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Prevention, Infant Therapy, and the Treatment of Adults Toward Understanding Mutuality
By Judith S. Kestenberg, M.D., with Arnhilt Buelte
Reprinted with Permission of Jason Aronson Inc.
This is the first in a series of papers about the relevance of infant therapy to the treatment of adults. A description of maternal and infantile movement patterns is used to substantiate our thesis that not only does the mother hold the child, but the child holds the mother. A good-enough holding environment is maintained when the mother's adult patterns of effort and shaping dovetail with the infant's inborn reflexes to make mutual holding possible. Mutual support enables mother and child to attune in tension-flow rhythms (used for need satisfaction) and to adjust in shape-flow rhythms (used for intake and output). Attunement is the physical core of empathy, and adjustment is the cradle of trust. Empathy and trust between therapist and patient develop in a good-enough holding environment which is derived from mutual holding in early infancy. Not only does the therapist provide a holding environment for the patient, but the patient does his share to support the therapist in his aims.
Winnicott (1963, 1965) introduced the term holding environment to describe a therapeutic setting modeled after the early caretaking functions. The term holding denotes not only actual physical holding, but also the total environmental provision for the child's well being-such as a crib, proper room- and bath-temperature, fresh air and other necessary environmental objects (Balint 1960). Mother's presence is felt everywhere, in a cot, a pram, or the general atmosphere of the immediate environment. Thus, the relationship between two people continues even if they are separated (Winnicott 1958, p. 30). The capacity to be alone is based on the experience of being alone in the presence of someone else. Winnicott considered it the "stuff out of which friendship is made" and thought that it probably is the matrix of transference (1958, p.33). Neither Winnicott himself nor Anna Freud (1976) believed that analysis can bring the patient back to the stage of infancy, but there are certain features of treatment reminiscent of the caretaking activities in early childhood. Modell (1976) referred to the holding environment as a metaphor modeled after certain aspects of the mother-infant relationship, and he extended this metaphor from its derivation in the infantile period to the broader caretaking functions concerned with the older child. In the treatment of transference neuroses, the extended holding environment functions silently. It is taken for granted as it constitutes part of the confidence the patient feels toward the therapist.
In most discussions of infant care and its derivations in patient care, the onus is put on the caretaker (the good-enough mother or the good-enough therapist), and the infant or patient is pictured as unable to contribute his share to the holding environment. Modell's conceptualization clearly implies that in therapy this occurs only in cases' of ego distortion, but is not necessary where the patient becomes actively engaged in "curing himself" (Freud 1920).
Erikson (1950) preferred not to speak of confidence (Benedek 1949) in the early stages of infancy. He chose the word trust because there is more mutuality in it. He added, "The general state of trust, furthermore, implies not only that one has learned to rely on the sameness and continuity of the outer providers, but also that one may trust oneself and the capacity of one's own organs to cope with urges; and that one is able to consider oneself trustworthy enough so that the providers will not need to be on guard lest they be nipped" (p. 220).
This suggests that mutuality is based on the infant's developing trust in the mother and the mother's developing trust in him, from which a sense of trustworthiness (in the sense of self-trust) arises. Mother and infant rely on each other's ability to fulfill the appropriate share of their cofunctioning (Call 1968). The infant's sense of trustworthiness evolves from the experience of trusting and being trusted. Searles (1976) went a step further when he spoke of the infant's curative efforts toward his mother. In such cases, the child not only functions for himself, but also for his mother; at least the child facilitates the awakening of maternal abilities by virtue of his trust-inspiring behavior. Mothers have a word for such children. They are good babies, easy to rear. Guntrip (1975) quoted Winnicott as saying that he, the analyst, was good for his patient, Guntrip, but that Guntrip was also good for him, the analyst. The quotation suggested that Guntrip was capable of raising Winnicott's self-esteem while another patient might lower it.
According to Winnicott (1960) good-enough holding gives the infant a feeling of continuity of being which is the beginning of psychic structure. The mother develops her sense of holding during pregnancy and continues this maternal action after delivery; she becomes able to interpret the external world to the infant. The analyst's understanding is equivalent to that of the holding mother who understands her child. In these passages Winnicott referred to two essential functions of the caretaker and the therapist-understanding and the ability to convey that understanding to another. Greenson (1960) looked upon empathic understanding as sharing, a two-way relationship. There are patients who can be easily understood and others who resist being understood and do not explain themselves. The same is true of analysts who may understand empathically but are unable to couch an interpretation so that the patient can respond to it.
When we speak of empathy, trust, and holding, we are dealing with those aspects of psychic functioning which cannot be easily separated ftom physical experience. Empathy is based on attunement to another's needs and wishes; trust is an adjustment of responses to make them coordinated and predictable. Neither can flourish without the primary ingredient of mutual holding, which constitutes a protection against bodily and psychic insult. This triad constitutes the core setting which facilitates the development of psychic structure in infancy. An analogous triad provides the setting for the restructuralization expected to take place during analysis. The patient's capacity to be alone in the presence of the analyst seems to be derived from his early relationship with an empathic and trustworthy mother. The same applies to the analyst's capacity to be alone in the presence of the patient.
In this paper we hope to demonstrate mutuality between mother and child from the start. Through a description of maternal and infantile movements and positions we shall show how each of them contributes to the creation of a holding environment in which empathy and trust can be generated. Using the same method, we shall illustrate how some early holding failures originate. Furthermore, we shall present examples to show that patient and analyst intuit the degree to which they can empathize, trust, and rely on each other from the way they move and from the way they hold themselves up. This type of mutuality enables them, more than words do, to reconstruct early holding failures which have left their traces in the adult's feelings about himself and others.
Without equating therapy with child-care, Winnicott (1960) maintained that three expenences-having been a child, a parent, and an observer of infants-sensitize us to the hidden meanings in patients' and in our own communications. To these sensitizing experiences we can add the practice of prevention through mother-infant therapy.
In our work with infants and mothers, we encounter the average maternal and infantile failures which stimulate differentiation and separation. We are also mindful of the many chances the child has to recuperate from previous failures, especially when his earlier needs, regressively revived, are met by new and more adaptive responses. Yet, we have seen that many early failures in mutual holding, which may have originated in the mother's or the child's lagging development, or in both, persist and burden later developmental phases. To prevent such consequences of early failure as fear of collapsing instead of holding-oneself-up, lack of self-confidence, and despair at not being understood, we have developed a nonverbal method of retraining mothers and children. (For a description of this method see Kestenberg and Buelte in this volume.) Our observations and method of treatment are based on a detailed exploration of movement patterns in the mother and the child. It is necessary therefore to introduce here those movement patterns relevant to our theme.
Movement Patterns
There are many ways to observe and classify movement. From the countless combinations of motion factors, observers can focus on developing skills and functions (Gesell 1940), on gestures and postures (Lamb 1965), on tension states (Reich 1927, Lowen 1958), on distancing (Hall 1959), or on the symbolic use of positions and directions (F. Deutsch 1953). In the special study on which our infant therapy is built, we devised a movement notation supplementing the effort-shape system that relies on the classification of movement styles originated by Laban and Lawrence (1947) and Lamb (1965). Our observations are drawn from normal development, from the progressive recovery of functions during infant therapy, from personally retraining mothers and children, and from the vicissitudes of patients' movements.
In the following sections we describe patterns of mobility present at birth and used for attunement and mutual adjustment. We distinguish them from those which mature later and are used to cope with environmental forces and objects. Both are intrinsic to the infant's holding environment. The advanced patterns can be noted in such caretaker-activities as picking up, carrying, and supporting the baby. The infant's inborn reflexes are used in conjunction with maternal functions, not only to facilitate them but also to hold and support the mother. Two examples of mutual holding will be given under the heading of stability-the nursing and the upright embrace. At the end of each subsection we shall give examples from or discuss aspects of therapy designed to show the relevance of our insights to the treatment of adults. To facilitate understanding of the movement terms used, we include two tables defining them. More detailed descriptions of interest only to some readers are given in notes.
Table 1. Classification and Definition of Movement Patterns Tension Body-Shape
Tension
Rhythms of tension-flow
Repeated alternations of tension change
Serves need-satisfaction and drive-discharge
Rhythms of shape-flow
Repeated alternations of shape changes
Serves self-expression
Qualities of tension-flow
Free or uninhibited flow
Bound or inhibited flow
Intensity factors
Maintenance of adjustment of tension levels
High or low intensity
Abrupt or gradual tension change
Tension-flow, mediated by the gamma system, underlies basic affects of feeling anxious or safe and their variations. Tension-flow is coordinated with shape-flow as seen in tension- and shape-changes in respiration. | Body-Shape
Rhythyms of shape-flow
Repeated alternations of shape changes
Serves self-expression
Qualities of symmetrical or asymmetrical shape-flow
Growing: Enlarging the shape of the body
Inhaling or opening the mouth
Shrinking: Diminishing the shape of the body
Exhaling or shutting the mouth
Three dimensions of growing or shrinking
Narrowing or widening
Lengthening or shortening
Hollowing or bulging
Shape-flow underlies affects of discomfort or comfort, repulsion or attraction, and their variations | | |
Efforts (Laban)
These patterns control tension-flow and make it subservient to the exigencies of reality by
Approaching space directly or indirectly
Serves attention
Dealing with weight via strength or lightness
Serves intention
Coping with time via acceleration or deceleration |
Shaping of Space in Directions and Planes
These patterns control shape-flow and make it subservient to their aims
Body dimensions projected into space create directions to be used as bridges to objects
Across the body or sideways
Downward or upward
Backward or forward
Shaping in planes creates multidimensional closed or open shapes in space which bar or expose to contact with others
Enclosing or spreading in the horizontal plane
Descending or ascending in the vertical plane
Retreating or advancing in the sagital plane |
Table 1. Tension-and shape-flow are qualities of all living tissue. Available to the newborn, they diminish in frequency of alternation and repetition when the more advanced effort-and shaping-patterns emerge.
1. Mobility
Tension Flow
Rhythmic changes of tension are the basic qualities of living tissue. Rhythmicity serves need and drive satisfaction. For example, in sucking, free (uninhibited) and bound (inhibited) flow alternately repeat themselves. When sucking- and milk-flow-rhythms are synchronized, the influx of milk is inhibited during swallowing and released when the oral cavity is emptied and the infant resumes sucking in free flow. Not only the lactation rhythms but the majority of the mother's tension-flow rhythms are attuned with those of the infant. He, in turn, is capable of attuning to her rhythms. Intrinsic to these rhythms are qualities of tension which change in intensity, frequency, and rate of repetition according to needs (table 1). While maintaining the basic maternal ego-attitudes, the mother regresses with the baby in the service of child care. During nursing, she may rock or tap the baby in an oral type rhythm. If he gulps and chokes, her own rhythmic tapping will reintroduce a lower intensity and a less abrupt manner into his nursing activity. The better he sucks and the more easily he can attune to maternal rhythms, the easier it is for the mother to maintain her regression without losing sight of her role as a mother. At the end of feeding, she will readily change her tension-flow rhythms to serve other needs of the baby, such as diapering him. After she puts him into his crib, she will devote herself to other activities which do not necessitate regression to infantile rhythms.
When mother and baby attune to each other's needs, empathy develops. A similar process occurs in analysis as well, except that both patient and therapist regress in the service of therapy. A controlled regression facilitates the flow of associations, freeing and binding them rhythmically. Speaking with "free floating attention," one must inhibit some interfering associations in order to select ideas which can be expressed comprehensively. The analyst's empathic understanding is more sensitive when his patient's and his own flow of associations are synchronized, or attuned. However, when the patient stumbles and cannot resume the flow of his thoughts or verbalizations, the analyst may help him restore an acceptable rhythm by freeing him from an excessive inhibition. The analyst will help lower the patient's intensity and reduce his impetuosity when his associations become unduly free and an excess of primary process material makes his productions incomprehensible and frightening. Not only the therapist but also the patient must maintain certain controls during the session. The patient is not free to jump and run or destroy furnishings. The good-enough patient is not only a self-caretaker (Winnicott 1972) but also takes care not to injure the analyst. Under these conditions mutual empathy and trust can develop and deepen. At the end of each session, empathy is reduced considerably when the partially suspended ego-controls are resumed and both patient and therapist assume a new nonanalytic attitude in which the normally prevailing secondary process thinking replaces free associations.
Efforts
We have discussed the rhythmic changes in tension used for need- and drive-discharge in the infant and the adult and have drawn attention to a similar rhythmicity which pervades free associations in analysis. Through this tension-flow medium, babies reveal their needs to the attuned mother and patients disclose their feelings to the attuned analyst. The ensuing empathy is not one-sided. Attuning to the mother, the baby learns to understand her, as the attuned patient develops an understanding of the analyst's communications. Overlaying these processes are advanced ego-functions which are instrumental in creating an organized holding environment. Adults are in control of these functions; the baby is not. The caretaker of the child uses the ego-controlled patterns, called efforts, which safeguard the child against the hazards of the environment.
Efforts are motion factors suitable for coping with environmental forces of space, gravity, and time (table 1). A mother must be capable of approaching the space in which childcare is transacted directly (with precision) or indirectly (trying out variations). She must be able to evaluate relative weights and use strong or light efforts to lift her own weight, the child's, and that of objects around her. She must know how to accelerate to catch a child's fall or decelerate in order not to rush the child. A stable holding environment is the result of efforts executed in the creation of the child's immediate environment. The overuse of efforts, however, implies that this task is never accomplished and that continuous work is involved to achieve it.
Mothers greatly concerned with the external details of the environment frequently suffer from a lack of empathy with the child. They may be efficient and dependable caretakers but they often treat the baby as if he were one of the items in the room. They will use steady strength in picking him up instead of rhythmic tension changes which synchronize with the baby's attempts to climb up as he is being picked up. They will accelerate to catch the baby's fall, but may give him no opportunity to do his share in restoring his equilibrium. They may place him in the crib with precision without attuning to his need to stretch, twist, and change tension in various parts of his body, as he settles himself in his new location. On the other end of the maternal spectrum are the careless mothers whose effort control is deficient. They may drop the baby, fail to pick him up in time, or put him down every which way. However, once the child incurs an injury, they may quickly attune to his distress and soothe him with empathy.
In therapy we encounter intellectual, efficient patients who are afraid to regress and equally dependable therapists, who do not allow their empathy to unfold. For instance, they explain all time changes and vacations at certain set specific time intervals and will interrupt the patient's associations to do so. There are also careless patients and lax therapists. Careless patients do not come on time, drop their belongings, and frequently change their position on the couch. Careless therapists may think they are flexible when they are late, change their mind frequently, and readjust their own positions in a conspicuous way. Careless patients may let their feelings overflow and often have an uncanny ability to understand what the analyst feels. They are especially sensitive to losses of ego control in others. They may disrupt the holding environment of the average therapeutic setting to such a degree that their therapists are prevented from maintaining their habitual constancy in time, space, and weight (Kestenberg 1977a).2
In the ordinary child-care or therapy setting, we do not usually encounter such extremes of efficiency or carelessness. Each individual is characterized by specific lags in empathy on the one hand and effectiveness on the other.
At first, the infant uses his inborn reflexes as an aid in the creation of his own holding environment. Once his tension-flow rhythms come under the control of efforts, he can begin to establish a proper balance between affectivity and reality-oriented achievement. Through periods of regression and progression, he assists his mother in organizing an optimal ratio between empathy and reason which allows for commensurate changes in the holding environment.
Shape-Flow
We have discussed attunement in tension-flow from which empathy arises and the use of efforts to create external safeguards for a good holding environment. In this section we describe shape-flow rhythms: the patterns of mutual relatedness from which trust arises.
As the body takes in substances its shape grows; as it expels waste its shape shrinks. The foremost example of this flow of shape is symmetrical growing and shrinking in inhalation and exhalation (Kestenberg 1967). An asymmetrical form of shape-flow rhythms consists of growing toward and shrinking from localized, attractive and repulsive stimuli. In a good-enough nursing embrace, mother and baby come close to one another when they inhale and separate when they exhale. This contact regulates the baby's immature breathing and creates a balance between states of comfort and discomfort. When the baby dozes off and ceases nursing, his mother can "grow" toward him and, in this manner, stimulate a renewal of alertness and resuscitate nursing. She may herself shrink away from the baby prematurely, giving him a sign that she has become uncomfortable and would like to terminate contact. Breathing toward her, the baby invites a renewal of contact and may reinstitute maternal comfort and interest.
In harmonizing shape-flow rhythms within all the body dimensions, babies and mothers widen and narrow their chests during nursing, lengthen and shorten during upright support, and bulge and hollow as they approach or separate (table 1). In this manner, they give one another comfortable breathing space. The trustworthy baby does not lean on the mother so heavily that she cannot breathe in comfort, nor does the trustworthy mother hold him in a rigid embrace which interferes with his respiration. The same is true of shape-flow rhythms, which further growing into pleasant stimuli and shrinking away from unpleasant contact. When the baby's mouth bulges to seize the nipple, it meets an erect,1 bulging form which yields the pleasure-giving milk. When his lips withdraw to avoid an overflow of milk and choking, the nipple shrinks a bit also. Pushing the nipple (and later the spoon) into the baby's mouth before he has swallowed the last mouthful, disrupts the inborn, preformed connection between pleasure and growing toward the source of food. The intrusion into the body of the child becomes a source of displeasure from which he shrinks. The result is a loss of trust on the part of the baby. Similarly, a mother may not develop, or may lose, her trust in a baby who digs into her breast when she feels empty or responds to her loving touch by shrinking away. In either case, mother and child are not sure what to expect from one another, and the feeling of primary relatedness is shattered. The Isakower phenomenon (1938) depicts the terror of the pressing breast which prevents breathing. The fear of engulfment and of being swallowed up is a frequent sequel to early failures in shape-flow adjustment. In average development, shape-flow adjustments lead to mirroring and identification, while slight misalliances in shape-flow enhance differentiation.
Similar fine adjustments and failures occur in therapy when patient and therapist react to each other's signs of growing and shrinking. The patient may become dimly aware that the analyst breathes shallowly or has changed his position to veer away from the patient. He may react with an unconscious fantasy of being betrayed and rejected, and this can lead to breath holding or silence. There may be hesitation in his voice when he talks, or a sigh may reveal his feeling of dejection and his loss of trust. In a full circle of such interaction, the therapist feels that the patient is moving away from him and may in turn become reserved as if he distrusted the patient. Mutual trust can be restored, however, either through very fine readjustments of relatedness or through drawing the patient's attention to the estrangement.
Via frequent adjustments of shape-flow rhythms and harmonizing them with their maternal counterparts, the child becomes acquainted with the dimensions and shapes of both bodies. Outer and inner stimuli provide the external and internal sources for the structuring of images of fullness versus emptiness, of expansion versus constriction, and of growing bigger versus becoming smaller. Through corresponding changes in tension, the outlines of these shapes vary from overflowing (free flow) to becoming fixed (bound flow). The outlines give the affective overtones to early psychic representation.
The proximity of the mother enhances the incorporation of maternal body boundaries and shapes into the baby's own. Prolonged separations impoverish these aggrandizing features and Des Press vital functions. The vascularization and turgor of body surfaces may diminish; breathing may become shallow and irregular; the whole body of the child may look drawn in and shapeless. Regular, phase-adequate, short separations, however, promote differentiation and enhance the practice of projecting body dimensions and shapes into space, in search of the absent mother.
Shaping in Space
Touching mother and self is an aid in differentiating body surfaces. Looking and listening facilitate the bridging of distances to find the object. Growing toward the distant object brings no contact, but extending the arm in the direction of the object and taking its shape in visually provides the illusion of togetherness. Orientation in spatial directions is the structural mainstay of the interpersonal holding environment. Seeing mother, seeing one's hand, and remembering the direction in which they can be found transforms spatial bridges into holding lines.
An eight-year-old boy who suffered in his infancy from asthma and feeding problems used to invite his mother into the analyst's office and tie her up to the furniture. As soon as he was able to transfer his feelings to the analyst, he tied her up and took the spool of thread with him to the car. In his fantasy, he could pull the spool and thus locate the analyst while away from her. He thus created the holding environment he could not achieve in his infancy.
The manner in which analyst and patient use spatial structure evolves in part from the early period during which locations and directions served to create a lasting tie between child and mother. Patients and analyst have their assigned locations in the office. Patients tend to occupy the same chair in the waiting room, and they expect the ana,lyst to come in at the same spot each day. One adolescent patient put it to me very succinctly: "You have no business coming all the way into the waiting room when you have never done it before." She had to remain standing in my office until I sat down. Only then could she lie down and talk. Only when the proper holding distance was established could she engage in the therapeutic process.
When shape-flow becomes subordinated to a directional framework, trust and distrust become object-directed. A mother who can integrate the baby's and her own shape-flow rhythms, vision, and hearing through her own direction-giving movement helps convert early stimulus-related patterns into object-seeking mechanisms. In this she is aided by the baby's inborn reflexes which help direct the child's movement toward objects (table 2). When the mother ignores or suppresses the child's rooting or following movements (Wolff 1966), he has to rely solely on her directions. He may still develop a sense of trust, but there is the danger that he will become unduly dependent on the anaclitic object and lose the feeling of trust when left alone. When a mother relies too heavily on adult patterns of spatial orientation, she may show the baby her breast to guide him or may push the nipple into his mouth. She may be primarily interested in maintaining the attachment to the nipple and thus allow the rest of the child's body to remain unsupported. Unable to elicit or give support the baby may stiffen and cling to his mother. His developing trust is disturbed by the experience of simultaneous gratification and discomfort.
Some patients lie rigidly on the couch, hold on to themselves, and assume uncomfortable positions, all along speaking incessantly. They do not allow the analyst to interrupt for fear they will lose contact when they cease speaking. Like sucking infants, they seem to cling to the analyst with their mouth arid enjoy it. It becomes very apparent to the observer of infants that early positions and directions; imposed upon the infant, can become embedded in individual body attitudes which intensify during analysis (Kestenberg 1975, chapter 10). When this theme comes to the fore in analysis, verbal intervention must be brief and address itself to the core of the problem in order to be understood. Such succinct remarks as, You don't seem to be comfortable, You hold on to yourself, You want me to say something, or You feel you must go on, give these patients the minimal directions they need to function without undue loss of trust in themselves and the analyst.
The average mother uses directions consistently to structure the holding environment in such a way that biphasic and multiphasic shape-flow patterns can merge and separate in a meaningful way. When the baby turns to the mother's breast, her sense of direction helps her to contact him in the right place, where mouth and nipple meet. When she adjusts to his breathing and aids him in adjusting to hers, she will not turn her head in another direction, but will react to his turning away from her at the end of the feeding, by moving back and allowing him to maintain a distance from her. Carrying him, she will coordinate changes in his and her body dimensions with the direction she takes and will help him project his;:newly acquired dimensional self-feelings into ~patial directions. By the way she approaches, supports, and embraces the baby, the mother provides models of spatial configurations into which he can fit and which he can emulate. He can thus become an active participant in the creation of an object-filled holding environment. In it, the shapes of the nursing embrace and its disengagement are externalized in such shaping patterns as enclosing and spreading in the horizontal plane; the shapes of the mutual upright support and let-go positions are reproduced in the shaping of ascent and descent in the vertical plane; and the shapes of approach and withdrawal form the basis for the shaping of advancing and retreating in the sagittal plane (table 1). Through shaping of his space in spatial planes, the older child communicates his wishes, shows his understanding of other people, and anticipates their actions. By shaping the holding-space in coordination with the child's vision and his inborn reflexes, parents model for the baby how objects fit into cradling embraces, into holds, and into less constricted forms which permeate the outer limits of the horizon. Long after internalization has been accomplished, these spatial forms provide a framework to relationships which persist as an external referent to the memory of the concrete shape of the object. Shaping of space is an adjunct of speech (Birdwhistell 1970). Language retains the traces of its origin in the shape of things and in the shaping of relationships. Within the context of such well-known combinations of words and movement as, How big is the baby?, I love you so much, or Come to Mommy, the holding environment combines multisensory experiences into integrated permanent structures.
Maternal shape-flow responses contribute to the harmony between mother and child as she rocks him, stoops to him, picks him up, and walks with him. From such stuff trust is made, but this source of trust must be secured by the delineation of directions and spatial planes which constitutes the three-dimensional structure of our space.
When directions and shaping patterns are used excessively, at the expense of harmonizing with the baby's shape-flow rhythms, relationships are isolated from feelings of comfort and discomfort and trust is supplanted by reasonable expectations. Some parents are incapable of directing and shaping sufficiently, and they look to their young children for the structure they themselves lack. Under normal conditions, spatial boundaries which expand and limit relationships are not just gifts from the mother or contributions from the inborn and maturing Systems of the child; they are created by both, under the guidance of maternal ego functions.
Difficulties in the beginning of treatment often arise because the analyst, the patient, or both, overdirect and overexplain at the expense of developing harmony in the therapeutic relationship. Some therapists and patients can develop confidence only when a rigid structure is imposed upon them and inflexible rules of therapy guide their conduct. Less often a therapist will look up to his patients expectmg him to organize the treatment. In a good-enough therapeutic alliance, the therapist guides the patient so that together they can create a good-enough holding structure-one which can withstand the impact of regressive repetitions of infantile failures.
Table 2. Inborn Relfexes of the Newborn and Young Infant
- Rooting or Search Reflex
When the cheek or perioral area is touched the head turns toward the stimulated side and the mouth opens. - Rooting and Spontaneous Creeping
In prone position, the infant pulls one or two of his legs under the pelvis, and one or both arms extend. The head may rise or burrow on the surface of the sheet or turn sideways as the cheek touches the sheet and the mouth opens. Through the thrust of the leg-flexion and arm extension, the infant propels himself in an irregular fashion, rooting like a puppy in search of the breast (See note 3). - Stepping Reflex
Supported in an erect position with the soles of the feet resting upon the edge of a table top, the infant extends the legs upon contact and makes alternate stepping movements. Loss of contact results in~flexion, which makes for variations in the infant's attempt to climb up on the mother. - Startle Responses
Extension and flexion, abduction and adduction, of limbs, in response to loss of support or jarring, sudden noises; rotating the head and tapping of the abdomen. In spontaneous startles the stimulus is not known. - Scratch Reflexes
When one foot is scratched at the sole the leg flexes. When the leg is flexed at the time of the stimulus, it is thrust into extension. When one leg is flexed and the other extended and the foot sole stimulus is applied to the sole of the flexed leg, it will flex the other leg, and vice versa.
Tonic Neck Reflexes
When the head of the baby is passively turned to one side, the whole side of the body on the chin side of the tu~rned head assumes a heightened extensor tonus and the other side assumes a heightened flexor tonus. If the head is extended passively (dorsiflexed), there ensues a bilateral extenso? tonus in the upper limbs and a bilateral flexor tonus in the lower. - Righting Reactions
Rotation of head induces body rotation as a whole.
Table 2. All these inborn reflexes and reactions can be seen at birth or a few weeks after. They underlie the infant's stable positioning which facilitates the mobility necessary for gratification and relief from discomfort. (Compiled from Pratt (1954), Fiorentino (1963), Bartenieff (1977), and personal observation.)
II. Stability
Inborn Reflexes and Holding
Since a young baby is not yet capable of using efforts or shaping, one is tempted to assume that he has no share in creating the holding environment but must rely solely on his caretaker's stability to maintain his body integrity. Robbins and Soodak (1972) discovered that the newborn's inborn reflexes are the mechanisms by which he can hold his mother (table 2). Through these reflexes the baby can, in contact with his nurturing mother, assume positions in space which help maintain his stability during nursing. Intrinsic changes in the flexor and extensor tonus enable the infant to practice rudimentary antigravity patterns. He has inborn mechanisms of attachment and disengagement timed in accordance with his needs. These primitive inborn reflexes, which he uses to contribute his share to the holding environment, contain rudiments of the much later maturing patterns of effort and shaping (Bartenieff and Davis 1972, Bartenieff 1977). When, during early care, reflexes such as the tonic neck reflex and the creeping or stepping reflexes (table 2) are allowed to function in harmony with the mother's shaping and direction-giving actions, they become the 'stable core on which identification with the mother and thus relationship~ are built. Holding and being held, mother and baby respond by forming a bond between them. At the same time, the mutuality of holding in the first days and weeks of life becomes the mainstay of future holding-oneself-up and feeling self-reliant.
Our preliminary investigations suggest that holding modes become engrained in the psychosomatic memory and are used again and again over generations so that certain holding habits are ritualized in specific cultures (Mead and Bateson 1942). Some cultures make good use of the infant's inborn holding mechanisms; others assign the principal task of holding to the caretaker and suppress the use of early infantile holding reflexes. Correspondingly, whole generations of children tend to become self-reliant and others dependent.
We will confine ourselves here to the description of two basic holding positions: the nursing embrace and the upright embrace with shoulder-chest contact. One promotes intake of nurturing and provides the optimal environment for filling the child's body; the other facilitates output of waste and aids in the emptying of the body. One is a model setting for gratification-pleasure and the other for relief-pleasure.
The Nursing Embrace
There are a great many ways of holding an infant for nursing, in addition to those established by custom. They depend on the mother's and child's physiques, the position of the breast, the maturity of the baby, and individual preferences. The following description presents an abridged model of holding which promotes an optimal interaction and fits with the child's inborn holding reflexes.3
During nursing, the mother supports the baby's head and spine, providing the necessary stability to counteract startling and disengagement from the nipple. To do so, without tiring, she needs good back- and arm-support herself; and she functions much better when she crosses her legs. Together with the torso her limbs provide a concave cradle for the baby, allowing him to extend and flex to the degree that he is capable of changing his recent cramped intrauterine balling. The cradle is characterized by (a) the firm support given by the mother's arm and leg, which extends from the baby's head (in the nook of the maternal elbow) through his spine, pelvis and legs, and (b) the more flexible contact between the front of the baby's body and the maternal chest. As an external counterpart of the placenta, the upper front of mother's body provides an elastic and plastic cushion for feeding and breathing. Her warm and pulsating tissue is shaped to fit the baby's shape.
The baby not only sucks and breathes when the nutritive supplies of milk and oxygen are offered to him, but also follows his own attachment and holding procedures, which are designed to fit in with analogous maternal behavior. Through rooting (Spitz 1965), a rotation of the head is accomplished and the nipple is seized; this is a synchronous attachment behavior of mother and child (Bowlby 1958). Through the tonic neck reflex, evoked by head turning, tension is distributed so that the baby can hold his mother, almost duplicating the way she embraces him (Robbins and Soodak 1972). The high intensity of bound flow in the embracing limbs is a counterpart of the firmness through which mother gives support to the baby. The turning of the baby's body toward the mother and the adjustments of turning before the nipple is found (Spitz 1965) are analogues of maternal ways of approaching space in conjunction with enclosing the baby's body with her own. The latter, a shaping pattern, is preformed in the baby's tonic neck reflex, which positions his limbs and body to make an enclosing of the mother possible.. In addition, mother and child stimulate each other's skin. by gentle, stroking or dabbing actions. The child's hand and fingers knead the breast or clutch it; mother may help him with similar actions. From time to time, the baby's fingers play on the mother's:side back, and toes contribute their share to the seff-stimulating and mother-arousing behavior. Especially when sucking slackens or the baby seems uncomfortable, maternal hands move and stroke him. Both the child's and the mother's rhythmic play is attuned to the prevailing nursing rhythm.
During a good-enough mutual nursing embrace, many mothers feel strong uterus contractions. Nursing mothers are rarely conscious of the slight, gradually rising and falling tension waves which emanate from their inner genitalia, radiate upward, and become transformed into sinus rhythms. The latter are identical with the synchronized oral rhythms of milk-ejection and sucking which are coordinated with corresponding breathing rhythms. The mutual attunement in tension-flow and adjustment in shape-flow rhythms form the psychophysical base of mutual empathy and trust. When responses abated in the child or mother, digit-play acts as restorer of attunement and harmony. The experienced mother and mature baby attain this type of mutuality in functioning during the first day of the baby's life. The novice mother and the immature baby take longer and need more help to establish comfortable and secure patterns of holding one another for nursing.
What are the direct consequences and further developments of a good-enough mutual holding? Foremost, it provides a basis for a balanced ratio between stability and mobility which, in turn, prepares for differentiation between basic functions, beginning in the first days of infancy.
A division is initiated between the two hands: one assisting the nursing process by kneading the breast and the other holding the mother. Both the doing and holding hand and the corresponding toes play as well. We see here the origin of work and play and their relationship to one another (Kestenberg 1977b).
The firm support of the back of the body enhances extensor tonus and a delineation of body boundaries. The frontal region of the body is less stabilized and its boundaries have considerable leeway. Their elasticity and plasticity provide the tension- and shape-flow base for gradations of basic, intimate relationships between people. The feeling of being enveloped by the maternal embrace becomes the affective core of the child's body-image. The mother, whose shape and self-image have undergone a change during pregnancy, is helped by the child's embrace and support to build a new one. Moreover, the child's fingerplay seem~to activate the child's and the maternal gamma system in such a way that a redistribution and reintegration of tension, breathing, circulation, and temperature is initiated (Kestenberg 1977c, Kestenberg and Weinstein 1977). This physiological mechanism which originates the primary relatedness called transsensus-outgoingness by Glaser (1970) ceases tp operate smoothly when the mutual embrace is disturbed by such mishaps as dropping the baby's head, or swaddling him (immobilizing the body), or by his breath-holding, limping, or becoming rigid. In such instances, restorative finger play is either abolished or becomes ineffective.
Thus, three functions which evolve from the mutuality of the nursing embrace of the nursling can be singled out:- The beginning of differentiation between the holding and the "doing" hand, specific to the human species.
- The differentiation between the supporting and supported back and the more mobile, elastic front of the body
- The vitalizing function of finger and toe play which seems to act as a subtle trigger for the restoration of function through the reestablishment of lost unity between mother and child.
These three functions are basic to the formation of the kinesthetic and tactile body image (Schilder 1935)tthe first rudimentary psychic structure, from which self- and object-representations will emerge. Through the increasing influence of vision and hearing (via long distance receptors), the child begins to stare and listen attentively. These patterns enlarge the baby's horizon and become another source of stabilization. The mutual embrace can be now dominated by visual fixation (Spitz 1965). The increasing mobility of coordinated eye and hand movements is experienced as freedom from confinement while the pleasure of nursing diminishes in proportion to the need for voluntary self-support and independent exploration through movement.
Failures of the early holding environment lead to early clashes between mother and child. Sometimes both make valiant efforts to overcome the estrangement. When a mother lets the baby's head drop, his neck sink between his shoulders, or his legs dangle (Mead and Bateson 1942, p. 125, picture 7), she may try to overcome his discomfort by becoming rigid or by leaning over him to secure the nipple to his mouth. The baby may try repeatedly to lift his head to become more securely attached to the nipple. In trying not to slip further away from the source of his satisfaction, he too may become rigid or his holding arm and leg may fall limply and cease to embrace his mother.
As indicated by Winnicott (l972), the adult patient does not remember what happened to him in his early infancy. However, the early holding failure becomes embedded in his manner of holding himself and in the ways he resettles to achieve more comfort. A patient feels deprived, makes demands on the analyst and is unable to find ways to soothe himself when he is anxious, or comfort himself when he feels a loss. We deduce from his demeanor that he is fixated in the oral phase and we anticipate material that will explain the nature of his oral deprivation. Sometimes, we can detect in the patient's use of words that he has little faith in his own capacity to hold himself up and wants to be picked up and held. He looks to the analyst as someone who will restore his functioning, but he also scrutinizes him for signs of weakness. ln some instances he engages in an acting in (Zeligs 1957) which repeats in analysis the early holding failure.3 The analyst himself may tend to activate such acting in by providing a pillow or chair which does not allow sufficient flexion in the neck. The patient may try to resettle and, in so doing, will slide upward and meet the gaze of the analyst. He may want to substitute the lack of neck support by visual contact. He may want to come closer to the analyst. A confident analyst will acknowledge the patient's lack of comfort and his need to establish himself more securely in the analytic situation. A beginner, intent on keeping to rules, may become uncor~ortable when the patient looks at him. Through his reproving gaze he may engage in what Langs (1975) calls a misalliance with the maladjusted patient. He may become rigid to combat an urge to readjust his own position into a more comfortable one.
The analyst habitually settles into' his most comfortable position while the patient settles himself. There is a silent understanding that changes are perceived and have a meaning in the therapeutic context. A defensive turning away or slumping by the therapist may be interpreted by the patient as a rejection. The transition from the perception of the analyst's movement to the patient's ensuing feeling that he is being abandoned or dropped may be quickly repressed, but can recur in dreams of losing support or getting lost. The therapist often takes a deep breath or resettles before he makes an interpretation. A sensitive, empathic patient becomes immediately attentive, giving the analyst support through his stable listening stance. A patient will resettle on the couch or in the chair when, either on his own or through the therapist's intervention, he becomes capable of making a substantial change in his self-representation. His new position reflects his new ability to support himself.
Instead of resettling, some patients to move their fingers, toes, or ankles in involuntary fashion. These rhythmic motions serve to revitalize the patient, especially when visual separation threatens his integrity. Such movements contain rudiments of early infantile modes used to reestablish kinesthetic contact with the mother. On a different level, they represent unconscious confessions of autoerotic play concealed from the analyst (Kestenberg 1966), the patient himself, or both. When a therapist draws the patient's attention to these involuntary rhythmic movements early in treatment, he may be rebuffing the patient's attempts to restore the holding environment or unwittingly scolding him for autoerotic practices. When the patient becomes aware of feelings that the analyst does not understand him, he may be more receptive to the analyst's interpretation of his rhythmic movements as attempts to revitalize himself and the analyst so that a milieu of mutual empathy can be established or renewed.
Mr. X, a compulsive patient, began his second analysis by complaining incessantly about aches and fears of becoming sick and dying. When the analyst drew attention to the rhythmic movements of his ankles and feet (Kestenberg 1966), a crucial point in the an1alysis occurred. He confessed that he had began to masturbate anally during'. his first analysis, when he replaced genital masturbation with perianal rubbing. The confession opened up transference manifestations which allowed us to analyze and work through the anal struggles of his toddlerhood, to which he had regressed.
Despite the good results of the analysis, Mr. X would come periodically to talk things over which bothered him. He was sitting up in these sessions and I could see much better than before that he held his neck and shoulders stiffly and could not perform enclosing motions. He suffered from a cervical disk compression and was not allowed to arch his neck backward. It became evident that many of his aches and pains, which had been only partially relieved during the analysis, were caused by a cervical radiculopathy. He aggravated this condition by periodically arching his neck when he looked away from me. He did not allow his neck to drop backward, but merely released his habitual stiffness a bit while arching. When I drew his attention to this habit, he denied it at first, but could readily understand that he was repeating a failure in his early holding relationship with his mother and substitute caretakers. He became tearful when he thought that his neck had not been supported and he could not relax and enjoy the pursuit of gratification without aches and fears. It was clear that temper tantrums and struggles over toilet training which had been worked through in analysis, had not been linked with the experiences of holding failure in the oral phase.
Upright Embrace
The nursing embrace promotes enough flexion in mother and child to allow for mutual gazing and to initiate an integration between kinesthetic and visual perceptions. Carrying the baby upright promotes vertical extension of the spine and face-to-face confrontation or looking in opposite directions. The transition from maternal arms during nursing to lying supinely in the crib contrasts with the transition from mother's shoulder to a prone position. Creeping, pulling oneself up, stooping, and walking all evolve from practicing in the prone and the upright postions.5 The child's ability to hold, strain, push, and relinquish voluntarily are the essential ingredients of bowel control, which can be accomplished only when the child is no longer afraid of losing equilibrium and falling. It is not surprising to discover that the upright shoulder-chest-pelvis support is most conducive to burping which brings relief by eliminating gas trapped in the bowels. Neither is it surprising to discover that the child's early participation in getting to, and remaining in, the upright position initiates the kind of self-reliance and autonomy which peaks in the second year of life (Erikson 1959, Kestenberg et al. 1971, Kestenberg and Buelte 1977, in this issue).
To pick up a young baby, the caretaker places one hand under the child's neck and head and the other hand under his rump. She lifts him in this position, maintaining the support of his head until he can rest on her shoulder. To pat the baby's back and facilitate burping, the mother makes sure that the baby's head remains supported and will not sink or wobble. If she is skilful in utilizing the baby's spontaneous rooting (Spitz 1965), she helps him creep up on her and will place his arms around her neck or on her shoulder-a horizontal surface he can push his head away from, using his arms as support. He can rest his head or raise it and turn it as he does in the prone position in his crib. Leaning against her chest, he feels her breathing and her heart beat. When he feels discomfort in his stomach or intestines, he can press against her and he may clutch her hair or clothing. When mother feels his discomfort she presses also. The child's flexed~ legs, conforming to the mother's supporting forearm will flex more and more and become bound in response to an abdominal cramp. The release of gas in either direction is experienced in synchrony with the relief-bringing extension of the body in free flow. These alternations between shortening and lengthening (table 1) add their share to the climbing reactions of the baby. A mother, attuned to the baby's tensions-flow rhythms will change her own rhythm to serve his needs. She will also shorten a bit when he shorterns and will lengthen at the time the child begins to feel relief (table 1). Their attunement and adjustment become more refined and modulated when they feel a good mutual support. There is a mutual embrace not only in the nursing but also in the upright position. Mother's embracing arm supports the child's pelvis; the child's embracing arm holds the mother's neck or shoulder. Together they form a holding unit which remains a model for mutual soothing, relief bringing, comforting, and reliance from infancy through adulthood.
What are the consequences and further developments of a good-enough upright mutual holding in early infancy? The rudimentary support patterns (at first subcortically controlled) become the basis for the latter cortically regulated creeping, standing, and walking. These are dependent on the development of a firm middle and a stable extension from the pelvic area through the back and neck. Combatting gravity through maturation of antigravity patterns (table 1) is facilitated by psychosomatic memories of holding, being held, and gaining support in an upright position.
In the nursing embrace, mouth, hands, feet, and digits (the periphery of the body) are mobile, and support is expen.en~ced primarily in the curved back. In the upright embrace, head, neck, the lower proximal joints and later the shoulders become more mobile, and stability is felt primarily in the extended trunk. A differentiation between the upper and lower part of the body seems to evolve from such motions as turning and clutching in the shoulder-arm-hand area and twisting and turning in the pelvis. Maternal rubbing and pressing and the child's responsive squirming and counterpressing facilitate elimination. these relief-bringing patterns presage the kind of play which makes hard work easier to bear. Whereas the digit play of the nursling seems to restore continuity, this type of upright play eases strain and pain. During flexing and stretching in the upright position, the baby begins to feel the differences between the inside and the outside of the body. The emergence of a solid middle which holds the upper and lower parts of the body together adds to the stability of neck and back support, from which self-holding develops.
Thus, three functions, which evolve from the early supporting environment of the upright infant can be singled out:- The beginning of differentiation between the upper and lower part of the body, the former more involved in holding on and the latter in holding-oneself-up.
- The beginning differentiation between inside and outsiDes Pressures with a focus on the body-middle as a solid, holding-in structure and on the neck and back as pillars of self-support.
- The relief-bringing function of squirming, twisting, and holding play which begins to be distinguished from the peripheral play that maintains or reestablishes gratification pleasure
These three functions supplement those which emerge from the nursing embrace (p. 354) and contribute their share to the formation of the body-image in depth. The upright position brings the baby's face closer to that of his mother. When held high enough he plays with her hair, neck, and ears. His mother's voice resonates and vibrates and his vision comes and goes as he raises and lowers his head. He is more alert and perceptive in the upright position (Prechtl 1958) and begin~ to become acquainted with rudiments of sound-volume and spatial depth. When he pushes himself away from his mother's body and resumes contact, he practices antecedents of separation and rapprochement (Mahler et al. 1975), and these become associated with painful discomfort and comfort-restoring relief. All these experiences combine to help him initiate a multisensory image of himself and his mother.
If a mother picks up baby by his armpits, she immobilizes his body and pulls up his shoulders in such a way that he seems to hang on them. His head sinks between his tense shoulders and his arms hang by his side. In this position he cannot attach himself to his mother. His primitive rooting reflexes are abolished and he cannot lean or hold on to his mother's shoulder or neck. His head will either arch backwards or slide down on her chest. The mother may respond by holding her chest to create a nook for him or she may lean and arch backwards to give in to his weight. She may touch the baby's feet stimulating reflexes which promote extension of his body, and reestablish good support. However, when this motion frightens her, she may immobilize him again or let him slide down once more.
The sliding child, who loses support and fails in supporting himself, will grow up in fear of falling and will not feel safe holding himself up (Kestenberg and Buelte 1977). As an adult he may still draw on the kinesthetic memory of being held and dropped. When standing up, he may frequently feel that his stomach is sinking or his knees are giving out. A most frequent sequel of a mutual holding failure is the fear of heights. Traces of old holding failures can be observed in the way patients carry their own weight whent they come to the office and leave. Subtler effects of holding failures lead to a persistence of the need to use all senses as a safeguard against object-loss.
Looking ahead or letting his gaze w!ander, listening to small noises, a patient may lift his head a bit, tense his shoulders, rest an arm on the wall or put one hand on top of the other, cross and uncross his legs in silence. He may be trying to use a multisensory approach to establish a mutual holding-situation. He may act as if he had lost the analyst and has no one to talk to. In a way, each silence is a parting and each parting is a loss which connotes a breakdown in mutual support. When the time is up and the support of the couch is being withdrawn, it is incumbent upon the patient to support himself. His self-support bridges over the ensuing separation and each separation becomes a practice in holding-himself-up. a flicker of sadness may be discovered in the slumping of the head or wobbliness of legs when he leaves the session. He may overcome it by raising himself up to feel bug and in control. The therapist's ability to carry his own weight securely and his steadying gaze constitute a supportive measure which fosters the mutuality of holding-each-other-up for the sake of therapy. When the therapist himself feels a loss of support and cannot participate in the uplifting process, he may stiffen, avert his gaze, pull up his shoulders, slump or hold on to his chair. The patient will leave with this image of the therapist. He will become discouraged or will muster his strength further to support the failing therapist. Each situation is different, depending on the patient, the therapist, the phase of treatment, and the holding failure which plagues one or both participants in the therapeutic process.
During his analysis, Mr. X complained about chest pain, a fear of falling, and about a seemingly unrelated obsessive thought that he would soil himself. The latter became prominent in transference. Whenever he returned to see the analyst, the old idea of soiling her would reappear on the way to, and in, her office. He would end each session with a compulsive act. He would confront the analyst on his way out and, to do so, would turn his whole body rather than the neck and torso. His shoulders and neck would remain stiff as he complained that he had been scolded or put down instead of receiving the support he came for. At one time, the immediate cause for his return was not an external practical event which he wanted to discuss, but a recurrence, in a new form, of his fear of heights. He was angry at the analyst and denigrated her, trying to make her fall from the pedestal on which she seemed to stand. It became apparent that his soiling obsession was connected with a fear of falling. If he were to collapse because I could not hold him up, he could no longer hold on to his feces and we would both get dirty. When I finally understood that he wanted me to lift and hold him so he could relax, enjoy himself, and find relief from his aches and pains, he left the session feeling better. He felt dizzy and his fear of falling was activated in the interval between sessions. His defenses against falling included a turning of passivity into activity which expressed itself in a need to look down at me and shoot me with his feces (see Kestenberg and Buelte 1977, p.388 in this issue).
Discussion
During the observation and treatment of infants one can study the nature and origin of empathy and trust. These develop from attunement and adjustment of maternal and infatitile rhythms. Under optimal conditions, sucking and milk ejection are synchronized and the coordinated breathing patterns harnonize to assure good nurturing. To bring relief for intestinal pain and discomfort, maternal patting and back-rubbing are attuned with the child's gastrointestinal rhythms, and the mother and child breathing harmonizes with holding and releasing. These mobile patterns (tension- and shape-flow rhythms, table 1) cannot proceed undisturbed unless there is a stable framework which protects the child against loss of contact and falling. The adult caretaker uses ego-controlled coping patterns (called efforts and shaping, table 1) which are instrumental in erecting such a framework. By providing a holding space for the child, combatting gravity, controlling the timing of contact, and arranging the child's total environment to secure his survival, the parents create the early holding environment. The infant has no relation to external reality and can neither use efforts nor shape the environment. However, he has at his command inborn inflexes, which are the core of later reality-oriented mechanisms (table 2).
Not only the mother holds the infant, but the infant holds the mother (Soodak 1971, Robbins and Soodak 1972). The rooting reflex is the baby's response to the stimulation by the maternal breast. The tonic neck reflex provides the framework for the child's embrace of his mother. Spontaneous rooting in the upright position combines with the stepping reflex and, if need be, with scratch reflexes to allow the baby to creep up, or climb, on his mother and hold her, supporting himself on her shoulder (table 2). The early reactions, used in mutual holding, are met by mother's effort and shaping, which she uses to embrace and support the child. Through primary, kinesthetic identification with the mother, the child begins early in life to transform primitive reflexes into ego-controlled modes of coping with the external environment. His ego development is guided by the developing stable structures, which evolve from repeated experiences of holding, being held, supporting, and being supported. Through the mutuality of the nursing and the upright embrace, the child begins to build his boundaries and the feeling of volume and solidity in the weight-bearing middle of the body. The foundation is laid for future creeping, standing, sitting, and walking, which rely on an adequate ratio between stability and mobility. The early reflexes and reactions "do not altogether disappear. They continue to serve as a basis of our various adaptations to the environment. Though overlaid by conscious selective modes of action, they are a facilitating, stabilizing factor in all our daily postural adjustment" (Bartenieff 1977).
Efforts and shaping leave permanent traces in the stable body attitudes which provide a solid core for the formation of the ego. This ego-core evolves from the experience of mutual holding which facilitates the processing of mobile, rhythmic patterns on which empathy (versus alienation) and trust (versus distrust) are built. Not only does the good-enough mother feel empathy for the child and evoke trust in him, but the good-enough child begins to feel empathy for his mother and becomes a trustworthy member of the mother-child team.
Insight gained from observations of good-enough early holding environments and from experiences in devising and using methods of treatment for holding failures, has a high degree of relevance to the treatment of adults. The therapeutic holding environment need not be considered a metaphor, but rather an adult model for a stable environment which facilitates mobility of thought processes. While the emphasis remains on verbal communication, empathy and trust based on mutual attunement in tension-flow and mutual adjustment in shape-flow are the basic ingredients of a therapeutic relationship. In this paper, examples were given of the manner in which patient and therapist move, but it must not be forgotten that tension-changes in the vocal apparatus and their correlation to breathing patterns are responsible for intonations, melody, and changing volume of speech. These elements of paralanguage (Birdwhistell 1970) convey feelings which may reinforce or contradict the content of speech. Within the stream of associations, we detect changing ratios of secondary and primary processes and the transitions are marked by corresponding changes in movement and body attitude.
To a degree, each patient suffers from a holding failure and presents us with a history of his attempts to secure or reinstate self-support, autonomy, and mutuality of response to 6bjects. Analyzing defenses and transferences brings on an imbalance and regression through which analyst and patient can recognize individual sources of anxiety and Des Pression. They can go beyond the analysis of fantasies and extend into the somatomotor sphere which underlies psychic phenomena.
This presentation is meant to be a bridge between our understanding of the infant's first ways of establishing psychic structure and our views of the adult's rebuilding of old and building of; new structures within the therapeutic process. In a detailed case history of holding failure and treatment of an infant and his mother, A. Buelte and the author (1977, in this issue) illustrate how the first roots of structure formation are not lost, but become gradually incorporated into the developing patterns of feelings and thought.
Notes
1. Every therapy relies on a mutuality between doctor and patient. However, psychoanalysis, more than any other form of psychotherapy, derives its special features from a modified repetition of the early holding environment. In discussing the therapeutic milieu, we have addressed ourselves principally to psychoanalysis, but much of what we say is applicable to other forms of therapy as well. It would take us too far afield to examine which basic derivatives of the early holding environment show up more clearly when the patient lies down and when he sits during treatment. It is to be hoped that future research will uncover these differences.
2. In studying Freud's technique with the "Rat-Man," I discovered that Freud's capacity to maintain these constancies (time, space, weight) allowed him to achieve success despite the many mistakes he made during Mr. Lorenz's treatment. Constancy in weight in the analytic holding environment refers to the analyst's and patient's ability to attach significance to items which promote the analytic process and suspend judgments based on conventional values. in child care, constancy in weight not only refers to the mother's ability to lift the child in accordance with his weight, but also to the mutual strategies throu'gh which they hold each other up (see pp.352-357). In this paper attention is drawn also to the analyst's and patient's carriage through which they reveal their ability to support one another.
3. When the mother puts the child to the breast, the breast~heek is stimulated and the rooting reflex evokes opening of the mouth and turning to the side of the stimulus. The mouth seizes the nipple in free flow and pulls on it in bound flow, followed by a pause during deglutition. Coordinated with the sucking rhythms is the baby's breathing, the child's body coming closer to the mother during inhaling (growing) and seinng of the nipple and shrinking away while exhaling, pausing, and swallowing. During the pause the nipple is partially released, to be seized again in its entirety in preparation for the next pumping action. The maternal holding must not be lax or the baby may lose the nipple, but it must not be rigid either because it might not leave room enough for sucking excursions and breathing.
When the baby's head rotates to the breast, the ensuing tonic neck reflex evokes an increased extensor tonus on the same side. As a result the baby's arm and leg stretch and embrace the mother. On the opposite side, the whole body assumes a heightened flexor tonus. One arm slips under the mother's holding arm, and the other flexes and turns to the breast. One leg comes closer to the mother's leg and pelvis, and the other flexes and crosses over stimulating the lateral abdominal area. Within the first few weeks of life, the rotation of the head induces body rotation as a whole, so that maternal and infantile fronts of the body meet. This righting reflex is anticipated by the mother who helps the baby's body to rotate toward her rather than be left behind with only the head attached to her. With his slightly flexed head safely ensconced in the nook of her elbow and his spine supported by; her arm, the baby can make use of the symmetrical tonic neck reflex which responds to head-ventroflexion with bilateral upper limb flexion and lower limb extension. This modifies the assymmetrical, neck reflex by reinforcing the flexion of the breast-limbs and diminishing the extension of the other side of the child's body, rounding out the mutual embrace. The baby's embracing arm crosses under the mother's embracing arm. On the other side of the body, the baby's embracing leg crosses over the mother's embracing leg. For the mutuality to encompass the total body, mother must cross her leg over to the same side on which she holds the baby. The baby moves his breast-arm alongside mother's breast; he may clutch her brassiere strap or put his own thumb into his mouth. With her free hand, mother may pat the baby, help pump her own breast or help support the baby's legs. The baby fingers the breast and the back or side of his mother in irregular intervals. His toes move ma similar fashion.
4. The consequences of head-dropping are not only related to physical danger but also to emotional estrangement between baby and mothe~. During nursing, the child's head may drop and extend over the arm of the mother with the child's neck arching around it. The head extension evokes a symmetrical tonic neck reflex which brings on a bilateral extensor tonus in the upper limbs and a flexor tonus in the lower. Both arms stretch out, but especially the already somewhat extended embracing arm, which now loses contact with the maternal body. The lower part of the body shrinks away from the mother's leg. Mother feels that the child is slipping away from her, and her embrace may become rigid so that she can better hold the baby. She may lift her shoulder and hollow her chest to create a nook for the baby. Her reactions may be due, not only to her own anxiety, but also to the baby's defect or lag in inborn tonic or righting reflexes. Some intuitive mothers will use whatever reflexes are available to the baby at the moment to effect a physical rapprochement. If the mother puts her hand on the shrinking-away (escaping) sole of the child's foot, she makes use of the spinal scratch reflex and is rewarded by an extension of the leg, which she may interpret as a return of the escaping limb. If he then pushes himself away from the mother's leg, mother, acting in synchrony with the reflex, can raise her elbow a bit and bring the child's head safely back into the elbow nook. A novice mother may continue to nurse the child in an uncomfortable position. She may have to bend sideways and forward, directing her torso and the breast to the child's mouth and putting more weight on his cervical spine. Trying to reach the hanging neck she sometimes acts as if she needed a visual communication to be sure that baby is still there and nursing.
A hazard compounded by habits of newborn nurseries arises from an immobilization of the arms which does not allow the child to embrace his mother. The immobilization of hand and fingers prevents finger play. The mother is frequently taught to attach a swaddled, inert baby to the breast rather than make use of the baby's own' attaching equipment. The discomfort arising from this failure in mutual hol4ing may lead to a dislike of breast feeding, as if it were a chore, and bottle feeding may be preferred. Bottle feeding is more prone to enhance symmetrical responses than breast feeding. It frequently deprives mother and baby of the frontal contact during which their early relatedness grows. Sometimes, the bottle-fed baby is dropped lower and lower until he rests on his mother's legs and hardly receives arm support. His face is averted from his mother and his hand may clutch the bottle. The mother does not receive support from the baby, as he cannot embrace her; finger play is precluded as both hands are inert or engaged in holding the bottle. When the child's head drops backward, he cannot hold the bottle any longer and he must rely solely on his mother to hold it. The end result of this holding failure can be seen in patients who need intermediate objects to establish contact and need to be fed, feted, and given presents before they can feel they have something to hold on to.
5. Lying prone in his crib, the young infant will push himself away from any hard surface which his sole touches. His legs flex and they get under his buttocks. His head will burrow into the surface of the sheet and his arms extend. Moving his head sideways, up and down, with his arms sliding in the cephalad direction or pushing themselves away, he behaves like a rooting puppy in search of the rnpple. Extension of his head (dorsiflexion) reinforces the flexion of the lower limbs and produces bilateral upper limb extension. Ventroflexion produces the opposite reaction. The symmetrical and assymmetrical tonic neck reflexes combine in such a way that the baby's spontaneous rooting appears to be an irregular creeping. Unless he is swaddled or rigidly blanketed he will locomote in his crib and can be found at its head after a period of time. These creeping reactions are used in the upright position to climb up on the mother. They are reinforced by scratch and stepping reflexes (Mead and Bateson 1942, p.97, picture 8). The better the baby's head-control, the more efficient his climbing reactions and the less control he needs from his mother. The more she holds him in a rigid grip, the more immobilized he is and cannot make use of growing and shrinking in the vertical dimension which ordinarily enhance his peristalsis.
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