psychiatric theory and practice: using sander's theoretical contributions to assist parents in...

IMHJ (Wiley) RIGHT BATCH

shortstandard

top of AH

123 base of drop

INFANT MENTAL HEALTH JOURNAL, Vol. 21(1–2), 123–130 (2000)� 2000 Michigan Association for Infant Mental Health

A R T I C L E

PSYCHIATRIC THEORY AND PRACTICE:

USING SANDER’S THEORETICAL CONTRIBUTIONS

TO ASSIST PARENTS IN MANAGING AGGRESSION

IN THEIR PRESCHOOL CHILDREN

ALEXANDRA MURRAY HARRISONHarvard Medical School

INTRODUCTION

Louis Sander has made major contributions to psychiatric theory in his work in infancyresearch and, more recently, dynamic systems theory (Sander, 1962, 1964, 1977, 1980a, 1987a,1991, 1995; Sander, Stechler, Burns, & Julia, 1970). These contributions, elaborated over halfa century, provide a broad framework for human development and psychiatric intervention.Yet there is relatively little commentary on how these concepts are useful in clinical experience(Nahum, 1994; Sander, 1980b, 1987b).1

The purpose of this article is to provide an example of the usefulness of key elements ofSander’s conceptual thinking to the treatment of children. Specifically, I consider the case ofdealing with aggression in preschool children, a common problem posed by parents who seekpsychiatric help for their children. As will be discussed, Sander’s thinking provides a morecomplex view of this clinical issue than typically used to formulate clinical problems and therelated therapeutic interventions. A model derived from this complex view can be of significantvalue to the therapist dealing with these clinical issues.

This article is organized as follows. The first section will introduce the key implicationsfor this article of Sander’s theoretical approach. The clinical case is the bulk of the article,providing an illustration of a treatment and its link to Sander’s insights. The final sectionprovides some brief concluding remarks.

KEY INSIGHTS PROVIDED BY SANDER’STHEORETICAL WORK

Sander has integrated a theory of human development derived from infancy research and dy-namic systems theory that complements and extends both bodies of knowledge. This integrated

Address correspondence to Dr. Alexandra Harrison, 183 Brattle Street, Cambridge, MA 02138.Work on using concepts from Sander and others to develop a theory of change in development and in psychotherapy1

is the focus of The Change Process Study Group of Boston (CPSGB): N. Bruschweiler-Stern; A. Harrison; K. Lyons-Ruth; A. Morgan; J. Nahum; L. Sander; D. Stern; E. Tronick. I wish to thank the CPSGB members for their criticalinfluence on the development of the ideas in this article.

124 ● A.M. Harrison

IMHJ (Wiley) LEFT BATCH

shortstandard

top of rhbase of rh

cap heightbase of textframework provides the basis for a clinical model that allows for a shifting focus of therapeutic

attention within a coherent perspective of the larger system. Such an inclusive model contrastswith most clinical models, which typically provide a more narrow focus for evaluation andintervention. Examples of more narrow frameworks include those organized around cognitiveprocesses, the individual unconscious, the dyadic therapeutic relationship, the family systemexclusively, or biology.

Sander’s framework deals with the process of interaction between people in a relationship,as well as comparable interactions with the larger context. Using a model informed by theseideas, interventions are designed to facilitate interactions of greater coherence and more effec-tive functioning within many domains of human experience. Rather than attempt to discuss thefull clinical implications of this complex theory, I have limited myself to three features ofSander’s view of the living system:

1. The living system is in constant evolution. Systems have an intrinsic capacity forchange.

2. Change takes place through interactions, which involve the disruption and recreationof specific connections among the component parts of the system.

3. The motivation for growth and change is based on hope, on a “positive expectancy”for the future.2

The feature of constant evolution refers to the capacity for intrinsic change within the system,for example, the family. Therapeutic interventions do not introduce change from outside butrather facilitate the family’s initiatives towards progress. In doing this, the therapist maintainsa flexible position, moving from the background to the foreground and back again in responseto his or her perception of what is needed to scaffold the family’s initiative and follow itsagenda.

Specificity of connection is a concept Sander adapted from the writings of the biologistPaul Weiss (Weiss, 1969), who proposed it to explain how the living organism maintains itscoherent organization during the constant flux of the developmental process. Growth takesplace through aspects of fittedness (Sander, 1998, p. 3) between the component parts of thesystem. A recognition process occurs in which components of the system perceive resonancebetween them and in this way achieve a new organization. The new organization, consistingas it does of parts in relation to each other, includes a common direction of activity. In humanbeings, this search for a common direction occurs in multiple domains, such as physiologicalstate regulation, motor activity, intention, and meaning.

Positive expectancy is a term Sander uses to denote the expectation of success in anendeavor. Such a positive outlook is developed in infancy and relates to the competence of theinfant and to the reliability of the caretaker in meeting the infant’s needs. These needs includephysiological needs such as food, sleep, and temperature control. They also include the infant’sneed to have his initiatives recognized and supported.

Positive expectancy emerges as a result of recurrence, the repetition of particular experi-ences over time. The positive expectation that if one perseveres, one will reach his goal, is animportant ingredient of hope.

Underlying these observations about how living systems work is the basic tendency to-wards integration at higher and higher levels of complexity and organization. Sander points to

Sander, L., as articulated in meetings of CPSGB.2

Psychiatric Theory and Practice ● 125


shortstandard

top of rhbase of rh

cap heightbase of textthe fact that the brain is always working to “put it all together”; at another level, two brains

are working to put it together between them, and so on (Sander, in press, p. 2). Thus, Sander’stheories of development stress the direction of human development as towards higher com-plexity and greater coherence.

INTRODUCTION TO CLINICAL MATERIAL

The negotiation of aggression in the parent-child relationship can be understood in terms ofthe process of recognition described by Sander. The parent and child begin the negotiation3

through an unconscious process of assessing each other’s state and affect, motor activity, andintention. A simple example of this process can be seen in the familiar experience of grocery4

shopping.If a child wishes to run through the aisles of a crowded supermarket, the parent automat-

ically makes decisions about what kind of limits to set on the basis of an assessment of whetherthe child is hungry or tired, whether he is angry or excited, and whether he is intending tocause trouble. The capacity of the parent to recognize the child in these various domains ofexperience will of course depend on many features of the parent, including how hungry, tired,and irritable the parent is and how the parent characteristically deals with aggression. Thisrecognition process is mutual, and the child is also registering the parent’s tolerance for hisbehavior. If all goes well, the two of them can find a common agenda of controlling the child’saggression. The agenda might have as an immediate goal the child not making people angrywith him, or getting the shopping done so that they can go home and relax, or both of themhaving a good time shopping. Once this occurs, the partnership has moved forward in a positivedirection, and the child and parent have learned how to deal in a more cooperative and effectivemanner with this situation and other similar situations in the future.

The clinical case to be considered involves this issue of managing aggression in the parent-child relationship. It is an issue that is commonly presented to mental health professionalsworking with children. I will use the case to illustrate the usefulness of Sander’s insights intogrowth and therapeutic change.

A CLINICAL CASE

Mrs. T contacted me when her first son, Adam, was 4 years old, because of her perception thatAdam rejected her and preferred his father, and because of his oppositional behavior towardsher and aggression towards his 2-year-old brother, Ben. She told me about her difficult preg-nancy with Adam, the prolonged labor, and the newborn period complicated by illnesses ofboth mother and baby. This situation made it impossible for Mrs. T to care for her baby theway she had hoped. Instead, Mr. T took over Adam’s care and developed a bond with him thatMrs. T appreciated, but also envied and resented.

I wanted to understand Adam’s problem in the context of his family system, so the eval-uation began with a family meeting. In the meeting, Adam addressed only his father anddeclined to make eye contact with his mother. However, his actions told a different story. Heflew a toy airplane in progressively larger circles around the room until he encompassed Mrs.

Here I will use the termaggressionin the general sense, in contrast to the useful distinction made between aggression3

andassertivenessby Stechler and Halton, 1987.This assessment is carried out in the procedural, or nonlanguage, realm of knowing in contrast to the semantic, or4

language, realm. Therefore, it is automatic and unconscious.



shortstandard

top of rhbase of rh

cap heightbase of textT as she sat on the floor nursing Ben. “This airplane has no place to land,” he said. Later in

the meeting Adam lined up farm animals at a trough and picked up a sheep too small to reach,saying sadly, “This little sheep cannot drink.”

Next, I wished to explore the fits and misfits among the family members. The first step inthis process was showing videotape of the family meeting to Mr. and Mrs. T, pointing out tothem the sequences that demonstrated Adam’s longing to make a connection with his mother.Mrs. T could see that her expectation of rejection by Adam interfered with her recognition ofhis longing for her, and created a misfit in their behavior towards each other. The visual imageson the tape stayed with Mrs. T and inspired hope that she might have a better relationship withher son. Consequently, I recommended a series of play sessions with Adam and Mrs. T.

In these sessions, important patterns of interactive behavior emerged. I thought of thesepatterns as attempts to resolve the dynamic tensions, or conflict, on both interpersonal andintrapsychic levels. The first pattern was Adam’s intense focus on making a connection withhis mother in the play. Using the matchbox cars he searched for trailers and trucks to hitchthem up to, deftly manipulating the connecting pieces with his little fingers in a way that hismother and I could not equal. Another pattern was his frustrated response to his difficultyaccomplishing this connection, a pattern that connected the two of them in painful experience(Tronick, 1998). He became increasingly disorganized and aggressive in his behavior until hewas dumping the cars out of their cases all over the rug and throwing the cars wildly aroundthe room. Mrs. T’s reaction to Adam’s aggressive behavior was to sit back in an anxious,withdrawn attitude, remonstrating him in a plaintive tone, “Sweetheart, don’t throw Dr. Har-rison’s cars!” Remarks such as this did not help Adam change his course of action, and in factseemed to support the repetition of the negative behavior and the unhappiness between them.

In viewing the tapes of these sessions, Mrs. T was able to recognize family patterns relatedto aggression. She saw how her anxiety about Adam’s aggression interfered with her attemptsto help him control it. Searching for the intergenerational transmission of common themes, sheand I were able to identify one source of her anxiety in her fear of her own aggression, whichwe could trace to her childhood experience. Mrs. T had told me the story of having beenorphaned early in her life and brought up by a foster mother who was extremely controllingand alternated affectionate, seductive behavior with relentless, hostile attacks and accusationsof disloyalty. We hypothesized that her foster mother’s behavior generated a retaliatory ag-gressive response, associated with feelings of helplessness and of being dominated. In herrelationship with her son, Mrs. T unconsciously repeated some of the strategies for negotiatingaggression she learned with her foster mother, with the associated affective experience.

The idea of intrinsic change also underscored my play therapy with Adam and Mrs. T. Ibegan with the assumption that a disruption of the maladaptive interactive patterns and theestablishment of a facilitating environment could create a context in which the family systemitself could initiate positive change. To that end I endeavored to provide a safe place withinwhich Mrs. T could experiment with managing Adam’s aggression and her own. I pointed outto her the places she moved away from her conscious agenda of supporting Adam’s initiative.For example, when she exclaimed to Adam that he frightened her with his aggressive behavior,I explained that rather than helping Adam get himself under control, this communication madehim feel abandoned with his out-of-control feelings. We again could see how her own angerand aggression frightened her and contributed both to her withdrawal from him and to herexcessive control of him. Mrs. T was intellectually capable of understanding these complexissues. Her capacity to acknowledge and manage aggressive reactions in her lived experience,however, was of course more difficult. Over time she was able first to borrow some of mytolerance and then to build some of her own to counter her unconscious self-criticism and



shortstandard

top of rhbase of rh

cap heightbase of textshame. This diminishing of her self-criticism also supported her expectation of success in her

efforts.Perceiving the sources of destructive aggression as Adam and her husband, Mrs.T com-

plained about not trusting Mr. T with the children, fearful that he “tuned out” and allowedthem to get into dangerous situations. Drawing on the principle of complexity in the model, Iwanted to explore the contribution Mr. T made to this problem. Therefore, I chose to shift myfocus temporarily from the dyad to the entire family to further evaluate family functioning.

The family meeting was illuminating in its exposition of how conflictual patterns betweenMr. and Mrs. T compromised both parents’ empathic availability to their children and, inparticular, interfered with Adam’s agenda of connecting with his mother. In my work withfamilies, I have found the work of Fivas-Depeursinge (1999) very helpful in understanding afamily’s procedures for dealing with developmental challenges, and in this case, I used amodification of the “Lausanne triadic play” model to test the family’s strengths and resiliency(Fivaz-Depeursinge & Corboz-Warnery, 1995). I requested the family first to play in two dyadsof Mr. T and Adam, and Mrs. T and Ben, and then later, when I asked them to, to “switch”partners (Fivas-Depeursinge, 1999).

In an initial move in which Adam grabbed Ben’s toy and no one prevented him fromdoing so, the family established Adam’s dominance over his brother, as well as his role inexpressing the aggression of the family. When I asked the family to “switch,” they were unableto do so. Mr. T invited Ben to play with him, but Ben’s reluctance to leave her was encouragedby Mrs. T’s ambivalent support: “Do you want to play with Dad? Do you want me to playwith you?” Adam himself took several initiatives to reach out to his mother by admiring themoney in the cash register Mrs. T was playing with and then by asking her questions about it.Mrs. T responded warmly. However, Mr. T—while overtly supporting Adam in his efforts—at the same time interrupted them by introducing an agenda of his own. Urging Adam to “askMum if that’s enough money to buy back the car,” he referred to his habit of buying expensivesports cars that Mrs. T thought the family could not afford. Complying with his father’s direc-tion, Adam asked the questions. Mrs. T’s subsequent rejection of Adam’s offer—“It’s notmine to sell”—caused him to collapse in frustration and rage, and was elicited by the para-digmatic conflict between his parents.

Reviewing the tape of the meeting began an extended effort to address parental conflictsthat undermined the trust and emotional security of the family. The pattern that emerged wasthat of Mr. T feeling attacked and abandoned by a woman who at the same time rendered himhelpless in a way that provoked his rage and frustration, and of Mrs. T feeling attacked andabandoned by a man oblivious to her needs whose lack of protectiveness resulted in the threatof an unbearable loss. A meeting was planned to better understand this interaction, but wasdelayed by summer vacation.

As the family prepared to go on vacation, Mrs. T brought me the suggestion of a friendto treat Adam’s Attention-Deficit Hyperactive Disorder (ADHD) with a stimulant drug. Had Ibeen using a different model, I might have experienced Mrs. T’s request as a disturbing dis-traction from our ongoing treatment. The inclusive model, on the other hand, allowed me toconsider Mrs. T’s idea without losing sight of the transference implications nor of the defensivesignificance of her demand. Moreover, the assumption that the system was at some level oforganization in constant motion, supported my belief that many different interventions coulddisturb the problematic equilibrium and contribute to the possibility of change. For these rea-sons, I thought that a biological approach was a legitimate addition to the current plan. Takingthe opportunity to support the parental partnership by including Mr. T in the decision, andaffirming the need to continue other modes of therapy, I proceeded to give Adam a trial of



shortstandard

top of rhbase of rh

cap heightbase of textRitalin using target symptoms established by his parents. Adam’s response to Ritalin was

felicitous. His impulsivity was significantly diminished, making it easier for both parents toset limits on his aggressive behavior.

The summer vacation went well, as the family continued to move towards positive change.Ben was growing more forceful and independent, and he went on an overnight camping tripwith his father, leaving Adam at home with his mother. At this point, Adam’s relationship withMrs. T was much improved.

I planned parent meetings to address the mistrust in the parents’ relationship. In the firstmeeting, I asked Mrs. T to find a story in her childhood that described the situation she feelstrapped in with her husband—one in which she feels unprotected and abandoned by a manwho is “tuned out” to his children’s needs and feelings. She immediately described her father’sself-destructive behavior leading to his death as exemplifying this pattern. “He took himselfaway from me.” I asked Mr. T to find a comparable pattern from his childhood in which hefelt controlled and abandoned by a woman. Only after a significant hesitation was Mr. T ableto disclose the fact of having been tied to his crib by his mother. Later in childhood he describedknowing how to “press (his mother’s) buttons” in order to provoke a negative connection withher when a positive one was impossible.

When after this discussion Mr. and Mrs. T began to attack each other in their habitualways, I stopped them. Perhaps in the context of our meeting together they had reached for anew way of being together, and unable to manage the intense affect, had fallen back on theirfamiliar strategy. I pointed out that in addition to the similar patterns we had just observed,they had an alternative, one with potential for tenderness and mutual understanding. Thatconnection was the experience of childhood trauma, of small children having been over-whelmed with hurt and anger without an adult to turn to. Mr. T, whose face usually alternatedbetween impassivity and studied geniality, became flushed and tears came into his eyes. Mrs.T told me later that this rare expression of “vulnerability” by her husband made her feel lessisolated, less angry, and more hopeful. This was the beginning of our efforts to achieve greatertrust and comfort with experiencing and expressing strong affect in our meetings.

My work with the T family continued to follow this variety of interventions—sessionswith one parent, both parents, parent with child, and whole family—all motivated by theintention of building tolerance for negative affect. Seeing my role as providing a safe contextfor loosening the rigid strategies for dealing with negative affect and aggression, I allowed theT family to search for new ways of “managing the forces” of family life and intimate relation-ships (Tronick, 1998; Tronick, personal communication). Slowly they were able to try out newstrategies, new ways of fitting together, just as specific, but requiring greater openness andtrust. My own vision for this family could contain the hope, the positive expectancy that theycould not achieve alone.

CONCLUSION

This clinical example suggests how a therapist can be more productive by including a morecomplete theoretical framework suggested by Sander’s insights. This framework focuses onintervening in the family system rather than with the individual child, and includes dynamicprocesses within the family in the therapeutic effort.

Sander’s framework allows the therapist to see both the forest and the trees, the broadbrush strokes of change and how they take place and the details of microscopic interventionsand their consequences. As part of a process of continual evolution, small moves initiated bythe therapist are designed to disrupt specific connections that interfere with a family’s healthyfunctioning. Each particular intervention—a series of mother-child play sessions; treatment of



shortstandard

top of rhbase of rh

cap heightbase of textthe impulsive child with stimulant drugs; parent sessions addressing conflicts in the couple—

accumulates to form a comprehensive treatment. They serve to destabilize the present equilib-rium, the present set of specific connections underlying a set of habitual interactive patterns.After each intervention, the therapist notes the effect on the system before planning the nextmove. Taking into account the unpredictability as well as the plasticity of the system, thetreatment plan cannot follow a linear trajectory but must instead be incremental, always re-sponsive to shifts within the system.

This clinical model involves a more complex role for the therapist, but not necessarily amore difficult one. The therapeutic process requires the therapist to move from the backgroundto the foreground of the system and back again in a continual effort to recognize and supportthe initiatives of the family members. The therapist is working with a moving target. Bycontributing hope as a new motivating energy in the family system, hope that derives from anaccurate recognition of the particular features and strengths of the family, the therapist assistsin the negotiation of a new direction of cooperative activity, one that promotes growth. Allthese therapeutic processes scaffold the forming of new interactive patterns in the direction ofresiliency and strength.

This clinical model, informed by knowledge about early child development and aboutchange processes in living systems, offers a more flexible approach to the therapeutic needs ofyoung children and their families than models with a narrower theoretical base. The generalprinciples of the theory allow for dialogue with other fields of contemporary scientific study.Finally, because of its versatility and general applicability, the model lends itself to globalefforts in both therapeutic and preventive health care for infants and young children. Indeed,such a model can allow the overall mental health system to address the current demands forgreater cost-effectiveness and responsivity to cost concerns.

REFERENCES

Fivas-Depeursinge, E., & Corboz-Warnery, A. (1995). Triangulation in relationships.The Signal, 3(2),1–6.

Fivas-Depeursinge, E., & Corboz-Warnery, A. (1999). The primary triangle: A developmental systemsview of mothers, fathers, and infants. New York: Basic Books.

Nahum, J. (1994). New theoretical vistas in psychoanalysis: Louis Sander’s theory of early development.Psychoanalytic Psychology, 2, 1–19.

Sander, L. (1962). Issues in early mother child interaction. Journal of American Academy of ChildPsychiatry, 1, 141–166.

Sander, L. (1964). Adaptive relationships in early mother-child interaction. Journal of AmericanAcademyof Child Psychiatry, 3, 231–264.

Sander, L. (1977). The regulation of exchange in the infant-caregiver system and some aspects of thecontex-content relationship. In M. Lewis & L. Rosenblum (Eds.), Interaction, conversation, and thedevelopment of language (pp. 133–156). New York: Wiley.

Sander, L. (1980a). Investigation of the infant and its caregiving environment as a biological system. InS. Greenspan & G. Pollack (Eds.), The course of life (Vol. 1: Infancy and early childhood, pp. 177–201). Bethesda, MD: NIMH.

Sander, L. (1980b). New knowledge about the infant from current research: Implications for psycho-analysis. Journal of the American Psychoanalytic Association, 28, 181–198.

Sander, L. (1987a). Towards a logic of organization in psychobiological development. In H. Klar & L.Siever (Eds.), Biologic response styles clinical implications [Monograph series] (pp. 20–36). Wash-ington, DC: American Psychiatric Press.



shortstandard

top of rhbase of rh

cap heightbase of textSander, L. (1987b). A 25-year follow-up: Some reflections on personality development over the long

term. Infant Mental Health, 8, 210–220.

Sander, L. (1995). Identity and the experience of specificity in a process of recognition, commentary onSeligman and Shanok. Psychoanalytic Dialogues, 5, 579–593.

Sander, L. (1998). Organizing complexity within the psychoanalytic framework: Toward an integrationof emerging knowledge of early development, biological systems, and therapeutic processes. Pre-sentation to The American Psychological Association Division 39 Symposium, April 24.

Sander, L. (in press). Thinking differently: Principles of process in living systems and the specificity ofbeing known. Psychoanalytic Dialogues.

Sander, L., Stechler, G., Burns, P., & Julia, H. (1970). Early mother-infant interaction and 24-hour patternsof activity and sleep. Journal of American Academy of Child Psychiatry, 9, 103–123.

Stechler, G., & Halton, A. (1987). The emergence of assertion and aggression during infancy. Journal ofthe American Psychoanalytic Association, 35, 821–838.

Tronick, E.Z. (1998). Dyadically expanded states of consciousness and the process of therapeutic change.Infant Mental Health, 19, 290–299.

Weiss, P. (1969). The living system: Determinism stratified. In A. Koestler & J. Smithies (Eds.), Beyondreductionism: New perspectives in the life sciences (pp. 3–55). Boston, MA: Beacon Press.

psychiatric theory and practice: using sander's theoretical contributions to assist parents in...

Documents