Section V - Continuing Education

Prevention, Infant Therapy and the Treatment of Adults: 1. Toward Understanding Mutuality

Commentary by K. Mark Sossin, Ph.D.

Judith Kestenberg's contributions to psychoanalysis filled a wide spectrum: including contributions to the domains of female development, intergenerational transmission of trauma, especially regarding child survivors of the Holocaust, and nonverbal/movement patterns and their psychological and developmental correlates (Sossin, 1999; Brenner, 1999). Kestenberg was guided by a unifying, ever-present concern for prevention of mental illness, and by an overarching and evolving theory of somatopsychic processes anchored in a highly systematized classification scheme pertaining to nonverbal movement patterns. Both historically and conceptually, Kestenberg was following upon the work of Schilder (cf. Kestenberg, 1985a), with whom she trained. Her larger developmental and metapsychologic scheme was difficult for readers to decipher from any one paper, though it was evident in a compilation of papers, Children and Parents (Kestenberg, 1975), and has been elaborated upon more recently in the collaborative work by Amighi, Loman, Lewis & Sossin (1999). Kestenberg was one of the first to write matter-of-factly about the employment of psychoanalytically-framed approaches to parent-infant observation, research and psychotherapy. Significant clinical implications for adult analytic treatment also followed from this work.

Between 1977 and 1985, amidst many other writings, Kestenberg wrote a series of four papers all super-titled "Prevention, Infant Therapy and the Treatment of Adults." The first three papers were co-authored by her long-term collaborator, Arnhilte Buelte (together, for 25 years, they had co-directed the Center for Parents and Children on Long Island where much of the parent-infant and nonverbal research was pursued). The papers were differently subtitled: 1: "Toward Understanding Mutuality (1977a)," 2: "Mutual Holding and Holding-Oneself Up (1977b)," 3: "Periods of Vulnerability in Transition from Stability to Mobility and Vice Versa" (1983), and 4: "The flow of empathy and trust betweeen mother and child" (1985b). For ideal study, the papers form a whole, in which one can trace an evolving set of ideas, each wed to a complex framework of nonverbal movement behavior called the Kestenberg Movement Profile (KMP). Here, however, we will discuss the first of this series of papers, for it exemplifies how Kestenberg & Buelte drew upon close observations of infants to influence both conceptual and technical aspects of adult analyses. Consideration of this paper shares certain properties with the initial paper discussed in this Continuing Education Program (Winnicott, 1967; Goldman, 2000) in that both pertain to gleanings of resonance between the infant-caregiver relationship and that of the analysand-analyst. Both papers also highlight the importance of the early holding experience, and, in fact, Kestenberg's very first sentence references Winnicott's formulation of the holding environment. Here, Kestenberg and Buelte utilize their language of movement to extend beyond Winnicott's metaphor, by aiming their focus on the specific and psychologically relevant patterns each partner utilizes in holding the other.

The turning point aspects of this paper are reflected in how presaging several propositions were of later shifts in psychoanalytic theory and practice, especially pertaining to affect development, neuropsychoanalytic integrations, differentiating factors in the mutual hold between both parent and child, and analyst and patient, as well to the clinical relevance of nonverbal behaviors, regarding both diagnostic and therapeutic processes. The backdrop to the paper is Kestenberg's complex system of classifying movements. The KMP is a psychoanalytically framed notational and assessment system extrapolating from the effort-shape notation of the choreographer Rudolf Laban; it suggests that certain classes of movements are indicative of drives, affects, defenses, ego-controls, self-feelings, for-other-feelings and internalized object-relations. The baby, Kestenberg proposed, enters the world with two primary regulatory systems operative, in the form of tension-flow, reflecting the elasticity of drive- and affect- related animate existence, and in the form of shape-flow, reflecting the plasticity of relational experience and structuralization.

Kestenberg & Buelte introduce shifts in conceptual and developmental perspective that pave particular paths to important technical considerations that underscore the reciprocity and mutuality that is ongoing in the analytic or therapeutic context. They proffer the idea of a triad of influences upon infant psychic structural development including empathy, trust and mutual holding. Empathy is operationalized as derived from shared patterns of tension flow (involving needs and drives), while trust involves adjustments in shape-flow (that come to define primary feelings regarding self and other). It is not only the mother, but also the infant, who attains a relative status of trustworthiness. When the triad of influences is working in analysis, and in the wake of adequate mutual holding experiences in earlier development, the patient demonstrates the capacity to be alone in the presence of the analyst, but the analyst also evolves the capacity to be alone in the presence of the patient. Kestenberg maintained this essential duality in both mother-child and in analyst-patient interactions. Each partner may introduce components that lead to failures in mutual holding. Moreover, her elaborate classification, tabled and described in the text, shifts attention pertaining to nonverbal phenomena away from the many more arbitrary classification schemes, and away from those that look at static features, to one in which each movement pattern has intrinsic developmental significance and psychological meaning, and to one that focuses on process.

It appears that Kestenberg had, through her larger body of work, and as exemplified in this paper, laid the groundwork for the shifts in perspective regarding mutuality that are more recently seen in the elaborations regarding parent-infant psychotherapeutic approaches (Stern, 1995), regarding developmentally-based psychodynamic therapy (Greenspan, 1997) and the further clinical implications of the mutual regulatory model (e.g. Tronick, 1998; Beebe, 1998).

Movements are reflective of psychic functioning, and in particular, the Laban-derived categorical system can be woven into psychoanalytic developmental theory, supported by close observation of young children and parents.
Nonverbal attunement, specifically of tension-flow, heightens empathy in the clinical situation. There is an association between one's rhythmic flow of tension and one's flow of associations, and a significant degree of attunement is required by the analyst to receive and decipher the patient's feelings. Reciprocal "kinesthetic identification" is an essential process in both early caregiving and in analysis.
Mobility and stability, in movement, and in the analytic process, are inter-dependent. Without sufficient stability, the development of mobility is impeded (as it is with excessive stability), and there is a developmental sequence of progressively moving from more mobile to stable to mobile stages, and so forth. This is characteristic of developmental neuromotor development, emotional development and of the analytic process. Sufficient "effort control," evident in attitudes toward space, weight and time, is required to maintain a stable holding environment, both by the mother (re: a young child) and by the analyst (re: an analysand).
Trust develops, alongside mirroring and identification, from patterns of mutual relatedness identifiable in shape-flow rhythms. Perfect harmony in shape-flow is not the goal, however, because it is through titrated misalliances that differentiation evolves. Similarly, the therapy process proceeds differently via "readjustments of relatedness" and/or interpretation depending on whether the patient is benefitting from identificatory/mirroring experiences or those that serve differentiation. Trust involves predictability in the domains of comfort-discomfort and approach-withdrawal regulation.
An effectual "holding distance" between patient and therapist gets negotiated in an evolving spatial structure in the therapy. The analyst/therapist can be clued as to patient's experiences in creating an "object-filled holding environment" with the caregiver as an infant through observation of body attitudes. Kestenberg & Buelte stress the need for the analyst to be succinct in verbal comments about these themes so as not to impact too negatively upon the existent trust.
"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"...."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" (p. 350). Here, Kestenberg & Buelte parallel development and therapeutic process via Kestenberg's developmental model which views the self-and-object relational path as following from bipolar shape-flow to unipolar shape-flow to two-dimensional directional (boundary-delineating) movements to more complex three-dimensional patterns. Trust and harmony come before interpretation, and they can only come through mutually-regulated patterns leading to sufficiently flexible spatial and relational boundaries.
In their prescient manner of considering development and treatment from a neuropsychoanalytically integrative perspective, Kestenberg & Buelte identified seven inborn infant reflexes which early on provide for stabilization. The resultant stability facilitates the emergence of modalities of mobility through which gratification or relief from discomfort can be sought. Considering holding phenomena (beyond metaphor) through close infant observation, Kestenberg & Buelte considered the elemental ways in which these reflexes become incorporated into the positions of the nursing embrace and the upright embrace (with shoulder-chest contact). They saw early-experiences of these holdings as becoming engrained in psychosomatic memory, and as being both physiologically based anchors of "primary relatedness" ("transsensus-outgoingness") as well as being significantly culturally influenced.
The mutuality of the nursing embrace serves the affective core of the individual's body-image, viewed as the "first rudimentary psychic structure, from which self and object- representations will emerge" (p. 355). Kestenberg & Buelte proffer that the early experiences of "holding failures" make their way into therapy in the patient's efforts to gain comfort or repair, but also through modes of "acting in." The implication is that nonverbal matchings between patient and analyst at these times can go far in helping the patient re-establish security in the analytic relationship. The analyst supports the patient. The patient supports the analyst too; both experiences potentiate changes in the patient's self-representation, and in the newly acquired ability to support him or herself. In some cases, it can be beneficial to comment on identifiable rhythmic movements, gestures or postures of the patient at particular junctures in analysis, which may lead to insights about experiences of early holding failures. Kestenberg (1985b) exemplifies and expands on this idea in her description of an analysis of a mother with young children.
In consideration of the upright embrace, Kestenberg & Buelte connect the baby's experience of the relief of discomfort (e.g. through the attunement of maternal tactile/tension-flow patterns with the infant's inner-organ rhythms as well as through shape-flow adjustments) to early experiences of later-developed self-reliance and autonomy, and the lifelong-course of mutual soothing and comforting that follows. Herein, they link early support patterns that are subcortically controlled to later holding patterns based on psychosomatic memories, and to later cortically controlled motoric attainments. Moreover, Kestenberg & Buelte reflect on the intricate ways in which self-support, other-support and holding failures, manifest in both the actual nonverbal repertoires of each participant as well as in the inner-world experiences and verbalizations that are reciprocated in the analytic context. A complex transference phenomenon can follow from, and lead to, such experiences, as in the case described of a man who feared falling with an associated soiling obsession, who was terrified of his own collapse if the analyst did not support him properly.

Further Discussion

By interrelating parent-infant and analyst-analysand experiences, and by drawing upon close observations of parent-infant interaction utilizing a remarkably coherent though complex movement language, Kestenberg and Buelte introduce us to the important ways in which caregiver-mediated early childhood experiences lead to the development of stable psychic structures. Such experiences do so through rhythmicity, the binding and freeing of tension, through manners of grappling with space, gravity and time, growing and shrinking in horizontal, vertical and sagittal dimensions and planes, and they do so especially through mutual holding. These are manifest in the characteristic ways of coping that are evident in adult patients. Kestenberg & Buelte's original work is notable for their emphasis on, and specification of, those somatomotor processes that are woven so inextricably into psychic experience. More explicitly than in other psychoanalytic frameworks, an observationally anchored developmental outline of these processes is provided within the larger body of work. Movement proceeds along dual (but interwoven) paths, emerging from original drive- and affect-laden tension-flow and shape/flow. As shape-flow and shaping patterns provide structure for tension-flow and effort patterns, so too do self- and object-relationship qualities provide structure for drive, defensive and ego-controlled qualities. Phase development is recast, not only putting newfound emphasis on urethral and inner-genital phases, but also by appreciating the multiplicity of phase elements evident at any one point in development. The way in which an individual's intra- and intersystemic conflicts and harmonies get internalized and structuralized is developmentally forecast by the manner in which conflict and harmonies (i.e. clashing and attunement, mismatching and matching) were experienced dyadically in the caregiving situation, and through other interpersonal experiences.

Moreover, this work anticipated later contributions to our understanding of mutual regulation of affect, as in an interactive repair of miscoordinated states, which Tronick et al.(1998) highlighed as particularly significant in the dyadic regulatory process in determining the infant's affective experience. Tronick builds upon systems theory to discuss how successsful regulation in the dyadic relationship between infant and caregiver leads to an expansion of consciousness. I would suggest that the Kestenberg & Buelte work amplifies our ability to discern the affective configurations of face, body, gaze and gesture that are underscored as pivotal in the mutual creation of dyadic states between both infant and caregiver and patient and therapist. Moreover, Kestenberg & Buelte's scheme bears application to primary prevention (through what they call "retraining") as well as to the clinical situation.

Kestenberg & Buelte suggest the primacy of interactive flow factors in each partner's contribution to experiences of empathy and trust. Their model resonates with Greenspan's (1997) emphasis on the role of the somatic affect states in the development of Des Pressive and paranoid behavior and ideation. The "acting in" that Kestenberg & Buelte refer to relates to what Greenspan refers to as reenactments in the transference which require the therapist to engage and empathize at the gestural interactive level. The language of movement Kestenberg and Buelte apply offers specific manners of employing the voice, eye-contact and body posture that Greenspan indicates is essential in the therapeutic creation of an interactive gestural system that is itself flexible and adaptive, laying the ground for a broader, more flexible representational system to emerge. In fact, embedded in the Kestenberg model is a framework for looking at affects, quite distinct from a neo-Darwinian labeling of discrete affects, or of underscoring their hedonic tone or intensity. Rather, this model focuses on the experience (and communication) of pleasure-displeasure affect sequences through tension flow rhythms, of comfort-discomfort affect sequences through bipolar shape-flow, and of approach-withdrawal affect sequences through unipolar shape-flow.

The suggestion that failures in empathy and failures in trust (stemming from early holding and support deficiencies) are usefully distinguished "clinical windows" (Stern, 1995) follows from the Kestenberg & Buelte work, and this is a contribution that fits within the model of ongoing regulations Lachmann & Beebe (1996) describe as occurring between therapist and patient. This also resonates with the "moment of meeting" concept of Sander (1995), and contributes to the increasing body of work pertaining to the procedural mode of processing in psychotherapy and psychoanalysis (Beebe, 1998). Notably, co-constructed dyadic exchanges can heighten empathy ("knowing" another's inner feelings through kinesthetic identification with the other's tension-flow) but not trust (based upon a mirroring identification through adjustment in shape-flow), or, conversely, such exchanges can heighten trust but not empathy.

This Kestenberg & Buelte paper, and the larger body of related Kestenberg work, is applicable to primary prevention, infant-parent psychotherapy, as well as to child, adolescent and adult psychoanalysis and psychotherapy. It may be that the complexity of Kestenberg's movement scheme, and the manner in which it is woven into her descriptions and constructs, made her papers difficult to encompass, yet in retrospect, it appears much can still be built upon their foundation. Against the backdrop of an intricate (but generative) revised developmental and theoretic framework, we are offered a portal into the early-anchored modes of holding and supporting that patients (as well as analysts) bring to the co-construction of the treatment process and that underscore potentially mutative factors of therapeutic action.

References

Amighi, J., Loman, S., Lewis, P. & Sossin, K. M. (1999). The meaning of movement: Developmental and clinical perspectives of the Kestenberg Movement Profile. Amsterdam, Gordon & Breach.

Beebe, B. (1998).A procedural theory of therapeutic action: Commentary on the symposium, "Interventions that effect change in psychotherapy." Infant Mental Health Journal, 19, 333-340.

Brenner, I. (1999). Obituary: Judith Kestenberg 1910-1998. International Journal of Psychoanalysis, 84.

Goldman, D. (2000). Commentary on D. W. Winnicott's "Mirror role of mother and family in child development." APA Division 39 Division V Continuing Education Program.

Greenspan, S. I. (1997). Developmentally based psychotherapy. Madison, CT: International Universities Press.

Kestenberg, J.S. (1975). Children and parents. Northvale, NJ: Aronson.

Kestenberg, J.S. (1985a). The role of movement patterns in diagnosis and prevention. In D. A. Shaskan & W. L. Roller (Eds.) Paul Schilder: Mind explorer. New York: Human Sciences Press.

Kestenberg, J.S. (1985b). The flow of empathy and trust between mother and child. In E. J. Anthony & G. H. Pollock (Eds.) Parental influences in health and disease. Boston: Little, Brown.

Kestenberg, J.S. & Buelte, A. (1977a). Prevention, infant therapy and the treatment of adults. 1: Toward understanding mutuality. International Journal of Psychoanalytic Psychotherapy, 6, 338-367.

Kestenberg, J.S. & Buelte, A. (1977a). Prevention, infant therapy and the treatment of adults. 2: Mutual holding and hoding-oneself-up. International Journal of Psychoanalytic Psychotherapy, 6, 369- 396.

Kestenberg, J.S. & Buelte, A. (1983). Prevention, infant therapy and the treatment of adults. III: Periods of vulnerability in transition from stability to mobility and vice versa. In J.D. Call, E. Galenson & R. L. Tyson (Eds.), Frontiers of infant psychiatry. New York: Basic Books.

Lachmann, F. & Beebe, B. (1996). Three principles of salience in the organization of the the patient-analyst interaction. Psychoanalytic Psychology, 13, 1-22.

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

Sossin, K. M. (1999). Legacies of Judith Kestenberg. International Psychoanalysis (IPA Newsletter)

Stern, D.N. (1995). The motherhood constellation. New York: Basic Books.

Tronick, E.Z., Bruschweiler-Stern, N., Harrison, A. M., Lyons-Ruth, K., Morgan, A.C.,

Nahum, J. P., Sander, L. & Stern, D. (1998). Dyadically expanded states of consciousness and the process of therapeutic change. Infant Mental Health Journal, 19, 290-299.

Winnicott, D.W. (1967). Mirror-role of mother and family in child development. In D. W. Winnicott, Playing and reality. London: Routledge, 1971.

We have joined up with Amazon.com to provide you with the convenience of ordering books online. In the pages to come you can order specific books that we cite in our courses, or you may browse Amazon.com.