, strategies to strengthen motor planning and sequencing, visual-spatial thinking, sensory processing, and perceptual motor skills are also critical. Gradual (ever so gradual) help with coping with more complex emotional themes and relationships is also an important ingredient of a comprehensive program. Families that tend to carry out these practices and that don't fall into the trap of reactive anger and intrusion or underinvolvement tend to facilitate progress.

Borderline Syndromes and Severe Personality Disorders

Individuals with borderline syndromes tend to evidence a developmental pathway characterized by vulnerabilities in sustaining logical bridges between internal representations in key affective, thematic areas, such as aggression or dependency. Under the pressure of intense affects, such individuals tend toward fragmented thinking, various types of fragmented, internal, representational, self-object organizations, and regressions where they escape into fantasy. The basic boundary between reality and fantasy is vulnerable. In addition, gray-area, differentiated thinking and thinking off an internal standard and sense of self, as well as other higher level capacities, are also vulnerable.

They evidence difficulties at earlier functional emotional developmental levels as well. At the prerepresentationallevels of co-regulated, affective interactions, such individuals have difficulties in integrating different affective polarities, such as intimacy, dependency, and anger. During the second year of life, we have observed that they and their caregivers are not able to shift easily within the same broad interactive sequence from one affective



pattern, such as aggression, to another, such as comforting intimacy. Therefore, separate affective islands are not integrated into a larger whole. Individual processing differences often contribute to the problem. These include sensory over- or underreactivity, relatively weak visual-spatial processing capacities, and in some instances, motor planning and sequencing challenges.

The developmental pathways that we described for depression, anxiety, bipolar, obsessive/compulsive, and narcissistic patterns may also contribute to borderline syndromes. When the developmental pathways that contribute to borderline syndromes, as well as anxiety, depression, or other specific psychopathologic profiles are both present, we tend to see borderline syndromes with additional characteristics, such as depression or narcissism. Severe personality disorders often include the same features as borderline syndromes except for two important differences. Instead of problems with building bridges between internal representations and an associated tendency toward fragmented thinking and vulnerable reality-testing, the individual with severe character pathology tends to wall off or avoid whole areas of affective experience. He does this to preserve the integrity of his personality structure. For example, intimacy, aggression, or assertiveness may be completely avoided or walled off (Le., a significant constriction in the affective, thematic realms incorporated into the personality). As a consequence of walling off or avoiding whole areas of affective experience, an individual may evidence fixed behaviors or thought patterns, such as passivity, instead of empathy and caring, and suspiciousness instead of intimacy and trust.

If the avoidance or constriction is extensive enough, reality-testing may also be compromised. Reality testing, however, will not be compromised because of fragmented thinking, as in borderline syndrome, but because of persistent distortions due to the massive constriction. The constrictions may include pre representational affect expressions, expressions, and interactions that are unintegrated. Therefore, the individual may experience extremely polarized affective patterns and related ideational patterns. Thinking may, therefore, be quite rigid and often distort complex events. For example, the individual may always see others as doing "bad things" to him or believe that everyone loves and accepts him quickly, without reservation. As indicated, the developmental pathways contributing to severe personality disorders, including sensory processing differences and prerepresentational, affective interaction patterns, will resemble the pathways described for borderline syndromes.



Developmental Basis of the Psychotherapeutic Process

Growing understanding of how the different levels of early preverbal, affective interactions influence the formation of psychic structures and adaptive and maladaptive development can contribute to a more comprehensive framework for the psychotherapeutic process. Such contributions do not involve the direct translation of early interaction patterns to the psychotherapeutic process. Rather, they provide a fuller understanding of the types and organizations of experiences that need to be the focus of therapeutic work. There are three processes that we described earlier as the Developmental, Individual-Difference, Relationship-Based model that can help define this focus: (1) mobilizing the formative, functional, emotional, and developmental process; (2) working with individual processing differences; and (3) employing the therapeutic relationship, as well as ongoing family and other relationships, to mobilize adaptive growth and overcome challenges.

The developmentally based psychotherapeutic process can have a broader and deeper focus than has traditionally been the case. It can work on (1) prerepresentational and representational levels; (2) motor, sensory, cognitive, and affective "processing" differences; and (3) the here-and-now interactive, as well as the transference aspects of relationships. This approach is described in detail in Developmentally Based Psyclwtherapy and The Development of the Ego (Greenspan, 1989; 1997a).

The following principles describe a general approach to implement these goals.

Principle I

Construct a developmental profile that includes an initial impression of the adult's or child's functional emotional developmental level; individual processing capacities; and ways of relating. The developmental profile should be formulated during the initial sessions through engaging and listening to the patient as he discusses concerns and reviews his background or through observing and interacting with the child patient as she plays and interacts with the clinician, parents, and/or other caregivers. It should also include a review of the patient's history. Also see Developmentally Based Psyclwtherapy (Greenspan, 1997a) and The Clinical Interview of the Child (Greenspan, 2003).



Principle II

Engage the patient around her natural inclinations or interests (i.e., wishes, thoughts, and emotions). The clinician should follow the child's or adult's natural interests (e.g., observing his preoccupation with themes of anger or the toy cars, or his interest in looking out the window). He can then harness that interest to create motivation for the child or adult to participate in the work at hand. Opportunities for creating interactive exchanges exist for every interest. For example, even if a child is only interested in aimlessly wandering around the room, the clinician can wander with him, wondering out loud where they are going or what they are doing and, if necessary, playfully getting stuck in the child's pathway to create interactions. If an adult wants only to talk about cars, the therapist can explore the world of cars in both a concrete way to observe how the person relates, expresses basic feelings, creates new ideas, and so forth, and as a metaphor for the struggles of life (e.g., the car won't start).

Principle ill

Engage the patient at as many functional errwtional developmental levels as the person is capable of at the same time. In many psychotherapies, it is mistakenly assumed that most patients can use a highly differentiated representational system to perceive, interpret, and work through earlier experiences and conflicts. Often, however, children (especially younger ones) can't describe the patterns in their lives or reflect on their meaning. For some, even speaking a few words can be a challenge. By observing and then participating in an activity or interest that brings pleasure, satisfaction, or some other positive emotion to the child, the clinician can work at levels more basic than those involved with higher-level abstract and reflective thinking and use the child's own behavior and emotions (i.e., emotional signaling capacities) to work toward mastery of the various levels. For example, the clinician engages the child, challenges him to exchange gestures, and sees how much the child can elaborate in play and possible dialogues. Similarly, an adult patient may not be able to reflect on feelings or even observe his or her own feelings. The patient may only be able to describe feelings as a reality. "I am angry" rather than "I feel angry because ... " The goal with such a patient is to form a relationship, engage in co-regulated affective signaling, and gradually describe feelings with greater and greater self reflection. Another adult may be withdrawn. He may only be able to exchange emotional sig-



naling around anger, but not around intimacy, dependency, or closeness. The goal in such a situation is to help the patient engage by wooing him into interactions and then facilitating co-regulated, affective exchanges around a growing number of emotions. In other words, we challenge elaborations in all the emotional realms at both the basic level of gesturing and, eventually, the advanced level of symbols.

Principle IV

Always meet the patient at his current level of functioning. It is essential not to make the mistake of communicating with a child or adult in a manner that is inappropriately abstract or basic with regard to the functional emotional developmental levels he's achieved. For example, some children have not yet mastered the ability for verbal expression of their emotions. They may operate on a more basic, earlier level where affect spills over immediately into behavior. They stomp and yell and scream when they are angry; they cling when they are needy. When dealing with such a child, the clinician would want to avoid putting words in the child's mouth, such as, "Are you stomping and yelling because you're jealous of the attention your mommy and daddy give him? Do you think your mommy and daddy like him best?" Often, a child wouldn't fully understand the concepts suggested, but might take "the easy way out" and just agree. The child is not served in this way. Similarly, suggesting to the adult who is not able to represent feelings that he is feeling sad or angry may be bypassing critical therapeutic work (Le., helping the patient become able to represent feelings). Such an adult needs to learn how to "experience" and then describe feelings. More importantly, many children and adults will not evidence the capacity for long chains of co-regulated, affective interaction around certain themes, such as anger or sadness. Here the basic work will be at the preverbal, gestural level, where the goal is to tolerate and elaborate basic affects.

Principle V

Transform "global" emotional experiences and expressions into co-regulated affect exchanges. Often, children and adults experience certain emotions more globally than others. For example, anger may be experienced as a global or even catastrophic feeling that pushes for discharge (Le., the individual feels overwhelmed by the feeling, yells and screams, and may hit or take some



other aggressive action). The internal experience of the feeling is often described in global or general terms, such as "feeling mad" and so forth. The same individual may experience a feeling of closeness or dependency in a more differentiated manner and may be able to involve that emotional area in a back-and-forth (reciprocal) affective interchange. Instead of yelling or screaming or hitting, as he might for anger, he might flirt, show expressions of coyness, look for a response from the other person, respond sensitively to that response, and engage in a long chain of subtle back-and-forth negotiation around closeness or dependency. Some individuals may experience most of their feelings globally, while others may experience most of their feelings in these more differentiated ways.

To help individual transforms their global affective states into more differentiated patterns, the therapist needs to engage in a preverbal pattern of affect gesturing along with whatever verbal exchanges may be taking place. The therapist's goal is to help the patient transform the global affect state into a pattern of more subtle, regulated back-and-forth affect signaling. To do this, the therapist needs to consider a number of steps, including counterbalancing the patient's affect with his own (Le., becoming especially soothing in his tone of voice as the patient becomes agitated or becoming especially energizing and "wooing" as the patient becomes more self-absorbed). The next step may involve the therapist attempting to maintain a continuous flow of affect signaling (Le., a long back-and-forth dialogue involving the exchange of preverbal affects as well as words rather than short bursts of communication). A third step is to offer very subtle and differentiated regulating affective responses to the patient's more global affective expressions, encouraging more subtle counterexpressions on the patient's part. The fourth step may usefully involve increasingly subtle verbal explorations (for the verbal individual) of the patient's perception of her own feeling states (Le., becoming a poet of her own internal world). These steps may all occur simultaneously and are only a few examples of the ways therapists may explore assisting the patient in shifting from global affective experiences to more subtle, differentiated, co-regulated interactive ones. As we've discussed (Greenspan and Shanker, 2004), global, catastrophic affects are difficult, if not impossible, to transform into a representational organization because the pressure for discharge and action makes it difficult to separate the perception from the action in order to have a freestanding perception that can acquire multiple affective meanings. In contrast, co-regulated, affective exchanges enable the separation of perception from action, thereby enabling perceptions or images to acquire affective meanings and become organized at a representational level. Therefore, working



with transforming global emotional experiences into co-regulated affective exchanges must occur at the preverbal, as well as the verbal levels.

Principle VI

Broaden and extend the patient's range of emotional experience. The clinician also attempts to broaden the range of experiences the person can deal with at his current functional emotional developmental level. He then challenges him to extend to the next level. For example, if the child avoids being close to others or focuses only on being aggressive, the therapist's goal is to facilitate a full range of feelings at his current level. He will work on both expression of anger as well as expressions of dependency or loss. The person being engaged at his current level will work more easily with the clinician to begin the work of mastery of the next level. For example, as the person expresses more affects and exchanges more affective signals dealing with intimacy, the clinician is working on facilitating longer and longer affective exchanges. As more and more affective exchanges occur, the clinician is facilitating verbal descriptions and expansion of feelings. The clinician also facilitates building bridges between representations (e.g., "Why do you feel angry today?"). It is important to identify emotional areas where the patient is unable to engage in co-regulated affective interchanges and, therefore, is unable to symbolize a particular emotional domain. Consider, for example, the patient who is unable to engage in co-regulated, affective exchanges around intimacy and warmth. He tends to withdraw from relationships at the first sign of frustration, or he quickly becomes overly dependent on others.

Understanding the steps in the pathways from co-regulation of an affect to its symbolization can enable clinicians to further develop therapeutic approaches. The strategies of empathy, attunement, and containment (Kohut, 1971; Stern, 1974a; Fonagy, Gergely, Jurist, and Target, 2002; Beebe et aI., 1997) can serve as a foundation for differentiated affective exchanges that help the patient negotiate the steps in the pathway from reciprocal affective exchanges to symbolization. For example, they can engage in affective exchanges that help the patient express and experience a wider range of subtle affects, regulate them, integrate fragmented islands of affective interchange into cohesive patterns, and eventually integrate polarized patterns into more united emotional organizations. This process, in turn, fosters the formation of integrated internal representations and capacities for self reflection.



Principle vn

Engage the patient in the context of his individual processing and regulatory differences. 1 For example, an individual who is sensory hypersensitive requires soothing, but the underreactive, self-absorbed individual requires animated dynamic interaction. A child or adult with auditory processing and language challenges may require more visual information as well as extra practice with words. The individual with visual-spatial processing challenges may tend to be fragmented and have difficulty creating a "big picture" and, therefore, requires work on forming integrated patterns, and mental representations. The clinician needs to understand the person's unique processing profile in order to work with challenges or talents that person brings to the session (see Chapter 2 of Developmentally Based Psychotherapy (Greenspan, 1997a).

Principle vm

Effect change by helping the person negotiate the functional emotional developmental level or levels not already mastered, or only partially mastered, and help him strengthen vulnerable or limited processing capacities. The core purpose of the DIR approach is to fully master the functional emotional developmental levels in an age-appropriate manner. Some of these levels may have been bypassed or only partially mastered earlier in life and may appear constricted or simply may not present. The traditional role of the clinician as a commentator or insight-giver is not always appropriate with children or adults who may not have fully achieved the representational levels necessary for reflection and insight. Therefore, the clinician must also be a collaborator in the construction of experience.

Consider a practical example. Five-year-old Charlie came into the office with a bright smile and quickly took in the whole playroom. With a questioning look to the therapist and understanding the affirmative nod, he headed for the toys. As he went through one toy after the other, fiddling with it for a while and putting it aside, the clinician tried to engage him in back-and-forth interactions so she could get an idea of his strengths and challenges. Charlie could answer most of her questions, but rarely looked at her or included her in his examination of the toys. When she did get him to

lFor further explanation of processing regulatory differences, see the first level of functional emotional development described earlier.



look at her, he could flash a warm smile, though, and he was related to his parents, but tended to withdraw when frustrated. When the therapist asked Charlie a question that was too hard for him, he'd often just get up and wander to another part of the room and fiddle with something there. He was up, down, around and all over the place during the course of the interview.

For the purposes of this example, we'll separate out only a few challenges from Charlie's entire profile, which would also have included an assessment of the regulatory and processing challenges that might be involved in his difficulties as well. Among his challenges, the clinician noted Charlie's relative lack of mastery at the earliest levels of shared attention, regulation, and engagement and realized that this was an area that needed work. Following the first three principles, she watched for the moment when Charlie focused on a seemingly favorite toy, a car, and stayed with it for longer than five seconds. She worked to engage him around his interest and to help him share his attention with her. First, she inserted herself into his play by putting her hand in the way of his racing car, saying, "Uh oh, there is a big wall in front of the car. What can he do?" Charlie had to interact with her to keep his car going on its chosen track. He said, "I'll use a magic wall busted" Now they were interacting, engaging, and sharing attention a bit more. By continuing to engage Charlie around his interest, being playfully obstructive, and inserting herself into the play, the clinician was able to help him remain focused and attentive to the game and her for longer and longer periods of time-the first step in helping him increase his level of mastery at these early stages.

The clinician also noted that Charlie could engage in pretend play around themes of aggression, but not dependency or closeness. She was able to broaden Charlie's representational ability by challenging him to explore this neglected theme in his play. More importantly, he was able to do this only after he mastered "closeness" at the affective, pre symbolic level.

Consider another example. Margaret, a 45-year-old mother of three, was very anxious and compulsive. She was sensory hypersensitive and tried to control every part of her life so as not to be overloaded ("I can't stand surprises!"). She was very constricted at both the level of expressing and experiencing assertive, angry or even intense, pleasurable feelings, as well as representing these with words. The goal was, therefore, to create more co-regulated affective interchanges around the themes with which she had difficulty. Sometimes, it involved challenging her; other times it involved joking. Other times, it involved empathy. While they were always talking, the first goal was simply for an increased range of affects through facial ex-



pressions and gestures. This required lots of affective challenge and variation by the therapist, geared to the patient's processing profile.

Principle IX

Always promote the individual's self-sufficiency and assertiveness. The way learning occurs in life, and particularly in the psychotherapeutic process, is through the person's own active discovery in the context of his relationships. To achieve mastery at any particular level, the individual must amass a quantity of experience in dealing with the issues at that level. She can't just get a deep understanding by being told what she has to do; she actually has to experience the level. A clinician working with the person is merely the collaborator in this work, helping her be assertive and take the initiative. For example, in the case described earlier of depression the individual needed to learn how to maintain the affective rhythm and even pull in the other person when withdrawing. It's very easy for a creative and imaginative therapist to pull out a "bag of tricks" to engage the child and channel her into compliantly and/or passively doing one task or another. However, once the tricks are withdrawn, often the child cannot repeat the task on her own. Instead she must learn it from the inside through her interactions with the clinician (and/or her other relationships), exploring, being assertive and curious, and taking the initiative in that exploration.

Principle X

Focus sufficiently on prerepresentational, affective exchanges and understand that the representational system, including unconscious symbols, is only one of the functional emotional developmental levels. It is especially important to understand that the representational system, so central to most dynamic therapies, only deals with the most surface aspects of mental functioning. The ability to represent experience and elaborate on it, and the ability to differentiate between representations, are two levels of functioning acquired in later stages of ego development (Le., when children are already verbal and symbolic). As we have been discussing, there are four earlier levels that must also be mastered, dealing with the way experience is organized prerepresentationally. These include how regulation (sensory reactivity and processing) occurs; the way early engagements and relationships are formed and elaborated; and how early simple and complex, intentional,



gestural communication becomes a part of a prerepresentational pattern of mental organization.

By being aware of these early stages of ego development, the clinician can have a greater range, going beyond empathy to becoming an actual facilitator and collaborator in new ego development. While intuitive therapists have always been able to empathize with early affective states, most clinicians will be aided by a theoretical road map indicating what sensory, regulatory, gestural, behavioral, and affective signposts to look for.

Principle XI

Work at multiple representational levels in a progressive manner until age-appropriate levels of representational differentiation, integration, and self-observation are achieved. We have emphasized the different levels of affect signaling and helping individuals negotiate these early levels of affective interest in the world and the basics of forming an intimate relationship to complex patterns of co-regulated affect signaling. We also need to emphasize the importance of continuing the therapeutic work until all the relevant higher level representational capacities are also negotiated. Sometimes, these can be worked on together with the earlier levels and at other times only after earlier levels are somewhat mastered. In either case, the tendency to stop the therapeutic process with some self-observing capacities in place, but not the full range of age-appropriate ones, should be avoided.

As children progress into using symbols and adults rework or progress into using more internal representations for the first time, we can observe a number of levels that need to be worked with. First, we see internal representations or symbols used in an action way. In other words, they use words like "I mad," but they still hit. So the words just convey what they are going to do, but they don't yet use them instead of what they do, so it's an impulsive use. If that goes well, they simultaneously may use it in a somatic way: "My stomach hurts." But they are not saying, "It feels as though my stomach hurts," they are using words, but their stomach actually hurts, so they are somaticizing the affect and the symbol isn't helping them take distance from the affect. So they usually discharge it or somaticize it.

The second level involves polarization of affects. They can actually take distance from the affect but they polarize it-it's all or nothing, it's black or white, either "I love you" or "I hate you." We see this in the peer relationships. We also see it in adults. Someone looks at a person in the wrong way,



"He must hate me." Not, "Gee, maybe he had a bad day or ate the wrong thing." At another level, the thinking is fragmented.

A third level involves rigid patterns. Ideas are logical and reflective, but in rigid, fixed categories. They are not quite all-or-nothing; they are fixed and compulsive. If an individual can get beyond that category, he goes to a level where the symbolic system can be used reflectively to reason about feelings and problem-solve. He can talk about how he feels. If that goes well, the person gets up to multi-cause and triangular thinking. He looks for multiple and indirect reasons for his feelings. If that goes well, he can look at differentiated gray-area feelings (e.g., "I feel a little bit angry, a little bit sad"). He can explore gradations in feelings and their cause. If that goes well, a person takes the capacity for gray-area thinking and multi-cause thinking and reflects on feelings in the context of an internal standard and a sense of self (e.g., "I shouldn't feel as angry in this situation as I do. I wonder what's gotten me so irritated. I feel angrier than I did yesterday."). This is a very differentiated, gray-area, comparative, multi-cause statement measured against a standard of the self (e.g., I normally don't feel this way). This level can further progress to incorporate an ever widening set of affective experiences and challenges characteristic of adolescence, adulthood, and the aging process (Greenspan and Shanker, 2004).

Not every individual will need to negotiate each of these levels. For adolescents and adults, however, clinicians should have a road map and the goal of helping the person observe and reflect off of an internal standard and subsequent levels. Therefore, in working with older children, adolescents, and adults, the goal on the one hand is to work at the co-regulated affective interaction level and on the other hand work at the levels of symbolic elaboration including using the internal sense of self as a standard for reflection.

Conclusion

In summary, observations and clinical work with infants, young children, and their caregivers provides insights into early developmental pathways leading to different types of psychopathology. It also suggests developmentally informed psychotherapeutic principles. These principles define a psychotherapeutic process to help the child or adult negotiate the functional emotional developmental level or levels not already mastered, or only partially mastered, strengthen vulnerable or limited processing capacities, and move on to new developmental levels. Key prerepresentational



stages that often require therapeutic work include the different levels of co-regulated, affective interactions. A developmental, biopsychosocial model-the DIR approach--conceptualizes these processes to guide the clinician and the patient in their collaboration.

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