Delgado, S. V., Strawn, J. R., & Pedapati, E. V. (2015) - Contemporary Psychodynamic Psychotherapy For Children and Adolescents PDF

Contemporary
Psychodynamic
Psychotherapy for
Children and Adolescents
Integrating Intersubjectivity
and Neuroscience
Sergio V. Delgado
Jeffrey R. Strawn
Ernest V. Pedapati
123
Contemporary Psychodynamic
Psychotherapy for Children and Adolescents
Sergio V. Delgado • Jeffrey R. Strawn
Ernest V. Pedapati
Contemporary
Psychodynamic
Psychotherapy for
Children and Adolescents
Integrating Intersubjectivity
and Neuroscience
Sergio V. Delgado, MD Ernest V. Pedapati, MD, MS
Division of Psychiatry Division of Psychiatry
and Child Psychiatry and Child Psychiatry
Cincinnati Children’s Hospital Division of Child Neurology
Medical Center Cincinnati Children’s Hospital
Cincinnati, OH Medical Center
USA Cincinnati, OH
USA
Jeffrey R. Strawn, MD
Department of Psychiatry
and Behavioral Neuroscience
University of Cincinnati
Cincinnati, OH
USA
ISBN 978-3-642-40519-8 ISBN 978-3-642-40520-4 (eBook)

DOI 10.1007/978-3-642-40520-4
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014956865
© Springer-Verlag Berlin Heidelberg 2015

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To my patients and students
—SVD
To Elliott Nicole and Rachel Marie

—JRS
To Carolyn, Noah, and Harrison

—EVP
v
Foreword
Psychodynamic psychotherapy with children and adolescents is undergoing a tran-

sition. With the advent of this carefully crafted and wise volume, the sea change
unfolds before our eyes. Setting full sail, billowing out with the strong and refresh-
ing wind afforded by the creativity and responsiveness of working intersubjectively
in the here and now, the authors chart the metamorphosis from a one-person psy-
chology to a two-person relational psychology. This is done in such fashion that we
want to take the voyage with them that they collegially invite us on.
Sea metaphors aside, the book explains, integrates, and summarizes an incredi-
ble amount of information between two covers. Building on and furthering concepts
cogently developed in Delgado and Strawn’s striking first volume, Difficult
Psychiatric Consultations: An Integrated Approach, the present masterful volume,
with an additional coauthor Pedapati, starts with a thorough grounding in the his-
tory, evaluation, distinct characteristics, and vocabularies of the one-person and
two-person models.
Additionally, contributions of key pioneers from both ways of conceptualizing
and working, including transitional figures and long-neglected trail blazers ousted
by the orthodoxy, are respectfully examined evaluated and contrasted. The advances
in attachment theory, systems theory, developmental psychology, genetics, and neu-
roscience are synthesized and beautifully applied to the subject at hand. Case exam-
ples covering all phases of development synergistically illustrate the two-person
relational approach.
The neurobiology of intersubjectivity, alongside research advances in meaning-
making processes, relational schemas, implicit working memory, social reciprocity,
cultural factors, temperament, and cognition are explained and their application to
psychotherapy demonstrated. These concepts dance along in the narrative and are
combined in interesting ways, building into a deconstructing force upon stale ideas
and bounding toward a joyous rendering of contemporary thinking, buoyed by the
wealth of recent knowledge. Moreover, all of these contemporary concepts are
admirably clarified and explained and their therapeutic applications demonstrated,
in the writing of these authors. When you put your own subjectivity firmly on the
playing field, you are no longer in the stands observing the fray; you are in the fray.
The mindfully solid cornerstone of the book is the explication of the four pillars
of the contemporary diagnostic interview, namely, temperament, cognition, cogni-
tive flexibility, and internal working models of attachment. As noted by the authors,
vii
viii Foreword
“The four pillars are the synergy of innate and environmental processes that become
the blueprint of how a child learns to develop and maintain self-regulation abilities
and unique implicit relational patterns to successfully interact with others.” How
this approach is applied and the variables involved in the application pave the way
toward understanding how one arrives at accurate diagnostic formulations and how
these are used in developing sequential treatment plans, tailored for each individual
patient and their family, that have the best chance of a successful outcome. Useful
tables, wise suggestions, and rich case vignettes give immediacy to the concepts
that come alive in the here and now for the reader now fully absorbed in the
material.
This was my experience as a reader. Also, I experienced something very interest-
ing when going through the four pillars chapter and indeed with the reading experi-
ence of the book overall. The book is put together and flows in such a way that a
sense of safety and security becomes present in the reader. Even more importantly
the book engenders a “space of vitality” that frees the mind as one experiences the
welcoming and accepting atmosphere that pervades the book. In reflecting on my
personal “voyage” with the authors, with some surprise I perceived that I was learn-
ing the material at an implicit level. My recall had a clarity and substance that gave
a conviction that I was prepared and ready to use these concepts without feeling the
need to go back over things, reread paragraphs, or laboriously memorize anything.
My reading experience was so attuned to the intentions of the authors that the mate-
rial was entering into my implicit nondeclarative memory system. Extraordinary.
In conclusion, I feel it is important to note that the lead author, Sergio V. Delgado,
MD, was my supervisor and teacher throughout my child and adolescent psychiatry
training at the Menninger Clinic as well as for the duration of my training in child
and adolescent psychoanalysis through the Topeka Institute for Psychoanalysis. In
addition he was vitally important in preparing me for my last position at Menninger
as Director of the Child and Adolescent Psychiatry training program in the Karl
Menninger School of Psychiatry. He also ensured that I graduated “under the wire,”
so to speak, as the last child and adolescent psychoanalyst graduating from the
Topeka Institute of Psychoanalysis. I never stop learning from him, and these pre-
liminary remarks reflect that. May the reader’s learning experience from this book
be equally gratifying.
Topeka, KS, USA Kirby Pope, MD

Preface
This book is written with several audiences and several goals in mind. First, we aim
to expand, synthesize, and contextualize the contemporary two-person relational
psychodynamic psychotherapy literature as it relates to children and adolescents.
Second, we seek to integrate the contributions from developmental research, neuro-
science, and intersubjectivity with regard to the clinical work of the two-person
relational psychotherapist. These important contributions have historically been
considered as having limited value by those of the traditional one-person model.
Third, we hope to guide child and adolescent psychiatry trainees, as well as newly
minted and experienced child and adolescent psychotherapists, to discover the
advantages of a multidimensional, four-pillared contemporary diagnostic interview
(CDI) in order to carefully develop well-informed diagnostic formulations. These
formulations will allow the psychotherapist to identify those children and adoles-
cents for whom a psychodynamic psychotherapeutic approach will be most helpful,
as well as those for whom this approach may not be ideal. Here, we would also note
that the CDI facilitates observing and participating in the interactions of patients
and their parents or caregivers, which will ultimately capture a spectrum of informa-
tion not accessed in a standard diagnostic interview that is based solely on criteria
from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-
5). In addition, the information obtained through a CDI (e.g., temperament, cogni-
tion, cognitive flexibility, and internal working models of attachment) enhances the
relevance of the clinical signs and symptoms that are obtained through the “standard
interview,” thus facilitating a comprehensive two-person relational psychodynamic
formulation. Moreover, we include a CDI tool that will help guide the clinician to
choose the interventions needed (e.g., psychodynamic, behavioral, or pharmaco-
logical). Further, we provide real-world cases that allow the reader to intimately
follow the thought processes of the two-person relational psychotherapist in his
work with children and adolescent.
We recognize that, as with any approach, there will be skeptics about our think-
ing and way of working. The notion of a two-person, relationally based psychody-
namic model of psychotherapy may not be well received by some clinicians,
including those who may be anchored in traditional one-person psychoanalytic cir-
cles, as it challenges a key tenet of the one-person model: the archaeological
approach of unearthing an unconscious and conflicted past. However, we would
argue that the traditional one-person model must accept the relevance of two-person
ix
x Preface
relational psychotherapeutic interventions within the context of accrued knowledge

from attachment and temperament theories, contemporary neuroscience, develop-
mental research, as well as cognitive and social psychology. Knowledge of the two-
person relational approach to psychotherapy will allow for a more comprehensive
understanding of the complexity of the human mind and how it works. A two-person
relational model relies on an understanding of the bidirectional communication that
is inherent in the here-and-now experiences between the patient and the psycho-
therapist. This bidirectional influence depends on continuous work with their mutual
intersubjectivities (i.e., the participating in and understanding of the subjective
experiences of another that occur in the psychological field between the two partici-
pants) and involves an intimacy with the patient and his or her parents or caregivers
that some may challenge as compromising the “true objectivity of the transference
manifestations.” To this, we respond that “true objectivity” as a construct fails to
take advantage of recent contributions from neuroscience, developmental research,
attachment theory, and intersubjectivity. Additionally, our hope is that the reader
may appreciate some of the persistent dilemmas that have evolved in the two-person
relational model and that this book will provide the student, in the broader sense of
the term, with a clear, relevant, and practical approach to the young patient, as well
as an understanding of when a psychodynamic psychotherapy approach is deemed
to be beneficial. Ultimately, this book will have day-to-day clinical relevance to the
practicing child and adolescent psychiatrist or psychotherapist.
The seeds from which this book grew were sown by the lead author’s years of
practicing and teaching in both the traditional one-person and two-person relational
psychoanalytic psychodynamic theories. The lead author, as he has taught child and
adolescent psychiatry trainees, as well as candidates in adult and child psychoanaly-
sis, recognized that the traditional one-person model of conceptualizing the psycho-
logical difficulties of the child and adolescent limited clinicians. Disenchanted by
the prevailing explanations of unconscious drives, ego defenses, object relations,
and self-psychological constructs for his patients’ struggles, he recognized that
these approaches often fell short. He felt these formulations did not account for the
psychotherapist’s here-and-now experience. Moreover, the experience of teaching
two-person relational psychology to child and adolescent trainees and psychoana-
lytic candidates revealed the need for understanding the four pillars of a contempo-
rary diagnostic formulation of patients’ difficulties (i.e., an understanding of
temperament, cognition, cognitive flexibility, and the internal working models of
attachment).
There is an urgent need for a practical and clinically relevant approach to help
trainees tease out their patients’ strengths and weaknesses and to help the trainees
tailor treatment interventions. This is particularly relevant in the current era in which
trainees now evaluate and treat more psychologically ill patients and increasingly
struggle to “find good psychodynamic psychotherapy cases.” Moreover, trainees
now more than ever are treating children who need help learning how to survive and
how to grow in their disruptive and unpredictable environments. Thus, the decision
to write this book began with a number of active discussions among the authors,
despite generational differences. The authors also became increasingly aware of a
Preface xi
disconnect between teaching and supervision in the contemporary model. This dys-
synchrony occurs in the context of the traditional one-person psychology model,
wherein the relevant and practical concepts from the contemporary relational and
intersubjective theories are neither taught nor integrated into clinical practice.
Importantly, this happens despite the increasing acceptance of two-person relational
psychology in many psychodynamic venues, and it is perpetuated by a dearth of
user-friendly material in the standard psychiatric texts and journals that are fre-
quented by trainees. In fact, most articles regarding contemporary two-person rela-
tional psychotherapy are found in psychoanalytic journals and publications for
psychologists and social workers, thus limiting its dissemination to the child and
adolescent psychiatry trainee. The junior author began to nudge the lead author by
asking, “Why don’t you start a relational advanced psychotherapy program or, even
better, write a book about two-person relational psychotherapy in children and ado-
lescents? The last book about relational child psychotherapy was published in 2002.”
We are happy to say that what started as a collection of ideas has become a real-
ity. The Relational Advanced Psychotherapy Program (RAPP) is in its second year
with ten members—some being trainees and others faculty. We are also happy to
say that we completed our book with the hope that it will become a “go-to” resource
for child and adolescent psychiatry trainees and clinicians who may wish to learn
about the captivating and rewarding contemporary two-person relational approach.
Although the authors’ paths in learning about the two-person relational psychol-
ogy were different, our destination has been the same: to share with our colleagues
what we have learned and what has shaped us. Therefore, in this book, we have
made efforts to represent the views of both the expert in the two-person relational
model and the skeptic of the two-person relational model in order to help readers
arrive at their own conclusions.
The Authors’ Journeys
Sergio V. Delgado
I was fortunate to train in child and adolescent psychiatry and child psychoanalysis
at the Menninger Clinic in Topeka, Kansas, more than 20 years ago. This helped me
be thoroughly emerged in traditional one-person psychology and also exposed me,
in readings and in person, to the early pioneers of the two-person relational discov-
eries. At the Menninger Clinic, the faculty and supervisors were predominantly
psychoanalysts who taught in a pluralistic and eclectic manner. Some were Freudian,
others were skilled in teaching Kleinian object relations theory and ego psychology,
and some adhered to self-psychology. In tandem with the psychoanalytic teachings,
family therapy was a requirement for trainees and was taught by skilled social work-
ers who favored understanding patients within the context of their family system.
The skilled family therapy supervisors were instrumental in requiring exposure to
the readings of the works of such well-regarded family therapy theorists and clini-
cians as Minuchin, Haley, the Milan group, Satir, and Bowen.
xii Preface
My training included learning the value of using information obtained through

cognitive psychological testing and of corroborating and expanding upon the infor-
mation gathered from the clinical diagnostic interviews. This provided a wider base
of understanding through adding clinical information on cognitive deficits and
learning problems. In essence, during my training, I learned that the psychological
landscape of the child and his or her family was best understood when approached
from different theoretical perspectives and integrated in a coherent manner to tailor
useful and practical treatment recommendations, including psychotherapy, family
therapy, tutoring, and medication management.
Additionally, during my training, developmental research had begun to emerge
and gain momentum across the country. I was fortunate to have participated in video
recordings of the stranger anxiety experiments involving infants and toddlers of
unwed teenage mothers, which were used to learn about the quality of these moth-
ers’ attachment to their children and were reassessed at 6 and 12 months.
As a resident, I met Sir John Bowlby, who, in spite of recovering from painful
shingles, had the energy to discuss with great fervor the importance of internal work-
ing models of attachment between infant and caregivers necessary for survival.
Several years later, I was exposed to Dr. Daniel Stern, who gave a Grand Rounds
presentation at the Menninger Clinic. Stern had theoretically departed from Margaret
Mahler’s work and discussed his research about the complex developmental strides
of the child during the first 2 years of life when their mother provides the necessary
affective attunement. Further, I was asked by my colleagues and friends, Kathryn
Zerbe and Glen Gabbard, to present at a clinical case conference to Dr. Robert
N. Emde, a psychoanalyst and mentee of René Spitz, who was to be the discussant.
Dr. Emde was distinguished by his work in infant research, explicating the role that
emotional availability, affective attunement, and social referencing had in the child’s
attachment to their caregivers. The clinical case presentation led to the publication,
with Drs. Emde and Pope as coauthors, of An atypical eating disorder in a 2-year-old
female, which solidified my thirst to learn two-person relational psychology in depth
and began my questioning of the “truths” of the traditional one-person model. This
proved to be a more challenging task, as I had begun the time-demanding training in
adult and child psychoanalysis at the Topeka Institute for Psychoanalysis (TIP).
At the TIP, I was exposed to an eclectic curriculum, with readings from such
prominent authors as Freud, Jung, Suttie, Erikson, Horney, Sullivan, Klein, Kohut,
Rinsley, Fairbairn, Guntrip, Fonagy, Benjamin, and Hoffman. I later became a train-
ing and supervising adult and child analyst and eventually the director of the child
psychoanalytic training program. Becoming a training and supervising adult and
child analyst in an eclectic institute permitted me to have a balanced and in-depth
understanding of the pluralistic traditional one-person models and the two-person
relational models, which is not common in all institutes. This gave me an advantage
that allowed me to recognize the enchantment and limitations of the traditional one-
person psychology with more clarity.
In 2002, I moved to Cincinnati to join the department of child psychiatry at the
Cincinnati Children’s Hospital Medical Center, with the goal of enhancing the child
and adolescent psychiatry trainee’s psychotherapy courses. I also joined the
Preface xiii
Cincinnati Psychoanalytic Institute as a training and supervising adult and child

analyst, which has had a tradition of adhering to the one-person model and shown
more reluctance in accepting the contemporary two-person relational model.
However, two-person relational articles have gradually made their way into the
readings at the Cincinnati Psychoanalytic Institute’s Faculty Study Group. My
launching of the Relational Advanced Psychotherapy Program (RAPP) has been
slow to garner significant institute support but has been very gratifying
nonetheless.
Jeffrey R. Strawn
I completed my residency training in general psychiatry at the University of

Cincinnati. Following my general psychiatry training, I completed a fellowship in
child and adolescent psychiatry at Cincinnati Children’s Hospital. My training at
the University of Cincinnati, a program with strong foundations in traditional one-
person psychodynamic psychotherapy, and my early psychotherapeutic work were
strongly influenced by Freud’s drive theory, object relations, and self-psychology,
with an emphasis on neutrality and boundaries. However, I began to notice limita-
tions of the “archaeological” approach to patients’ problems, which emphasized the
unearthing of conflicts and felt, at times, limited by an emphasis on therapeutic
neutrality and interpretation as the primary vehicle of change in the context of tra-
ditional psychotherapeutic treatments. As I began my child and adolescent psychi-
atric training, I was exposed to the two-person relational approach by the lead author
of this book. I quickly began to recognize the importance of alternative
intersubjectivity-based approaches. In parallel with this increasing exposure to and
practice of two-person relational psychotherapy, I directed the Pediatric Anxiety
Disorders Clinic and Research Program, wherein I was using functional magnetic
resonance imaging (fMRI) to examine the neurofunctional basis of anxiety disor-
ders in children and adolescents and working to understand the neurophysiology of
emotional processing in youths. As I conducted these research studies with various
fMRI paradigms (i.e., tasks), I began to observe activation in a number of structures
and regions that subserve self-other processing. The findings of this neuroimaging
research reverberated with my contemporary two-person relational psychothera-
peutic work with children and adolescents. I enjoy teaching the two-person rela-
tional approach to psychotherapy to medical students, general psychiatry residents,
and child and adolescent psychiatry fellows at the University of Cincinnati and
Cincinnati Children’s Hospital Medical Center.
Ernest V. Pedapati
In my final year of medical school at the University of Massachusetts, I still could

not decide between the body and the mind. Instead, I embraced my ambivalence and
pursued the Triple Board Residency at the University of Cincinnati and Cincinnati
xiv Preface
Children’s Hospital Medical Center. Unlike conventional child psychiatry training,

the Triple Board emphasizes pediatric medicine with later specialization in psychia-
try and child psychiatry. Rather than distance myself from mental health, my train-
ing in pediatrics inspired a curiosity for childhood development and gave me a new
lens to pediatric psychopathology. I struggled with understanding why a child rav-
aged with bone cancer struggled so vigorously to live or why a child caught in the
depths of depression would so earnestly wish for death. Although my early supervi-
sors helped me understand children psychologically through a traditional one-
person lens, over time I found common ground with my pediatric training as I began
to deepen my understanding of attachment theory, neuroscience, and social cogni-
tion. This inevitably led me to wholeheartedly embrace two-person relational psy-
chotherapy, and I am grateful for the lead author’s invitation to collaborate in writing
this book, which will enhance my colleagues’ psychotherapeutic experience.
Cincinnati, OH, USA Sergio V. Delgado, MD

Jeffrey R. Strawn, MD
Ernest V. Pedapati, MD
Acknowledgments
We wish to credit our respected and admired colleagues Robert Emde, MD; Paul
Wachtel, PhD; and Neil Altman, PhD, who laid the foundation for our journey to two-
person relational psychotherapy through their eloquent and clinically masterful writ-
ings. We are forever appreciative of the time and effort that they took to read selected
chapters and to make insightful comments that have greatly improved this book. We
also are indebted to our close friend Kirby Pope, MD, who read the first drafts of this
manuscript, as well as subsequent revisions, and was gentle in sharing comments that
helped shape the flow of the content of this book. The editorial comments of Drs.
Emde, Wachtel, Altman, and Pope were mindful that, in many respects, two-person
relational psychology has evolved from what was a one-person psychology.
We would like to express our heartfelt gratitude to our young patients, who
unknowingly contributed intersubjectively to this book in remarkable ways. They
provided the clinical material through their subjectivities in here-and-now moments
with us as psychotherapists. We also wish to thank our mentors and teachers, who
provided the foundation for our appreciation of the multiple theories and complexi-
ties that must be considered if we are to understand and help our patients and their
families. Additionally, we are indebted to our students, who helped us appreciate
the pressures of trying to “fit in” learning about the evolution of two-person rela-
tional psychology and psychotherapy, due to the prevailing pressures by colleagues
and supervisors loyal to the traditional one-person psychology and those loyal to
solely psychopharmacological interventions. Our students were also pivotal in
encouraging the authors to “put it in writing,” not only the tenets of two-person
relational psychology but, more importantly, specific case examples discussed from
both a traditional one-person model and a two-person relational model, which we
realized was very much needed.
We want to express our warm thanks to Corina Schaefer, associate editor of clini-
cal medicine at Springer Publishing. We are grateful for her steadfast support when
we requested Springer to sponsor our book. She has provided the energy behind
these pages and both believed in us and supported this project. Also, we give a
heartfelt thank you to Greg Ford for his masterful and sensitive editorial assistance,
with attention to detail, and his ability to make clearer our sometimes muddled sen-
timents with his skillful use of the written word and grammatical prowess.
We are grateful to the colleagues and students who took the time to read selected
chapters and generously provided constructive criticism. They were kind enough to
xv
xvi Acknowledgments
point out what was not clear, what was confusing, what required further elaboration, and
what we had omitted. Among these colleagues are: Mary Ahn, MD; Mary Singeltary,
DO; Amanda Jones, OTR/L; Chris Marrett, MD; Heather Adams, DO; John Vraciu,
DO; Yesie Yoon, MD; Deborah Reynolds, LISW-S; and Kellie Ryan, LISW. We also
express our gratitude to Michael Sorter, MD and John Kerechek, MAS, who provided
the enthusiasm and support for our work to become a reality. To all we say, thank you!
I am indebted to Erin, my true love and muse, for providing the inspiration and
patience to complete this book. She provided the challenging and clarifying com-
ments due to her expertise in traditional one-person psychology. I will always
remember her sharp and “loving” comments—“it sounds too much like gobbledy-
gook”—when the manuscript needed help clarifying the complexities of two-person
relational psychology, which proved to be useful “unedited” critiques that improved
the readability of this book. Finally, I want to thank my friends and coauthors, Jeff
and Ernie, who tolerated my Hispanic grammar and my strong views about the limi-
tations of a traditional one-person approach, which they at times felt needed to be
softened. We were able to maintain our close and intersubjective friendship despite
our not-so-subtle disagreements.
Finally, I apologize to the readers who may feel more could have been written to
further clarify two-person relational clinical concepts or that may have wished for more
clinical cases with lengthier and more detailed explanations. To them I say, our work is
incomplete; we all have much to learn and we could have easily taken more time and
energy without being able to capture all the nuances of a two-person relational model.
Therefore I kindly encourage the reader to make use of this book as a springboard to
further read the many eloquent books and papers referenced throughout the book.
—SVD
This work would not have been possible without the loving support of my wife,
Lara, who from the beginning helped me to balance our life with the writing of this
book, although she may still not agree that we reached equilibrium. Also, I thank
my daughters, Elliott Nicole and Rachel Marie, for their daily lessons in intersub-
jectivity and attachment theory. My regular reminders of implicit relational know-
ing and development ultimately made the writing of this book possible. Finally, I
thank my friends and coauthors, Sergio and Ernie, whose encouragement and
always-present enthusiasm were the driving force for this work.
—JRS
The efforts placed on this book were greatly inspired by my own desire to relate
and be in relation with my dear wife, Carolyn, and my two young and rambunctious
sons, Noah and Harrison. I also recognize the implicit imprints left upon me by the
careful care of my father, Francis, mother, Elsie, and my sister, Sheila. Though many
of my contributions were informed by my clinical work, much was crafted in the
cauldron of the messiness of real life, learning how to be a good therapist, a loving
husband, and a caring and inexperienced new father. I am truly grateful for the encour-
agement and wisdom of my great friend and mentor Bob Turner, who over the course
of two decades, continues to inspire in me a passion to be curious. As we conclude this
project, I am thankful for Sergio and Jeff, who began as my mentors and continue as
my friends and to whom I feel deep admiration for their tenacity and creativity.
—EVP
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Making the Case for Two-Person Relational Psychodynamic
Psychotherapy: A Neurodevelopmentally Informed Treatment . . . 4
Introduction to Two-Person Relational Psychology . . . . . . . . . . . . 5
1.2 Context and Key Concepts in Two-Person
Relational Psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 Limitations of Two-Person Relational Psychology. . . . . . . . . . . . . 10
1.4 How to Use This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Traditional One-Person Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 Traditional One-Person Psychology . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2 Historical Background of Traditional One-Person
Model of Child and Adolescent Psychoanalysis
and Psychodynamic Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3 Freud and Classic Psychoanalytic Theories . . . . . . . . . . . . . . . . . . 17
Sigmund Freud (1856–1939): Drive Theory. . . . . . . . . . . . . . . . . . 17
First Child in Psychoanalysis: Little Hans . . . . . . . . . . . . . . . . . . . 19
A Two-Person Relational Psychology View: Little Hans . . . . . . . . 20
2.4 Freud’s Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
William Stekel (1868–1940) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Carl Gustav Jung (1875–1961) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Hermine von Hug-Hellmuth (1871–1924) . . . . . . . . . . . . . . . . . . . 22
Berta Bornstein (1899–1971) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.5 Ego Psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Anna Freud (1895–1982) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Heinz Hartman (1894–1970) Autonomous Ego Functions. . . . . . . 25
Erik Erikson (1902–1994) Theory
of Psychosocial Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Two-Person Relational Psychology View: Ego Psychology . . . . . . 25
2.6 Object Relations Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Melanie Klein (1882–1960) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Donald Winnicott (1896–1971). . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Margaret Mahler (1897–1985) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
xvii
xviii Contents
Peter Blos (1904–1997) The Second Individuation

Process of Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Personality Disorders in Children and Adolescents . . . . . . . . . . . . 29
Two-Person Relational Psychology View: Object Relations . . . . . 31
2.7 Self-Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Heinz Kohut (1913–1981). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Anna Ornstein (1927–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Two-Person Relational Psychology View: Self-Psychology. . . . . . 33
2.8 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3 Two-Person Relational Psychology for the Child
and Adolescent Relational Psychotherapist. . . . . . . . . . . . . . . . . . . . . 37
3.1 Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . . . . . . 38
Making the Case for a New Paradigm . . . . . . . . . . . . . . . . . . . . . . 38
3.2 Historical Background of Two-Person Relational
Psychology in Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Freud’s Dissenting Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
British Relational Theorists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
American Relational Theorists . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Psychology in Child and Adolescent Psychotherapy . . . . . . . . . . . 46
American Two-Person Relational Child
and Adolescent Psychotherapists . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Other Two-Person Relational Child
and Adolescent Psychotherapists . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.4 Two-Person Relational Psychodynamic Psychotherapy . . . . . . . . . 50
Basic Principles of a Two-Person Relational
Psychodynamic Psychotherapy Process . . . . . . . . . . . . . . . . . . . . . 51
3.5 Two-Person Relational Experiences Are Contextual . . . . . . . . . . . 53
Realities in the Environment That Trigger
a Person’s Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Interactions with Another Person That Implicitly
Trigger Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
The Patient Unknowingly and Implicitly is Trying
to Engage the Psychotherapist into a Relational
Pattern that is Contextually Familiar. . . . . . . . . . . . . . . . . . . . . . . . 56
Uncertainty in Two-Person Relational Psychotherapy . . . . . . . . . . 57
Anxiety in the Two-Person Relational Psychotherapist . . . . . . . . . 58
3.6 Critiques of the Two-Person Relational Model. . . . . . . . . . . . . . . . 59
3.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4 Key Pioneers of Two-Person Relational Psychology. . . . . . . . . . . . . . 63
4.1 Developmental Psychology Researchers . . . . . . . . . . . . . . . . . . . . 63
René Spitz (1887–1974) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Robert Emde (1935–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Contents xix
Daniel Stern (1934–2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

The Boston Change Process Study Group (BCPSG) . . . . . . . . . . . 66
L. Alan Sroufe (1941–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Edward Tronick (1942–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Andrew Meltzoff (1950–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Colwyn Trevarthen (1931–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Peter Fonagy (1952–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.2 Developmental Psychology Synthesizers . . . . . . . . . . . . . . . . . . . . 70
Allan Schore (1943–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Daniel Siegel (1957–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.3 Developmental Theory and Theorist’s . . . . . . . . . . . . . . . . . . . . . . 71
Attachment Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
John Bowlby (1907–1990) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Mary Ainsworth (1913–1999). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Mary Main (1943–) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Lev Vygotsky (1896–1934). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Adoption Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.4 Temperament Theorists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
5 Key Concepts in Two-Person Relational Psychology . . . . . . . . . . . . . 79
5.1 Meaning-Making Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5.2 Affective Attunement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
5.3 Emotional Availability and Social Referencing . . . . . . . . . . . . . . . 84
5.4 Temperament. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
5.5 Internal Working Models of Attachment (IWMA) . . . . . . . . . . . . . 88
Attachment Patterns: Secure, Insecure-Ambivalent/Anxious,
Insecure-Avoidant/Dismissive, and Insecure-Disorganized . . . . . . 89
Secure Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Insecure-Ambivalent/Anxious Attachment . . . . . . . . . . . . . . . . . . 89
Insecure-Avoidant/Dismissive Attachment . . . . . . . . . . . . . . . . . . . 90
Insecure-Disorganized Attachment . . . . . . . . . . . . . . . . . . . . . . . . . 90
5.6 The Contextual Nature of Attachment . . . . . . . . . . . . . . . . . . . . . . 91
5.7 Fundamental Principals of Two-Person Relational
Psychotherapy: Implicit Relational Knowing
and Intersubjectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Implicit Relational Knowing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Intersubjectivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
5.8 Real Relationship, Present Moments, Now Moments,
and Moments of Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Real Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Present Moment, Now Moments, and Moment of Meeting . . . . . . 96
Fuzzy Intentions and Sloppiness. . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Mentalization and Intersubjectivity. . . . . . . . . . . . . . . . . . . . . . . . . 101
xx Contents
5.9 Corrective Emotional Experience . . . . . . . . . . . . . . . . . . . . . . . . . . 102

5.10 Key Concepts: Implications for Two-Person
Relational Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Andrew: A Securely Attached Child . . . . . . . . . . . . . . . . . . . . . . . . 103
Implications for Two-Person Relational Psychodynamic
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Bonnie: A Child with an Ambivalent/Anxious Attachment . . . . . . 104
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Carlos: A Child with an Avoidant/Dismissive Attachment . . . . . . . 105
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Daniella: A Child Who Grows in a Disorganized Environment . . . 108
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6 Deconstruction of Traditional One-Person
Psychology Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.1 Two-Person Relational Psychodynamic Psychotherapy:
A Historical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.2 Clinically Relevant Concepts from Traditional
One-Person Psychology: A Two-Person
Relational Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
6.3 Traditional Unconscious in Traditional One-Person
Psychology and Two-Person Relational Psychology . . . . . . . . . . . 119
Unconscious in Traditional One-Person Psychology . . . . . . . . . . . 119
Unconscious in Two-Person Relational Psychology. . . . . . . . . . . . 120
6.4 Psychic Determinism in Traditional One-Person
Psychic Determinism in Traditional One-Person Psychology . . . . 121
Psychic Determinism in Two-Person Relational Psychology . . . . . 121
6.5 Drive Theory in Traditional One-Person Psychology
and Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . . . 123
Drives in Traditional One-Person Psychology . . . . . . . . . . . . . . . . 123
Drives in Two-Person Relational Psychology. . . . . . . . . . . . . . . . . 123
6.6 Id in Traditional One-Person Psychology and Two-Person
Id in Traditional One-Person Psychology . . . . . . . . . . . . . . . . . . . . 124
Id in Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . . 124
6.7 Ego in Traditional One-Person Psychology and Two-Person
Ego in Traditional One-Person Psychology . . . . . . . . . . . . . . . . . . 124
Contents xxi
Ego in Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . 125

6.8 Superego in Traditional One-Person Psychology
Superego in Traditional One-Person Psychology . . . . . . . . . . . . . . 125
Superego in Two-Person Relational Psychology . . . . . . . . . . . . . . 126
6.9 Psychosexual Stages in Traditional One-Person
Psychosexual Stages in Traditional One-Person Psychology . . . . . 127
Psychosexual Stages in Two-Person Relational Psychology . . . . . 127
6.10 The Oedipus Complex in Traditional One-Person
Freud’s Oedipus Complex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Jung’s Electra Complex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
The Oedipus and Electra Complexes in Two-Person
6.11 Latency in Traditional One-Person Psychology
Latency in Traditional One-Person Psychology . . . . . . . . . . . . . . . 131
Latency in Two-Person Relational Psychology. . . . . . . . . . . . . . . . 131
6.12 Adolescence in Traditional One-Person Psychology
Adolescence in Traditional One-Person Psychology . . . . . . . . . . . 132
Adolescence in Two-Person Relational Psychology . . . . . . . . . . . . 133
6.13 Defense Mechanisms in Traditional One-Person Psychology
Defense Mechanisms in Traditional One-Person Psychology . . . . 135
Defense Mechanisms in Two-Person Relational Psychology . . . . . 136
6.14 Object Relations Theory in Traditional One-Person
Object Relations Theory in Traditional One-Person
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Object Relations Theory in Two-Person Relational
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
6.15 Transitional Objects in Traditional One-Person
Transitional Objects in Traditional One-Person Psychology . . . . . 139
Transitional Objects in Two-Person Relational Psychology . . . . . . 140
6.16 A Review of the Most Commonly Cited Defense
Mechanisms in Traditional One-Person Psychodynamic
Psychotherapy: A Two-Person Relational View . . . . . . . . . . . . . . . 141
Introjection, Projection, and Projective Identification
in Traditional One-Person Psychology . . . . . . . . . . . . . . . . . . . . . . 141
Introjection, Projection and Projective Identification
in Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . . . . 143
xxii Contents
6.17 Fantasy in Traditional One-Person Psychology

Fantasy in Traditional One-Person Psychology . . . . . . . . . . . . . . . 144
Fantasy in Two-Person Relational Psychology . . . . . . . . . . . . . . . . 144
6.18 Splitting in Traditional One-Person Psychology
Splitting in Traditional One-Person Psychology. . . . . . . . . . . . . . . 146
Splitting in Two-Person Relational Psychology . . . . . . . . . . . . . . . 146
6.19 Identification with the Aggressor in Traditional One-Person
Identification with the Aggressor in Traditional One-Person
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Identification with the Aggressor in Two-Person Relational
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
6.20 Treatment Goals in Traditional One-Person Psychology
Treatment Goals in Traditional One-Person Psychology . . . . . . . . 148
Treatment Goals in Two-Person Relational Psychology. . . . . . . . . 149
6.21 Neutrality in Traditional One-Person Psychology
Neutrality in Traditional One-Person Psychology . . . . . . . . . . . . . 150
Neutrality in Two-Person Relational Psychology . . . . . . . . . . . . . . 152
6.22 Transference in Traditional One-Person Psychology
Transference in Traditional One-Person Psychology . . . . . . . . . . . 153
Transference in Two-Person Relational Psychology. . . . . . . . . . . . 154
6.23 Resistance in Traditional One-Person Psychology
Resistance in Traditional One-Person Psychology . . . . . . . . . . . . . 154
Resistance in Two-Person Relational Psychology . . . . . . . . . . . . . 155
6.24 Interpretations in Traditional One-Person Psychology
Interpretations in Traditional One-Person Psychology . . . . . . . . . . 156
Interpretations in Two-Person Relational Psychology . . . . . . . . . . 156
6.25 Dreams and Parapraxes in Traditional One-Person Psychology
Dreams in Traditional One-Person Psychology . . . . . . . . . . . . . . . 157
Parapraxes (Freudian Slips) in Traditional
One-Person Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Dreams in Two-Person Relational Psychology . . . . . . . . . . . . . . . . 159
Parapraxes (Freudian Slips) in Two-Person Relational
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
6.26 Countertransference in Traditional One-Person Psychology
Countertransference in Traditional One-Person Psychology . . . . . 161
Countertransference in Two-Person Relational Psychology . . . . . . 162
Contents xxiii
6.27 Boundaries and Self-Disclosure in Traditional One-Person

Boundaries in Traditional One-Person Psychology . . . . . . . . . . . . 163
Self-Disclosure in Traditional One-Person Psychology . . . . . . . . . 164
Boundaries in Two-Person Relational Psychology . . . . . . . . . . . . . 164
Self-Disclosure in Two-Person Relational Psychology. . . . . . . . . . 165
6.28 The Role of Parents and Family in Traditional One-Person
The Role of Parents and Family in Traditional One-Person
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
The Role of Parents and Family in Two-Person Relational
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
6.29 Everyday Life of the Patient in Traditional One-Person
Everyday Life of the Patient in Traditional One-Person
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Everyday Life of the Patient in Two-Person Relational
Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
6.30 Psychopharmacology in Traditional One-Person
Psychopharmacology in Traditional One-Person Psychology . . . . 172
Psychopharmacology in Two-Person Relational Psychology . . . . . 173
6.31 Other Forms of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
6.32 The Use of the Couch in Traditional One-Person Psychology
6.33 Fairy Tales in Traditional One-Person Psychology
Fairy Tales in Traditional One-Person Psychology. . . . . . . . . . . . . 176
Fairy Tales in Two-Person Relational Psychology . . . . . . . . . . . . . 177
6.34 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
7 The Neurodevelopmental and Neurofunctional Basis
of Intersubjectivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
7.1 Developmental Psychology: A Foundation for
the Neurofunctional and Neurostructural Understanding
of Two-Person Relational Psychotherapy . . . . . . . . . . . . . . . . . . . . 186
7.2 Core Concepts of Development . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
7.3 The Neurobiology of Two-Person Relational Psychotherapy. . . . . 193
Neurodevelopment: A Broad Overview . . . . . . . . . . . . . . . . . . . . . 193
7.4 Structures and Networks in Two-Person Relational
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Anterior Cingulate Cortex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Medial Prefrontal Cortex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
The Amygdala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
The Default Mode Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
The Mirror Neuron System and Its Functional
Neurophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
xxiv Contents
7.5 Genetics and Two-Person Relational Psychotherapy . . . . . . . . . . . 199

Neurochemistry and Two-Person Relational Processes . . . . . . . . . 200
Neurostructural and Neurofunctional Basis of Temperament. . . . . 200
The Neurocircuitry of Implicit Relational Knowing. . . . . . . . . . . . 201
Neuroscience of Reflective Functioning . . . . . . . . . . . . . . . . . . . . . 202
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
8 Putting It All Together: The Four Pillars
of the Contemporary Diagnostic Interview . . . . . . . . . . . . . . . . . . . . . 207
8.1 Contrast of the Contemporary Diagnostic Interview
(CDI) to a Traditional Diagnostic Interview . . . . . . . . . . . . . . . . . . 208
8.2 Overview of the Contemporary Diagnostic Interview
(CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
8.3 The Contemporary Diagnostic Interview . . . . . . . . . . . . . . . . . . . . 213
The Clinician Provides an Atmosphere of Safety . . . . . . . . . . . . . . 213
Approaching the Patient and Parents or Caregivers
with Vitality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
The Alliance: Goodness of Fit for Mutual Curiosity . . . . . . . . . . . 214
The Clinician Has an Open Frame of Mind . . . . . . . . . . . . . . . . . . 215
8.4 The Four Pillars of the Contemporary Diagnostic Interview . . . . . 218
8.5 Temperament. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Temperament Traits Derived from Thomas et al. (1970) . . . . . . . . 219
Temperament Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
The Easy or Flexible Temperament Style . . . . . . . . . . . . . . . . . . . . 220
The Slow-to-Warm-Up Temperament Style . . . . . . . . . . . . . . . . . . 220
The Difficult or Feisty Temperament Style. . . . . . . . . . . . . . . . . . . 221
The Mixed Temperament Style. . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
8.6 Cognition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Cognitive Weakness and Learning Disorders . . . . . . . . . . . . . . . . . 222
Assessing Cognition and Learning in a CDI. . . . . . . . . . . . . . . . . . 224
Assessing Visual–Spatial Abilities . . . . . . . . . . . . . . . . . . . . . . . . . 226
8.7 Assessing Cognitive Flexibility (Sense of Agency,
Theory of Mind) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Cognitive Flexibility in Adolescents. . . . . . . . . . . . . . . . . . . . . . . . 228
Brief Assessment of Cognitive Flexibility in Adolescents . . . . . . . 228
Cognitive Flexibility in Preschool and Elementary
School Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Brief Assessment of Cognitive Flexibility in
Preschool and Elementary School-Age Youth . . . . . . . . . . . . . . . . 229
8.8 Internal Working Models of Attachment (IWMA) . . . . . . . . . . . . . 229
Secure Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Ambivalent/Anxious Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Avoidant/Dismissive Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Disorganized Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Emotional Availability and Time-Outs . . . . . . . . . . . . . . . . . . . . . . 233
Contents xxv
8.9 Putting It All Together: The Four Pillars of a

Contemporary Diagnostic Interview . . . . . . . . . . . . . . . . . . . . . . . . 234
Beginning the Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Attending to the External Attributes of the Patient
and Parents or Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Other Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
8.10 Diagnostic Formulation and Treatment Plan. . . . . . . . . . . . . . . . . . 241
Diagnostic Formulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Disclosure by the Child and Adolescent Psychiatrist
or Clinician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
8.11 Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Psychotherapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Two-Person Relational Psychodynamic Psychotherapy . . . . . . . . . 243
Cognitive and Behavioral Therapies . . . . . . . . . . . . . . . . . . . . . . . . 244
Criteria for Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Formal Cognitive Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Criteria for Formal Cognitive Testing . . . . . . . . . . . . . . . . . . . . . . . 245
Pharmacological Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Criteria for Pharmacological Interventions. . . . . . . . . . . . . . . . . . . 246
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
9 Setting the Frame. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
9.1 What to Expect from the Psychotherapist. . . . . . . . . . . . . . . . . . . . 250
9.2 “Setting the Frame”: The Contemporary Diagnostic
Interview (CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
9.3 “Setting the Frame” in Two-Person Relational Psychotherapy. . . . 251
Consent to Treat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Goals of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Working with Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Fees for Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Third-Party Payers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
The Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
The Waiting Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Confidentiality (HIPAA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Office Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Consent for Video Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Use of Electronic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Telepsychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Home and School Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Use of Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Families as Ambassadors for Two-Person Relational
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
xxvi Contents
9.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
10 Two-Person Relational Psychotherapy: Infants
and Preschool Age Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.1 Psychodynamic Psychotherapy in Infants
and Preschool Age Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
10.2 Adam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
History of Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Past Family History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Adam’s First Appointment with the Child Psychiatrist. . . . . . . . . 268
Allowing Subjectivities to Meet: Developmentally
Informed Mental Status Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Contemporary Case Formulation Following Use of the CDI . . . . 270
10.3 Case Conceptualization from a Traditional One-Person Model . . 271
10.4 Two-Person Relational Psychodynamic Psychotherapy
in Infants and Preschool Age Children . . . . . . . . . . . . . . . . . . . . . 272
Facilitating Enactments Cocreating New Relational Schemas . . . 273
Timing Self-Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Working with Parents Intersubjectively . . . . . . . . . . . . . . . . . . . . 274
Letting Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
10.5 Dilemmas in Two-Person Relational Psychodynamic
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
11 Two-Person Relational Psychotherapy: Elementary School
Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
11.1 Psychodynamic Psychotherapy in Elementary School
Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
11.2 Heather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Past and Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
11.3 Case Conceptualization from a Traditional One-Person Model . . 283
in Elementary School Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . 284
Allowing Subjectivities to Meet . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Letting Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Final Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
11.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Contents xxvii
12 Two-Person Relational Psychotherapy: Middle School

Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
12.1 Psychodynamic Psychotherapy in Middle School Age Youth . . . 294
12.2 Charlie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Past History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
12.3 Case Conceptualization from a Traditional
One-Person Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
in Middle School Age Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Subsequent Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Traditional One-Person Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Letting Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
13 Two-Person Relational Psychotherapy: High School
Age Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
13.1 Psychodynamic Psychotherapy in High School
Age Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
13.2 Michelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Past and Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
13.3 Case Conceptualization from a Traditional One-Person
Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
in High School Age Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . 316
Letting Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Postscript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
13.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
14 Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
14.1 Historical Background of Psychotherapy and Core
Psychotherapy Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Psychotherapy Supervision as a Core Competency . . . . . . . . . . . 333
xxviii Contents
14.2 Becoming a Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Supervision: From a Traditional One-Person to a
Relational Two-Person Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Supervision in a Traditional One-Person Model. . . . . . . . . . . . . . 335
Critiques of the Traditional One-Person Approach
to Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
14.3 The Two-Person Relational Model and Its Relevance
to Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
14.4 The Two-Person Relational Supervisor. . . . . . . . . . . . . . . . . . . . . 338
Goals for the Relational Supervisor . . . . . . . . . . . . . . . . . . . . . . . 338
Limitations to a Two-Person Relational Supervisory Approach . . 339
14.5 Case Conceptualization in Two-Person Relational Supervision . . 339
14.6 The Supervisee in Two-Person Relational Supervision . . . . . . . . 342
Using Intersubjectivity in Two-Person Relational Supervision . . 343
Lying in Supervision: A Two-Person Relational Approach . . . . . 346
Spontaneity in Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
14.7 The Use of Video Recordings in Supervision . . . . . . . . . . . . . . . . 348
14.8 Concluding Thoughts on Two-Person Relational
Psychotherapy Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
About the Authors
Sergio V. Delgado, MD Dr. Delgado is Professor of Psychiatry, Pediatrics, and

Psychoanalysis at Cincinnati Children’s Hospital Medical Center and the University
of Cincinnati. Dr. Delgado is a graduate of the School of Medicine of the University
of Nuevo Leon, and the Psychiatry and Child Psychiatry programs of the Karl
Menninger School of Psychiatry and Mental Health Sciences. He also completed
training as a supervising and training analyst in adult and child psychoanalysis at
the Topeka Institute for Psychoanalysis. Currently, Dr. Delgado is an adult and child
supervising and training analyst at the Cincinnati Psychoanalytic Institute. He cur-
rently is the Medical Director of the Outpatient Child and Adolescent Psychiatric
Services at Cincinnati Children’s Hospital Medical Center. Dr. Delgado is the
co-chair of the psychotherapy committee of the American Academy of Child and
Adolescent Psychiatry. He is the President for the Cincinnati-Dayton Regional
Council of the American Academy of Child and Adolescent Psychiatry. He also
serves as a Child and Adolescent Psychiatry Oral Board Examiner for the American
Board of Psychiatry and Neurology.
Dr. Delgado actively teaches in the adult and child psychiatry training programs
and is Director of Psychotherapy for the child and adolescent training program. He
is a frequent recipient of numerous teaching awards for his helpful and pragmatic
teaching and supervising style. Dr. Delgado is frequently sought for supervision and
consultation involving difficult psychiatric cases. He is a strong advocate for the
integration of individual psychotherapy, family psychotherapy, and psychopharma-
cological interventions in the treatment of patients. Dr. Delgado has authored mul-
tiple journal articles and book chapters about the integration of psychopharmacologic
and psychotherapeutic treatments in the youth, on the assessment and treatment of
learning disorders, and on psychological development and intersubjectivity-based
interventions in adolescents. Dr. Delgado is the Founder and Director of the rela-
tional advanced psychotherapy program (RAPP) in Cincinnati.
Jeffrey R. Strawn, MD Dr. Strawn received his bachelor’s degree in biology from
the University of Kentucky and then completed his residency training in general
psychiatry at the University of Cincinnati. Following his general psychiatry train-
ing, he completed a fellowship in child and adolescent psychiatry at Cincinnati
Children’s Hospital.
xxix
xxx About the Authors
Currently, Dr. Strawn is an Assistant Professor of Psychiatry and Pediatrics at the

University of Cincinnati and Cincinnati Children’s Hospital Medical Center and is
the Director of the Pediatric Anxiety Disorders Clinic at the University of Cincinnati.
His clinical work focuses on the psychopharmacologic and psychotherapeutic treat-
ment of anxiety disorders in children and adolescents, and his research program
focuses on elucidating the underlying neural circuitry of these conditions, using
functional magnetic resonance imaging. Additionally, he is actively involved in the
testing of innovative treatments for youth with mood and anxiety disorders. Dr.
Strawn has published more than 75 papers and book chapters, and his research has
been acknowledged by numerous organizations, including the American Psychiatric
Association and the American Academy of Child and Adolescent Psychiatry.
He enjoys teaching and is actively involved in the teaching of psychotherapy
with adolescents and the treatment of adult and pediatric anxiety disorders to medi-
cal students, general psychiatry residents, and child and adolescent psychiatry fel-
lows at the University of Cincinnati and Cincinnati Children’s Hospital Medical
Center.
Ernest V. Pedapati, MD Dr. Pedapati is an Assistant Professor of Psychiatry at the

University of Cincinnati and maintains a joint appointment in the Division of
Psychiatry, Neurology, and Pediatrics at Cincinnati Children’s Hospital Medical
Center. He completed medical school at the University of Massachusetts. He com-
pleted his Triple Board Program at Cincinnati Children’s Hospital Medical Center
which is a combined residency in pediatrics, adult psychiatry, and child and adoles-
cent psychiatry. He is board certified by the American Board of Pediatrics.
Dr. Pedapati is extensively involved in clinical and research work involving
autism and developmental disabilities. He received the institutional Proctor
Scholarship which supports the career development of early physician scientists. He
is currently a child psychiatry consultant to the Division of Developmental and
Behavioral Pediatrics at Cincinnati Children’s Hospital Medical Center. Dr. Pedapati
is a member of the Autism Research Group at Cincinnati Children’s Hospital
Medical Center and conducts clinical trials and basic psychological research in chil-
dren with social impairments and repetitive behaviors. In addition, he is a part of an
interdisciplinary research team which studies the neurophysiology of neuropsychi-
atric illness through transcranial magnetic stimulation.
Introduction
1
If I had to give a young writer some advice I would say to write
about something that has happened to him; it’s always easy to
tell whether a writer is writing about something that has
happened to him or something he has read or been told.
— Gabriel García Márquez
This book will provide the novice or experienced child and adolescent psychiatrist or
psychotherapist an objective view of how the advances in attachment theory, systems
theory, developmental psychology, and neuroscience have contributed to the contem-
porary practice of psychotherapy in children and adolescents. Consequently, with
these advances, child and adolescent psychodynamic psychotherapy has transitioned
from a traditional one-person model to a contemporary two-person relational psycho-
therapy model to an understanding of the psychological development of children and
adolescents.
We define traditional one-person psychology as that which is based on traditional
psychoanalytic concepts and the form of technique that emphasizes the role of the
psychotherapist as an objective observer (one-person) of the patient’s ego defenses
(the symptoms) and the discoverer of the truth regarding the patient’s intrapsychic
conflicts and object relations (the patient’s inner life). Further, a goal of the tradi-
tional one-person model is to make the repressed and unconscious conflicts con-
scious through the use of interpretations by the psychotherapist.
We define two-person relational psychology as a model based on the integra-
tion of innate genetic, biological, psychosocial, and cultural factors. The psycho-
therapeutic intervention occurs at an implicit level, with the goal of a new
emotional experience to create more adaptive patterns of interaction with others.
To this, the psychotherapist and patient are mutually engaged in each other’s
subjectivities (two-person) and states of mind. The two-person relational psy-
chotherapist facilitates the psychotherapeutic process through enactments and
self-disclosures that frequently occur unknowingly by the psychotherapist,
although, at times, can be carefully timed, to move along the psychotherapeutic
relationship. As Wachtel (2010) states, “two-person psychology takes the rela-
tionships seriously.” The choice of the term two-person relational psychology is
designed to convey to the reader that in any here-and-now interaction, there are
two present and active people mutually influencing each other’s subjectivities in
the intersubjective field.
© Springer-Verlag Berlin Heidelberg 2015 1

S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children
and Adolescents: Integrating Intersubjectivity and Neuroscience,
DOI 10.1007/978-3-642-40520-4_1
2 1 Introduction
Although the interaction may be of two people (e.g., patient and psychothera-
pist), it is important to note that, in vivo, these processes are actively influenced and
directed by previous relational experiences. In contrast to a traditional one-person
model, the in vivo experiences in a two-person relational model require that the
psychotherapist be “real” and genuine to allow the patient to implicitly know about
his or her state of mind. That is, each person brings to the interaction a multitude of
relational experiences stored in nondeclarative memory systems that influence the
encounter, which are not limited to the relationship to their parents or primary care-
givers. Nondeclarative memory refers to a dynamic nonconflicted unconscious also
referred to by the Boston Change Process Study Group as “nonconscious” (Chap. 5).
The nonconscious processes begin during infancy and help the infant implicitly
learn how to perform certain tasks without the use of conscious thought. Everyday
examples include: walking, talking, smiling, laughing, playing, and riding a bike.
The nondeclarative memory is also known as implicit or procedural memory.
Infantile memories from early childhood are not accessible to verbal or symbolic
recall, but rather are encoded within the nondeclarative memory system machinery
that is unique to each child and is driven by their innate cognitive abilities (or limita-
tions). A person’s representational models are fine-tuned in perpetuity as they make
sense of the meaning, affect, and intentions of others within the intersubjective field.
Nondeclarative memory system is distinct from Freud’s “conflicted unconscious.”
Freud’s conflicted unconscious is a central tenet to all one-person psychologies (i.e.,
drive, ego, object relations, and self) and is a concept that adheres to an innate psy-
chic determinism, where nothing occurs at random; all mental events are caused by
the interplay of the unconscious forces between the id, ego, and superego that pre-
ceded the event (see Chaps. 2 and 6) and are consciously retrievable through free
associations and dreams.
In this book, we will review the work of major psychodynamic psychoanalysts
and psychotherapists over the last century (Table 1.1); our goal is to both applaud
and critique their unique contributions. In addition, we will demonstrate the seduc-
tive nature of the pursuit of understanding human behavior by each theoretical
school.
For some, the transformation of the scientific advances in early childhood devel-
opment into clinical applications has been viewed with a great deal of skepticism. It
is reminiscent of the manner in which the works of John Bowlby, Donald Winnicott,
and Donald Fairbairn were initially viewed, with skepticism, as they gave impor-
tance to the actual loving relationship between the infant and the mother while dis-
tancing themselves from Freud’s drive theory and Klein’s object relations theory.
To date, the schism between the schools of traditional one-person psychology
and two-person relational psychology remains, and we view this as problematic for
the young clinician. Under the broad umbrella of psychodynamic psychotherapy for
children and adolescents, there are those that hold to the importance of the Oedipus
complex and the internal life of the child in the form of object relations when help-
ing the child. In essence, the traditional one-person psychology model can be
viewed as a long journey with the psychotherapist leading the patient to the excava-
tion site considered by the psychotherapist to hold the valuable artifacts. Over time,
1
Table 1.1 Evolution of traditional one-person and two-person relational psychologies
Anna Freud-Ego Psychology

Melanie Klein-Object Relations
Sigmund Freud Inner world-Unconscious conflicts
Margaret Mahler-Sep-Individuation
Psychoanalysis Interpretations
Peter Blos-2nd Individuation of Adol
Introduction
Heinz Kohut-Self Psychology
John Bowlby
Donald Winnicott
Attachment Theory
Ronald Fairbairn
One person Psychology
Peter Fonagy Mentalization
Cognitive Psychology Affective Attunement, Corrective Emotional Experience

Jean Piaget Intersubjectivity Co-construction, Enactment,
Erik Erikson Developmental Psychology Self-disclosure
Cognitive Behavioral Therapy

Aaron Beck René Spitz Harry Stack Sullivan Contemporary
Robert Emde Stephen Mitchell Child Psychotherapists
Dialectical Behavioral Therapy Mary Ainsworth Jay Greenberg
Marsha Linehan Mary Main Irwin Hoffman Neil Altman
Stanley Greenspan James Fossage Kenneth Barish
Family Systems Daniel Stern Phillip Bromberg Alan Levy
Salvador Minuchin Beatrice Beebe Paul Wachtel Robert Gaines
Two person Psychology
Murray Bowen Frank Lachmann David Wallin Richard Briggs

Nathan Ackerman Alan Meltzoff Jay Frankel
Mauro Mancia Richard Bromfield
Temperament/Learning Deficits Vittorio Gallese Daniel Gensler
Alexander Thomas Karlen Lyons-Ruth
3
Stella Chess BCPSG*

Joseph Palombo
*The Boston Change Process Study Group
4 1 Introduction
using specialized tools, a careful reconstruction of the original site is accomplished

by removing the suspected calamity, thereby ultimately resulting in a return to hap-
piness. For many of us who are physicians or academics, this approach is not only
personally appealing but consistent with our years of training. Yet, we would offer
that such an approach to psychodynamic psychotherapy is somewhat lonely and
distant for the patient, as the psychotherapist is an objective observer and thus con-
sidered a “one-person” model.
Under the same umbrella of psychodynamic psychotherapy for children and ado-
lescents, are those— authors included—that have incorporated the advances in devel-
opmental scientific research in the form of meaning-making processes, emotional
availability, social reciprocity, relational schemas, implicit working memory, and right
brain regulatory functions into their theoretical understanding. These functions under-
score the complexities in understanding that what may appear as a developmental or
behavioral disturbance in the present may ultimately represent patterns imbedded in
disturbances of the original caregiver–infant relationships (Sameroff and Emde 1989).
We posit that the difference from a “one-person” model is that in the “two-person”
model, the original caregiver–infant relationships are stored in a dynamic noncon-
scious at an implicit preverbal level and are not retrievable through autobiographic
recall. As the title of this book suggests, the authors are very much immersed in a
contemporary two-person relational model of psychodynamic psychotherapy for chil-
dren and adolescents that integrates concepts of intersubjectivity—“the capacity to
share, know, understand, empathize with, feel, participate in, resonate with, enter into
the lived subjective experience from another” (Stern 2005)—and neuroscience (see
Chap. 5). Emde (2009) further states, “Much that is important to us as human beings
is shared implicitly. We now have a neurobiology of intersubjectivity that is rapidly
accumulating new knowledge; it involves basic nonconscious functioning and it has
major implications for psychoanalytic work.” Additionally, Rustin and Sekaer (2004)
state, “Although some psychoanalysts still dismiss the impact of neuroscience on psy-
choanalysis as ‘Darwinian,’ the general view is changing.”
The two-person relational concepts reviewed in this book are written to help the
reader expand, synthesize, and contextualize their applicability to a contemporary
two-person relational psychodynamic psychotherapy, as it relates to children and
adolescents. We seek to integrate the contributions from developmental research,
neuroscience, and intersubjectivity. We emphasize that our book is strongly influ-
enced by the works of Emde, Stern, Beebe, Lackman, Wachtel, Altman, Lyons-
Ruth, and the Boston Change Process Study Group.
1.1 Making the Case for Two-Person Relational

Psychodynamic Psychotherapy:
A Neurodevelopmentally Informed Treatment
The book’s subtitle—“Integrating Intersubjectivity and Neuroscience”—was care-

fully chosen to underscore the critical neurobiological and neurodevelopmental
basis of two-person relational psychotherapy. Importantly, recent advances in
1.1 Making the Case for Two-Person Relational Psychodynamic Psychotherapy 5
neuroscientific and behavioral research over the last two decades have greatly
improved our understanding of relatedness, social cognition, and implicit memory.
Moreover, these advances have given today’s two-person relational psychotherapist
a greater understanding of “(1) the importance of early life experiences, as well as
the inseparable and highly interactive influences of genetics and environment, on
the development of the brain and the unfolding of human behavior; (2) the central
role of early relationships as a source of either support and adaptation or risk and
dysfunction; (3) that powerful capabilities, complex emotions, and essential social
skills that develop during the earliest years of life; (4) the capacity to increase the
odds of favorable developmental outcomes through planned interventions” (Institute
of Medicine 2000). Thus, these advances in neuroscience serve as the bedrock for
the work of the relationally informed psychotherapist’s practice.
Increasingly, we appreciate the role of the infant as an active participant in the
reciprocal meaning-making relationship with his or her parents or caregivers and the
importance of the quality of this reciprocity with regard to his or her psychological
development. Inherent to this social reciprocity is the brain’s ability to process and
encode complex relational experiences and to manage complexity through the selec-
tion, processing, and storing of memories that are interwoven with experiences. While
the neurophysiologic processes that underlie these abilities (e.g., pruning, experience-
dependent changes in functional connectivity, long-term potentiation, and neuromod-
ulation) are discussed later in this book (Chap. 7), it is important to note that, in vivo,
these processes are actively influenced and directed by relational experiences.
We hope this book provides a path of collegial communication to better under-
stand the contemporary two-person relational psychology “from the inside,” thereby
clarifying misconceptions and minimizing misunderstandings. Additionally, we
hope that it will plant seeds that will germinate with understanding in the fertile
minds of the trainees, newly minted child and adolescent psychiatrists, and experi-
enced clinicians alike, who are embarking in the use of this approach in their clini-
cal work, and create cross-fertilization among different theoretical approaches to
the children and adolescents who seek our help.
Introduction to Two-Person Relational Psychology
Two-person relational psychology, unlike its forerunners in the traditional one-person

psychology arena, promotes the integration of concepts from intersubjectivity, mind-
fulness, family systems, cognitive therapy, dialectic therapy, interpersonal therapy,
and client-centered therapy, when working with patients in psychotherapy. As such,
two-person relational psychology encompasses the therapeutic work that is influenced
by the real-life and genuine subjective experiences between patient and psychothera-
pist. The psychotherapist will make use of his or her own intersubjective experience
to provide nonconscious or well-timed enactments and self-disclosures to promote
new adaptive patterns of interaction that occur at the implicit level and may not be
open to understanding at the explicit autobiographic level (see Chap. 3). In two-person
relational psychology, the psychotherapist must attend to the ever-present fact that
6 1 Introduction
interactions of mutuality are also influenced by context, bringing into the office the
realities of the child’s world (e.g., being bullied, witnessing family conflict, difficul-
ties with learning). Thus, in two-person relational psychology, it is no longer neces-
sary for the psychotherapist to feel that he or she must know the patient better than the
patient knows him- or herself, in order to provide insight about the origin of their
maladaptive ego defenses, which is a goal in traditional one-person models.
Certainly, contemporary two-person relational psychology grew from a rich field
of traditional one-person psychologies. However, we no longer are allegiant in our
loyalty to traditional, conflict-based, and object relations theories. It is worth noting
that even half a century ago, the psychoanalyst Donald Winnicott (Rodman 1987)
wrote in his letters to Melanie Klein and Anna Freud that integration of increasingly
disparate psychological schools was urgently needed. Winnicott, in pleading for
integration, soon realized that those who were not loyal to the tenets of traditional
one-person psychology and instead had divergent views would be described as
“difficult,” “destructive,” or, simply, “dissenters.” Our hope is that we will not be
viewed as “difficult or destructive” but rather that we will provide a much needed
revision of the practice of psychotherapy integrating attachment theory, neurosci-
ence, and developmental psychology. In Chap. 6, we discuss the reasons why the
concepts utilized by traditional one-person psychology are limiting in understand-
ing a patient’s psychological struggles. For example, we describe the clear distinc-
tion between matters of unconscious, transference, resistance, defenses, etc. and
suggest that the two-person relational psychotherapist jettison these terms in favor
of a new two-person relational lexicon.
We recognize that human interactions are shared experiences between two or
more people. Furthermore, each interaction with others is also shaped by implicit
stored experiences in nondeclarative memory systems of past relationships in the
form of “relational schemas” of people with similar characteristics. The reader, at
this point, may wonder whether the concept of relational schemas is similar to the
traditional one-person forms of transference or object relations’ internalizations.
Although at first glance the distinctions of relational schemas between traditional
one-person and two-person relational models may not seem necessary, with further
study, the differences become evident. In a two-person relational model the rela-
tional schemas are formed through the complex array of a multitude of prior rela-
tionships (e.g., siblings, cousins, grandparents, neighbors, etc.) that nonconsciously
influence new relationships (Emde et al. 1991). As an example, when a child
approaches a teacher, his or her reaction is influenced by the authentic and personal
attributes of the teacher, which will be implicitly processed through the child’s
nondeclarative memories of many other people with similar attributes, resulting in
the child inherently knowing how to relate with the teacher. If the teacher’s per-
sonal attributes are unfamiliar nonconsciously, the child will approach the teacher
and create a new relational schema that will be stored in nondeclarative memory
and can be used in the future. In the traditional one-person school, relational sche-
mas are considered to be a person’s internalizations of the attributes of the other
person in the form of “objects.” The internalizations are influenced by the uncon-
scious forces of the id, ego, and superego. In using the example of the teacher, in a
1.2 Context and Key Concepts in Two-Person Relational Psychology 7
one-person model, the child approaches the teacher and unconsciously compares
the teacher against internalizations of his or her original objects and will approach
the teacher as a familiar good or bad object (i.e., transference).
This concept of relationships influencing relationships helps understand the vari-
ability of how a person may relate in a certain way to one person and in a completely
different manner with another person (Emde 1989). The familiar relational schemas
that are nonconsciously evoked by to the characteristics of the other person are what
are known as implicit relational knowing processes. When a person interacts with a
person with unfamiliar attributes, a new relational schema is formed and stored in
nondeclarative memory (Chap. 5). Therefore, those involved in the interaction will
each have their own version of the truth of the cocreated experience. As an example,
a toddler during a trip to a local store becomes obstinate and yells at his parents for
not buying him the toy he wants. The toddler will likely experience some comfort
when the parents recognize the need to help the child regulate his emotions. When
things go well, the parent recognizes the appropriate developmental milestone that
the toddler demonstrates—a wish for self-sufficiency—but also that the toddler
needs the parental affective attunement reflecting back to the child that the action is
not permissible and that the behavior is rewarded only after he or she settles down.
The parent’s personal proclivities and past relationships with their own parents,
siblings, cousins, peers, nieces, nephews, etc. allowed them to implicitly “know
how” to help young children needing help self-regulating. That is, they had known
how to help their child before his birth.
In contrast, another parent may feel overwhelmed with the task at hand and
become anxious or upset and be unable to help the child regulate his emotions, due
to not having a nonconscious implicit relational model for this scenario, and conflict
ensues. The anxious parents did not have the relational schema to know how to help
a child learn to self-regulate. When the interaction with the toddler is viewed
through the lens of a traditional one-person psychology model, it seems reasonable
for the clinician to think that the parent became anxious or upset due to their uncon-
scious intrapsychic conflicts that were reawakened by the child’s negative request
for affective attunement. This presumes that the anxiety, which was reawakened in
the parents by the child’s demands, was the result of unresolved unconscious con-
flicts that originated in their own childhood.
1.2 Context and Key Concepts in Two-Person

Relational Psychology
There is no doubt that psychological forces lead patients to tenaciously hold

onto dysfunctional behavioral and relational patterns. In two-person relational
psychology, the psychotherapist seeks to recognize the nonconscious influences
(e.g., implicit memory systems reviewed in Chap. 3) of these patterns within the
context of the patient’s world. The psychotherapist attends to the contribution of
the patient’s contextual realities (e.g., physical limitations, genetic influences,
8 1 Introduction
relational schemas, financial hardships, etc.). The psychotherapist seeks to

influence these dysfunctional behavioral and relational patterns through a here-
and-now intersubjective and mutual approach in which he or she provides the
patient, nonconsciously and implicitly, new and more adaptive patterns of self-
regulation in the form of new emotional experience.
As such, this notion is an important point of divergence from the traditional
one-person model that presumes relational difficulties and dysfunctional behav-
iors are strongly influenced by unconscious intrapsychic processes (e.g., drive and
object relations) to their original parents. The one-person psychotherapist makes
use of the patient’s autobiographic memories to understand the reason for the
maladaptive ego defenses and, over time, provides insight through empathic sug-
gestions or interpretations.
As an example, the current obesity epidemic has not been helped by the barrage
of advertisements about the dangers of obesity with regard to medical and psycho-
logical health. In fact, there are new federal guidelines that require fast-food res-
taurants to display the calorie count of their meals, hoping that awareness will
change behavior—consumption patterns. There is general agreement that internal
psychological forces guide and shape our behaviors. In a traditional one-person
model, the etiology of the eating behaviors that lead to obesity might be viewed as
multifactorial, although they would generally be viewed within the context of
unconscious drives and object relations; consideration would be given to whether
the dysfunctional eating behaviors reflect an oral fixation to food, defense against
recognizing the need for others, feelings of deprivation or conflicts regarding indi-
viduation and intimacy, etc. From a two-person relational viewpoint, the food
choices and associated risk of obesity are influenced by: (1) genetic predisposition,
(2) temperament (3) cognition—meaning-making processes with regard to risk and
food, (4) implicit relational schemas, (5) early childhood socioeconomic factors,
and (6) cultural preferences. Therefore the two-person relational psychotherapist
of a patient who is struggling with obesity will need to carefully complete a con-
temporary diagnostic interview (Chap. 8) to assess the multifactorial aspects of the
obesity and tailor the interventions to be practical and realistic, in regard to the
patient proclivities—temperament, cognition, cognitive flexibility, and internal
working models of attachment.
Additionally, in two-person relational psychology, the psychotherapist takes
an active role with the patient, so that each becomes a partner to the other’s
intersubjective experiences during the treatment. That is, the intersubjective
experience incorporates both the patient and the psychotherapist’s personali-
ties—temperament, cognition, cognitive flexibility, and internal working mod-
els of attachment—which are brought into the context of the therapeutic
relationship. It is through this bidirectional process that the patient, over time,
becomes able to implicitly use the psychotherapist’s healthier and more adap-
tive way of interacting with others, thus providing a corrective emotional expe-
rience for the patient, which will be stored in nondeclarative memory (implicit
relational experiences).
1.2 Context and Key Concepts in Two-Person Relational Psychology 9
A Brief Glimpse into a Two-Person Relational Approach

An 8-year-old boy was brought to an initial psychiatric evaluation for his
anxiety. At the initial session, after creating an atmosphere of safety for the
boy and his parents, the child psychiatrist proceeded to perform a card trick in
which the boy selected a card from a deck and then replaced the card within
the deck. The child psychiatrist invited the boy to snap his fingers and say,
“Abracadabra!”
At that point, the child psychiatrist showed the boy the deck of cards; the
card the boy selected had “flipped over.” The boy smiled with excitement and
asked to see another trick, demonstrating an easy/flexible temperament (see
Chap. 5), and the boy’s parents supported his excitement (i.e., reflecting good
affective attunement and secure attachment within the family system).
Afterward, it was agreed that the boy would begin weekly play psycho-
therapy to help with his anxiety. During the first several sessions, the child
psychiatrist showed the patient a new card trick at each visit. The result: The
patient was eager to come to the clinic and knew when his appointments were
scheduled. Similarly, the boy’s parents were pleased by his initial progress and
noted that their son was less anxious and that at home he would say that he felt
better when he thought of the card tricks his psychotherapist had shared.
Thus, from a two-person relational model, the patient and psychotherapist had
embarked on a path of mutual meaning-making processes. The psychotherapist
took an active role in the here-and-now interactions with the child, to promote the
mutuality of their subjectivities. The psychotherapist would make use of his inter-
subjective experiences to guide him about when the boy experienced the psycho-
therapist as “being like me,” joyful and happy. In these moments, he would match
the boy’s tone of voice, language, and excitement, allowing for a new emotional
experience (i.e., card tricks) and the development of new, less anxious, implicit
relational patterns to be stored in nondeclarative memory, which will be described
in detail in Chaps. 3 and 5.
This experience of change occurring at the implicit level is ubiquitous among
two-person relational psychotherapists. Thus, although the changes may be noticed
by the psychotherapist, he or she will need the fortitude to tolerate frequently not
knowing specifically what led to the permanence of the changes. This is beautifully
captured by Bromberg (2010) when he says, “the quality of uncertainty is basic to
experience,” which is, ultimately, the vessel by which improvement occurs during a
two-person relational approach.
In the case of a child psychiatrist who is trained in the traditional one-person
model, he or she may struggle to understand the 8-year-old boy’s improvement
and might ask, “Was it a flight into health or unresolved transference manifesta-
tions?” “Was it a repressed conflict that card tricks allowed to be worked through
10 1 Introduction
in fantasy?” These hypotheses ostensibly exclude the nonconscious subjective

contribution from the psychotherapist, which is sine qua non in two-person rela-
tional psychology.
1.3 Limitations of Two-Person Relational Psychology
We are keenly aware that, despite the advantages of the two-person relational
approach, there will be skeptics, as is the case with any approach. Among the argu-
ments that may be levied against this approach is that our method invites for close-
ness with the patient, and, potentially, the family, and that this intimacy could
compromise true objectivity by the psychotherapist—although surely, based on
contributions from attachment theory and intersubjectivity, we must recognize that
“true objectivity” is a relative myth. Further, we believe that it is crucial to address
the limitation of some two-person relational literature retaining the language of the
one-person model. There is an urgent need to clarify the difference in meaning of
the terms used in traditional one-person psychology, as these terms continue to pre-
vail in the psychotherapeutic venacular and do not adequately represent two-person
relational psychology.
Additionally, we believe that some concepts within the context of two-person
relational psychotherapy of children and adolescents need to be studied more exten-
sively. Two-person relational psychology is a fairly new model of treatment, and
many questions have yet to be quantitatively answered, which is a limitation of any
new theory and could also be said to apply to some older theories. The two-person
relational literature has not fully incorporated and researched the important influ-
ences beyond the two-person here-and-now relationship, i.e., siblings, extended
family members, teachers, peers, etc. Therefore, we pose some questions that
require further inquiry in a two-person relational approach. Might a two-person
relational psychotherapist benefit from more actively interacting with other impor-
tant figures in the child’s life and have their input about how they subjectively expe-
rience the child and incorporate this information into the psychotherapy process?
How would the two-person relational psychotherapist understand the collateral
information, if ostensibly provided by psychologically healthy family members or
teachers, if they subjectively experienced the child or adolescent differently than the
psychotherapist? Is two-person relational psychology similar to the traditional one-
person model, in that it relies on the child and parent as the primary source of inter-
subjective information during psychotherapy? Further, we are aware that
intersubjectivity is inherently contextual. Might the context of a child’s or adoles-
cent’s real-life experiences be helpful for the two-person relational psychotherapist
to be familiar, beyond the here-and-now subjectivities with the patient? Wachtel
(2010) answers, “The contexts in which we find ourselves are very largely contexts
that we have ourselves contributed to creating, that we have co-created with those
who participate with us in that context.” Thus, how a two-person relational psycho-
therapist makes use of the variability in the “context” of a child’s or adolescent’s life
warrants further research. Further, what are the influences of executive functioning
1.4 How to Use This Book 11
difficulties in children with attention-deficit/hyperactivity disorder in regard to their

development of theory of mind and social reciprocity, essential for successful inter-
actions with others? How do the developmental and hormonal shifts occurring dur-
ing puberty influence nondeclarative memory systems? These are just a few of the
many complex questions with which we will need to grapple with in the future.
1.4 How to Use This Book
This book is written with several audiences and several goals in mind. First, we aim
to expand the contemporary two-person relational psychology literature and to pres-
ent an effective method of using this model in psychodynamic psychotherapy of
children and adolescents. Second, we have arranged the flow of this book to facili-
tate the reader being able to have a historical overview as to how these theories
emerged in the landscape of psychotherapy for children and adolescents (i.e., the
competing psychological theories: traditional one-person psychology and two-
person relational psychology). Third, we aim to guide child and adolescent psychia-
try trainees, as well as experienced clinicians, clinical psychologists, psychiatric
nurse practitioners, and social workers, toward using a two-person relational
approach in the practice of psychodynamic psychotherapy with children and adoles-
cents. We have also included tables for efficient review of relevant information
while tailoring the interventions as needed, and we have provided relevant cases that
allow the reader “to be on the shoulder of” the two-person relational psychothera-
pist during the sessions. We hope that this book additionally serves as a resource to
colleagues and students of psychotherapy to better understand the work with their
patients and to ask pertinent questions to their teachers and supervisors. Finally, we
hope that the reader can use our book to integrate the rich value offered by contem-
porary two-person relational psychology, when asked to teach a psychotherapy
course to students of their specific discipline.
We begin in Chap. 2, Traditional One-Person Psychology, by briefly reminding
the reader of the origins of the traditional drive, conflict-based, object relations, one-
person psychologies in working with children and adolescents and why its terminol-
ogy remains in our everyday discourse when teaching or practicing psychodynamic
psychotherapy. In Chap. 3, Two-Person Relational Psychology for the Child and
Adolescent Psychotherapist, we make the case that the work of contemporary two-
person relational psychotherapists has evolved from traditional one-person psycho-
logical approaches, and we review the main differences and concepts of each model.
After laying the groundwork for distinguishing between traditional one- and
two-person relational psychologies, in Chap. 4, Key Pioneers of Two-Person
Relational Psychology, we recognize the eloquent developmental researchers and
theoretical synthesizers who gave legitimacy to two-person relational psychology.
We follow with Chap. 5, Key Concepts in Two-Person Relational Psychology, in
which we provide the reader the necessary understanding of the origin and meaning
of two-person relational psychology concepts. In Chap. 6, Deconstruction of
Traditional One-Person Psychology Concepts, we survey the differences of terms
12 1 Introduction
used in both theories and provide a way to understand if they are interchangeable or
incompatible and represent distinctly different concepts.
Next, in Chap. 7, The Neurodevelopmental and Neurofunctional Basis of
Intersubjectivity, we review the neurobiology of two-person relational psychother-
apy that is ultimately subtended by a number of structures in the brain. In Chap. 8,
Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview,
we outline an integrated approach to an initial evaluation of a child or adolescent
that combines two-person relational psychology, neurobiology, and social science.
We provide tables that help tailor appropriate treatment recommendations, not lim-
ited to psychodynamic psychotherapy. After the child psychiatrist or clinician has
decided that psychodynamic psychotherapy in a two-person relational model is the
treatment of choice, in Chap. 9, Setting the Frame, we describe several important
practical aspects for patient and parents or caregivers, as they prepare to become
engaged in a psychotherapeutic process. This serves to provide reassurance about
what to expect, to avoid having surprises when conflict arises, and to have a sense
of predictability about the process.
In Chaps. 10, 11, 12, and 13, we will take the reader through a series of cases
involving an infant, school age youth, and an adolescent. These vignettes and the
accompanying discussion bring to life two-person relational psychology and illus-
trate the benefits and challenges of using this model. In these vignettes, we juxta-
pose the way in which treatment may have been developed using a traditional
one-person psychological understanding so that the reader can have a better sense
of the “then and now” psychodynamic perspectives. We close with Chap. 14,
Supervision, to help the supervisor of a two-person relational model have a better
understanding of how the theoretical concept of intersubjectivity can influence the
supervisory experience. For the child and adolescent psychiatry trainee or new-
comer to two-person relational psychotherapy, our aim is to provide guidance in
terms of what to expect in the context of a two-person relational supervisory hour
and contrast this with a traditional one-person supervision.
Finally, we hope this book will become a useful “go to” resource for child and
adolescent psychiatry trainees and clinicians who may wish to learn about a con-
temporary two-person relational approach in helping children and adolescents
achieve a more adaptive and happier life: to enjoy loving, playing, and learning.
References
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Petrucelli J (ed) Knowing, not-knowing and sort-of-knowing: psychoanalysis and the experi-
ence of uncertainty. Karnac, London, pp 22–45
Emde RN (1989) The infant’s relationship experience: developmental and affective aspects. In:
Sameroff AJ, Emde RN (eds) Relationship disturbances in early childhood: a developmental
approach. Basic Books, New York
Emde RN, Biringen Z, Clyman RB, Oppenheim D (1991) The moral self of infancy: Affective core
and procedural knowledge. Develop Rev 11:251–270
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Emde RN (2009) From ego to “we-go”: neurobiology and questions for psychoanalysis: commen-
tary on papers by Trevarthen, Gallese, and Ammaniti & Trentini. Psychoanal Dial 19:
556–564
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opment. The National Academies Press, Washington, DC, p 31
Rodman FR (1987) The spontaneous gesture: selected letters of D. W. Winnicott. Karnac Books,
London
Rustin J, Sekaer C (2004) From the neuroscience of memory to psychoanalytic interaction: clinical
implications. Psychoanal Psychol 21:70–82
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Stern DN (2005) Intersubjectivity. In: Person ES, Cooper AM, Gabbard GO (eds) Textbook of
psychoanalysis, 1st edn. American Psychiatric Publishing, Arlington, pp 77–79
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for psychoanalytic thought. Int J Psychoanal 91:561–581
Traditional One-Person Psychology
2
What Freud did not envision, however, is the extent to which useful theory has become relational.
—Robert N. Emde
Our efforts in this chapter will be to establish an essential foundation for the field of
child and adolescent psychoanalysis and psychodynamic psychotherapy, a model
that has radically changed over the past 50 years, in order to anchor the remainder
of this book in a two-person relational psychology model.
It is important to note that we do not intend to provide the reader with a complete
review of all the contributors to child psychoanalysis and psychodynamic psycho-
therapy. Rather, we will focus on those that have become the pillars of the tradi-
tional one-person psychology model and how their contributions helped influence
the transition to a two-person relational psychology for the current child and adoles-
cent psychiatrist and psychotherapist.
If the phrase “one-person psychology” does not initially appear puzzling, we
would kindly ask the reader to reconsider. It is not lost on the authors the sig-
nificance of calling any approach to psychodynamic psychotherapy “one person”
as clearly there are, at minimum, two people involved in any psychotherapeu-
tic process. Therefore, the concept of one-person psychology refers to the fact
that the “one person” is the objective observer and not an active participant who
shares his or her subjectivities with the patient during the interaction. Wachtel
(2010) and Hoffman (1998) capture the one-person process as seeing the per-
son in a fashion that assumes that the seer [psychotherapist] has no effect on the
seen [patient]. Further, Wachtel notes that the distinction between one-person and
two-person psychology is a useful beginning when considering that two-person
relational psychology evolved from a traditional one-person psychology. As such,
we define the concept of traditional one-person psychology as the psychodynamic
clinical model in which the analyst’s or psychotherapist’s goal is to discover the
patient’s unconscious conflicts that have hampered their ability to have a happy

DOI 10.1007/978-3-642-40520-4_2
16 2 Traditional One-Person Psychology
and successful life. One-person psychology model relies on the patient to transfer
or displace early, unconscious unresolved conflicted wishes and feelings about
their parents or caregivers to the analyst or psychotherapist. Therefore, in a tradi-
tional one-person model, transference is considered a critical element for psycho-
therapeutic change to occur in the form of insight. Pine (1988) proposed that the
unifying principle of traditional one-person models was a psychoanalytic plural-
ism: “The psychologies of drive, ego, object relations, and self…. While the four
certainly overlap, each adds something new to our theoretical understanding, and
each has significant relevance in the clinical situation.”
2.1 Traditional One-Person Psychology
Child and adolescent psychoanalysis and psychodynamic psychotherapy were

developed under the umbrella of adult psychoanalysis and psychodynamic psycho-
therapy and were modeled on traditional one-person psychology. The goals of treat-
ment were uncovering the child’s unconscious inner life to elucidate the intrapsychic
conflicts that created maladaptive patterns that led to a developmental interference
in their emotional growth and the working through of their conflicts in order to
achieve a healthier state.
Historically, fundamental psychoanalytic clinical concepts and treatments have
been understood as one-person phenomena (Aron 1990). Therefore, in a traditional
one-person model, transference is considered a critical element for psychotherapeu-
tic change to occur. Transference was understood as a process occurring within the
mind of the patient and not as an interpersonal event occurring between two people.
Through the process of remembering and repeating past intrapsychic and uncon-
scious conflicts, then transferring them onto the psychotherapist, the patient’s
unhealthy ego defenses, in the form of resistances, can be “worked through.” The
analyst or psychotherapist helps the patient identify what he or she needs to work
through (i.e., unconscious conflicts and maladaptive defenses), which when brought
to consciousness by the psychotherapist results in the patient developing insight and
improving symptomatically (Freud 1914). Resnik (2004) summarizes, “The aim of
analysis is self-knowledge largely achieved by the analysis and interpretation of
defenses against the underlying impulses, drives, urges, fantasies and so on.” Freud’s
“method” encouraged the use of neutrality, free association, dreams, and the psycho-
analytic couch to facilitate transferences to develop. Freud believed that psychoanal-
ysis had to be carried out in abstinence by the analyst (Freud 1914).
Traditional one-person psychology over the years collectively became what
Pine (1988) described as psychoanalytic pluralism. Pine deftly states,
“Psychoanalysis has produced what I shall refer to as ‘four psychologies’—the
psychologies of drive, ego, object relations, and self. Each takes a somewhat dif-
ferent perspective on human psychological functioning, emphasizing somewhat
different phenomena.”
Greenberg takes this a step further in defining this pluralism as “the wide-
spread acknowledgment that a range of legitimately psychoanalytic points of view
exists, whether or not there is any exchange of ideas among their adherents”
(Greenberg 2012).
2.3 Freud and Classic Psychoanalytic Theories 17
2.2 Historical Background of Traditional One-Person Model

of Child and Adolescent Psychoanalysis
and Psychodynamic Psychotherapy
Child and adolescent psychoanalysis and psychodynamic psychotherapy developed

under the umbrella of adult psychoanalysis and psychotherapy. Most early child
psychoanalytic and psychodynamic literature considered the psychological devel-
opment of the child in distinct psychosexual phases based on Sigmund Freud’s drive
theory: pre-oedipal, oedipal, latency, and adolescence. Herein, treatment was based
on helping the child overcome the conflicts of the psychosexual stage they were
unable to master, and then resuming their developmental trajectory.
Child and adolescent psychoanalysis is the treatment that relies in understanding the
child and adolescents past unconscious inner life that influence his or her feelings,
thoughts, and actions. The goal of child and adolescent psychoanalysis is the removal
of symptoms and psychological roadblocks that interfere with normal development.
Yanof (2005) reminds us that “for many years adult analysts questioned whether or not
child analysis was ‘real’ analysis.” Child and adolescent psychodynamic psychother-
apy is based on psychoanalytic principles and initially developed as an alternative
method to those children who could adhere to the four to five times a week schedule,
due to its regressive nature. Subsequently, child and adolescent psychodynamic psy-
chotherapy became a form of treatment used by psychoanalytically trained clinicians.
In child psychoanalysis, the concept of transference was controversial. Anna
Freud clarified the difficulties in the use of the concept of transference with chil-
dren: “The adult tendency to repeat, which is important for creating transference, is
complicated in the child by his hunger for new experience and new objects…”
(1965). In spite of the differences, early child and adolescent psychoanalysis and
psychodynamic psychotherapy were firmly grounded on the principle tenets of one-
person adult psychoanalysis.
To further illustrate the profound impact Freud’s work had in child and adoles-
cent psychoanalysis and psychodynamic psychotherapy over the last 100 years,
we will first review his drive theories and then describe his classic first case of
child psychoanalysis, Little Hans. We follow by comparing selected elements of
Freud’s Little Hans case formulation with a perspective of a two-person relational
psychotherapist. We next proceed to describe the influence some of his most
esteemed contemporaries had to his drive-based theories and conclude with a
description of ego psychology, object relations theory, and self-psychology in the
context of their contributions to child psychoanalysis and child psychodynamic
psychotherapy.
2.3 Freud and Classic Psychoanalytic Theories
Sigmund Freud (1856–1939): Drive Theory
Classic psychoanalytic theory was developed by Sigmund Freud, who based his theo-
ries on his work with adult patients. In his efforts to understand the human mind,
Freud proposed several hypotheses. First, the topographic model (Fig. 2.1) posits that
Conscious
Preconscious
Ego
Unconscious
Superego
Id
Fig. 2.1 Sigmund Freud’s topographic (left) and structural (right) models of the mind
most mental life occurs in the unconscious and that preconscious and conscious life is
rather limited. Later, in revising the topographic model, Freud developed the struc-
tural model (Fig. 2.1). In this model the unconscious is comprised of several intrapsy-
chic agencies: (1) the id, which embodies the instinctual sexual and aggressive drives
and seeks for immediate gratification (Freud 1920); (2) the superego, which consists
of the agency that seeks to obey cultural and societal norms incorporated into the
person’s psyche; and (3) the ego, an agency that moderates the conflict between the id
(which desires free reign) and the superego (which urges civility). Freud posited that
the key developmental task of children involved “taming the instinctual drives” of the
id through the development of the superego and ego (Freud 1916–1917).
Still later, Freud wrote about the importance of the sexual drive theory in the
form of psychosexual developmental stages determined by the organ of predomi-
nant interest to the infant/child for pleasure. As can be seen in Table 2.1, there are
psychosexual stages of development—and each requires that conflicts from the pre-
vious phase be successfully resolved. For Freud, unresolved conflicts of the oral,
anal, phallic, or oedipal phases led the person to have a neurotic fixation that, when
he or she is under stress, causes an unconscious regression of the ego functions to
behaviors of the stage fixated in. This is best exemplified when a 5-year-old child’s
newly born sibling arrives home and the 5-year-old child demonstrates his anger at
being displaced by the newborn by a regression to earlier anal level defenses (e.g.,
soiling himself or withholding bowel movements) which had been mastered prior to
the arrival of the infant.
Freud proposed that when the anxieties of the Oedipus complex are resolved, the
person achieves the healthy psychological genital phase of normal heterosexuality
2.3 Freud and Classic Psychoanalytic Theories 19
Table 2.1 Sigmund Freud’s psychosexual stages

Oral Anal Phallic Genital
Age 0–18 months 19 months to 3 years 3–4 years 4–6 years
Erogenous zones Mouth, tongue, Anus, rectum, Genitals and Genitals
lips, skin abdomen urethra
Typical Sucking, licking, Bowel movements, Touching Loving
pleasurable chewing, and elimination, and genitals, toward
activities biting retention masturbation, parent of the
urination opposite sex
Developmental Needy or passive Feelings of Castration anxiety Oedipal
conflict omnipotence (boys) and
(terrible twos), Electra
sadism complex
(girls)
Conflict resolution Curiosity, Autonomy, Competence, Sexual
facilitated by exploration successful toilet identification with identity
psychotherapy training same-sex parent
(Freud 1924). According to Freud, pleasurable heterosexual intercourse was the

goal of his psychosexual theories: “the subordination of all the component sexual
instincts under the primacy of the genitals” (Freud 1905).
First Child in Psychoanalysis: Little Hans
Freud had encouraged his friends and colleagues to collect observations of the sex-
ual life in their children to help him develop his theory of infantile sexuality (Freud
1909). In 1909, Freud wrote his famous case “Little Hans,” which is considered the
first recorded psychoanalysis of a child. Little Hans’ father was a friend of Freud
and a supporter of his theories. Although Freud did not conduct the analysis on the
child, he helped Little Hans’ father conduct the analysis primarily through corre-
spondence, although they met several times and Freud gave the father suggestions
on how to approach the child.
Freud applied his psychoanalytic theories to the treatment of Little Hans, a
5-year-old boy who had developed a phobia to horses for fear that they would
bite him or hurt his father. At 3 years old, Little Hans became interested in who
in his family had or did not have a penis. By 3.5, his mother found him touching
his penis and threatened him with castration if he continued to touch it (1909).
Freud marked the mother’s castration threat as the episode that began Little
Hans’ neurosis. Soon after the episode, the child was moved out from his par-
ents’ bedroom, as his new sister arrived and was to take his place in the crib.
After being moved, Little Hans took a special interest in comparing his body
parts with his mother’s, his father’s, and animals’, wondering if they had a penis,
a “wee-widdler.” Little Hans’ father tells Freud about the dialogue Hans had with
his mother (1909):
While looking on intently at his mother undress, before going to bed:

“What are you staring like that for?” she asked.
Hans: “I was only looking to see if you’d got a widdler too.”
Mother: “Of course, Didn’t you know that?”
Hans: “No. I thought you were so big you’d have a widdler like a horse.”
Freud interprets the dialogue as representing the child’s Oedipus complex: fear
that the father will punish him for desiring to have his mother and acting aggres-
sively toward the father. Freud added that because Little Hans’ father was acting as
the analyst, he was a real rival impeding the progress of the treatment. Little Hans
continued to struggle with his phobia, and Freud requested that the child be brought
to see him. Freud writes of this encounter:
I asked Hans jokingly whether his horses wore eyeglasses, to which he replied that they did
not. I then asked him whether his father wore eyeglasses, to which, against all the evidence,
he once more said no. Finally I asked him whether by “the black round the mouth” he meant
a moustache; and I then disclosed to him that he was afraid of his father, precisely because
he was so fond of his mother. It must be, I told him, that he thought his father was angry
with him on that account; but this was not so, his father was fond of him in spite of it, and
he might admit everything to him without any fear. Long before he was in the world, I went
on, I had known that a little Hans would come who would be so fond of his mother that he
would be bound to feel afraid of his father because of it; … “Does the Professor talk to
God,” Hans asked his father on the way home, “as he can tell all that beforehand?” I should
be extraordinarily proud of this recognition out of the mouth of a child, if I had not myself
provoked it by my joking boastfulness. (1909)
Freud believed that the case of Little Hans confirmed his theory of infantile neu-
rosis described in his Three Essays on the Theory of Sexuality (1905) and remarked
that he had learned nothing from the case that he had not already deduced from his
analysis of adults.
We conclude with Freud’s comments regarding child psychoanalysis:
What? You have had small children in analysis? Children of less than six years? Can that be
done? And is it not most risky for the children? … It can be done very well. It is hardly to
be believed, what goes on in a child of four or five years old. Children are very active-
minded at that age; their early sexual period is also a period of intellectual flowering. I have
an impression that with the onset of the latency period they become mentally inhibited as
well, stupider. (1926)
A Two-Person Relational Psychology View: Little Hans
In the case of Little Hans, several points are worth reviewing from a two-person
relational perspective. First, we note that he had slept in his parents’ bedroom until
the age of 3, when his sister arrived. It appears that from an attachment theory per-
spective, he seemed to be openly loved and had a great deal of exposure to his par-
ent’s interactions, including morning dressing and evening undressing. From a
contextual perspective, we do not have knowledge as to whether it was typical for
children in Vienna during 1909 to sleep in the parental bedroom. We also note that
2.4 Freud’s Colleagues 21
Little Hans was a bright and verbal child who spoke often with his parents about his
excitements and worries. One can hypothesize that he had an easy/flexible tempera-
ment and a secure attachment style (see Chaps. 5 and 8), reflected by frequent open
dialogue with his parents and the trips he took to parks with his father. Finally, he
had good cognitive flexibility (Chap. 8) demonstrated in his rich abstract reasoning:
(1) He was aware of differences between female and male body parts, inquiring
whether women can have a penis, and (2) he wondered about the size of horses as
related to adult safety, fearing the horse could fall on top of his father. Herein, from
a two-person relational model, it appears that Little Hans’ worries were occurring
within the context of a normal developmental process of a child. Little Hans’ singu-
lar horse phobia may very well have been part of his healthy curiosity or clinically
a simple phobia. We do not know if there were any other symptoms, and it appeared
that he was adjusting quite well socially and academically. In fact, when Hans was
19 years old, he met with Freud and shared that after having read his case history,
he could not remember the discussions with his father and did not recognize the
events discussed in his case and shared that he was ostensibly doing well in life.
Considering that Little Hans may have been evaluated by a two-person relational
psychotherapist, the treatment of choice would rely on here-and-now interactions
between the patient and the active and present psychotherapist whose goal is to
provide the patient a new emotional experience (see Chap. 5). Certainly the use of
play would have been important to assess Little Hans’ capacity for social reciproc-
ity and influence of the psychotherapist in the cocreated intersubjective field. The
two-person relational psychotherapist relies on intersubjective experiences cocre-
ated in vivo, influenced by each person’s internal working models of attachment
developed during the first years of life and stored nonconsciously in nondeclarative
memory systems (see Chap. 3). Additionally, in light of his fear of his father being
hurt by a horse and his curiosity of whether others had a penis, it is reasonable that
work with his parents would have provided a better contextual understanding of the
complexities in the family system. The two-person relational approach is in contrast
to a traditional one-person model which understands the patient’s symptoms as
deriving primarily from conflicted internal experiences (e.g., fantasies, conflictual
life), and attention to the external factors for some may be seen as a dilution of the
psychoanalytic approach.
2.4 Freud’s Colleagues
While Freud is well known as the founding father of psychoanalysis, many of his
contemporaries and followers also contributed to the field. Here we will introduce
some of his most notable colleagues and protégés.
William Stekel (1868–1940)
William Stekel, one of Freud’s earliest followers, was once described as “Freud’s
most distinguished pupil” (Wittels 1924). Stekel was an adult psychoanalyst,
although he is recognized for being the first male psychoanalyst who worked psy-
choanalytically with children and adolescents. He claimed that parents and the envi-
ronment in which children were raised were crucial to the development of a child’s
psychological well-being (1931). Stekel believed that the psychoanalysis of chil-
dren and adolescents was different from the psychoanalysis of adults, as it had to be
adapted due to the child’s mobility and the importance in the use of play. According
to Stekel, the analysis of children was not difficult because their neurotic symptoms
disappeared more rapidly than in adults (Wittels 1924).
Stekel eventually dissented from Freud’s drive theory, which led to his expulsion
from Freud’s inner circle and his later ostracism. Stekel may have been an early
two-person relational psychoanalyst in that he believed that when the analyst took
an active role as a real person in the psychoanalytic process, it helped the patient
feel safe and understood (see Chap. 3).
Carl Gustav Jung (1875–1961)
Although Carl Jung did not analyze children, he treated children in psychoanalytic
psychotherapy as young as 6 years old and had an interest in the observation of
infants. He had frequent communications with Freud about children’s emotional
development and decided that women were best suited to practice child psycho-
analysis due to their natural feminine intuition. He went on to provide child psycho-
analytic courses to some of his female students who later became child psychoanalysts
(Geissmann and Geissmann 1998).
Hermine von Hug-Hellmuth (1871–1924)
Hermine von Hug-Hellmuth was the first woman to apply psychoanalysis to the
treatment of children. She was described as among Freud’s favorite students; her
writings remain unknown to many current child psychotherapists (MacLean 1986).
Although her work was limited to children over the age of 7, in 1912 Hug-Hellmuth
published her seminal paper, The Analysis of a Dream of a 5-Year Old Boy (Drell
1982). Hug-Hellmuth was loyal to Freud’s psychoanalytic theories and was a strong
advocate for the use of play in child psychoanalysis. She was an early proponent of
children’s play being equivalent to free associations in adults, the royal road to the
unconscious mind of children. She also believed that the goal of child psychoanalysis
closely resembled the psychoanalysis of adults and that the transference neurosis of
childhood was amenable to change through the interpretation of their symbolic play.
Hug-Hellmuth was a teacher before she became a psychoanalyst, which helped her
recognize the role parents had in their child’s neurosis and encouraged providing
education to them in order to prevent from further conflicts in their child. Plastow
(2011) states, “[Hug-Hellmuth’s] theory and practice heavily influenced the direc-
tions taken after her, in particular by Anna Freud and Melanie Klein, even if this
influence is essentially unacknowledged by these authors.”
2.5 Ego Psychology 23
Berta Bornstein (1899–1971)
Berta Bornstein was an educator of handicapped children in Berlin. At the age of

20, she began her psychoanalytic training in Vienna and began to work closely with
Anna Freud. She was the first child analyst to emphasize defense analysis in chil-
dren. She opposed the view that during latency instinctual conflicts were repressed
and was among the first to write about countertransference issues in child psycho-
analysis ((Bornstein 1949). She had a strong influence in the use of child psycho-
analysis in Berlin, Vienna, and New York. Bornstein was among the early Freudian
child psychoanalysts in the United States. In 1945, she wrote her seminal paper,
Clinical Notes on Child Analysis, in which she stated, “The id of the child and of the
adult are alike, but the ego of each is unlike (Bornstein 1945).” She was an active
teacher of child psychoanalysis at the New York Psychoanalytic Institute and the
Institute of the Philadelphia Association for Psychoanalysis.
2.5 Ego Psychology
Anna Freud (1895–1982)
Anna Freud’s interest in psychoanalysis was clearly influenced by her father,

although her interest in child psychoanalysis developed quite naturally as she had
trained as an elementary schoolteacher. This gave her firsthand experience with
children in all socioeconomic levels. She is best recognized for her book Normality
and Pathology in Childhood (1965), in which she describes the defenses available
to a child’s ego and linked their origin to the stages of psychosexual development,
introducing the concept of “developmental lines”—expectable pathways based on
subtle interactions of internal and external factors—which all children go through.
The concept of developmental lines is rooted in psychoanalytic thinking and is
based on observations of children’s behaviors to assess whether the child’s develop-
ment is progressing in a healthy or unhealthy fashion. Anna Freud states, “The
diagnostic profile which we have set up serves the systematic assessment of child-
hood disturbances by seeing the picture of any given child against the background
of a developmental norm into which the state of his inner agencies, his various func-
tions, conflicts, attitudes, and achievements have to be fitted. In our psychoanalytic
theory, such developmental sequences are laid down so far as certain circumscribed
parts of the child’s personality are concerned” (Freud 1937/1966). She further
states: “We assume that with all normally endowed, organically undamaged chil-
dren the lines of development indicated above are included in their constitution as
inherent possibilities. What endowment lays down for them on the side of the id are,
obviously, the maturational sequences in the development of the libido and aggres-
sion; on the side of the ego, less obviously and less well studied, certain innate
tendencies toward organization, defense, and structuralization” (Freud 1965).
Flashman (1996) reflects on the importance of the developmental lines for the
child analyst, saying, “provide precisely the framework necessary for distinguishing
as clearly as possible between the activity of the analysand and that of the analyst in
the ongoing development that is taking place simultaneously in the continuous pres-
ent and in the analysis.”
Anna Freud’s pioneering work in child psychoanalysis led her to be known
as one of the most influential people in the development of psychoanalytic
psychotherapy with children. Her treatment relied on the application of psycho-
analytic principles to the understanding of child’s psychopathology, with con-
siderable efforts in loosening the rigidity of analytic abstinence common in
adult analysis. Anna Freud believed that psychoanalytic treatment helped the
child overcome the internal conflicts caused by the pressures of the different
developmental psychosexual stages a child had to go through. She believed that
knowing how a child or adolescent psychologically navigates through psycho-
sexual developmental stages was best studied through the ego defense mecha-
nisms employed in coping with daily-life anxieties and threats to self-esteem
from intrapsychic conflicts. Although Sigmund Freud was the first to describe
such defense mechanisms, contemporary understanding of these processes
comes from Anna Freud, who systematically classified these defenses, compil-
ing a comprehensive catalog in her classic work, The Ego and the Mechanisms
of Defense (Freud 1937/1966). Anna Freud believed that the analysts should
also serve as educators to the parents to improve their insight about their contri-
bution to the child’s neurosis.
Even though Freud was loyal to her father’s theories and techniques in her work
with adults, particularly neutrality, she seemed to have had moments when she
stepped away from the rigidity of the technique and demonstrated genuine empathy
with her patients. Erik Erikson shared that during a period in his psychoanalysis, he
would let Anna Freud know about his worry regarding his wife’s pregnancy and the
impact of having a child. Erikson repeatedly expressed anger toward Freud because
she did not speak and kept knitting. When Erikson announced that he had a baby
boy, Freud gave him the blanket she had been knitting all along (Couch 1995).
Although we do not know the comments Freud may have made to Erikson, we sus-
pect that due to her work with mothers and infants, they likely were genuinely
congratulatory. In traditional one-person psychoanalytic teachings, this interaction
may have been described as a countertransference enactment, as the analyst grati-
fied the patient’s wish, contaminating the transference due to the fact the analyst
showed her “real self” to the patient. In two-person relational psychology, the open
expression of affective attunement is essential in cocreating more adaptive shared
experiences (see Chap. 3).
We are in agreement with Mayes and Cohen (1996) who described Freud as
a contemporary in the field of developmental psychopathology: “She created
a developmental psychoanalytic psychology that is remarkably current and
draws upon principles of neurobiology, genetics, pediatrics, and social psy-
chology.” Nevertheless, in spite of Freud’s wonderful theoretical contributions,
most of her clinical work remained in the traditional one-person model, giving
importance to the interpretation of the child ego defenses against intrapsychic
conflicts.
2.5 Ego Psychology 25
Heinz Hartman (1894–1970) Autonomous Ego Functions
Heinz Hartman, a psychiatrist and psychoanalyst who was often described as one of
Freud’s favorite students, became the leading Freudian theorist in the United States
during the 1940s and 1950s. He developed the school of American ego psychology.
Holding that the ego has a biological substrate that includes perception, memory,
concentration, motor coordination, and learning, he believed these innate ego
capacities had autonomy from the sexual and aggressive drives of the id and were
not products of frustration or conflict. Hartman coined the term “autonomous ego
functions” (Hartman 1958), and his ideas share much with recent concepts concern-
ing implicit memory systems and internal working schemas stored in nondeclara-
tive memory systems, which will be discussed in further detail in Chaps. 3 and 5.
Erik Erikson (1902–1994) Theory of Psychosocial Development
Erik Erikson, the analysand and student of Anna Freud, made important contribu-
tions to psychoanalytic theory regarding the creative processes from the ego and
proposed a theory of ego development. His theory encompassed eight developmen-
tal stages, from basic trust versus mistrust during infancy to integrity versus despair
in old age. Libidinal stages and psychosexual development are incorporated into his
epigenetic schema. Erikson also gave importance to the role play had in the psycho-
analysis of children. He approached children’s play in a similar fashion to that of
dreams in the psychoanalysis of adults. He believed that it was crucial to systemati-
cally interpret the meaning of play, although he recognized that perhaps play had a
cathartic effect in which the child was able to “play it out” (Erikson 1940). He, like
Anna Freud, noted the importance of the role a mother’s psychological state had on
the emotional growth of a child.
Two-Person Relational Psychology View: Ego Psychology
In a traditional one-person psychology model, the ego is the mediator of conflicts

between the id and the superego, and the psychotherapist helps the patient work
through the pressures from the id: “where id is, there shall ego be” (Freud
1916 – 1917). In contrast, in two-person relational psychology there is attention
given to that which occurs at a nonconscious and implicit level (see Chaps. 3, 4, 5,
6, 7, and 8). As such, the two-person relational model does not adhere to Freud’s
structural theory; it therefore does not consider the ego as a necessary concept,
which presupposes the need for an id and superego (see Chap. 6).
As a note, Anna Freud’s later writings reflect that she was aware of the work by
her student John Bowlby, regarding the infant’s innate wish for a relationship with
its caregiver and the development of internal working models based on these inter-
actions. Freud supported Bowlby’s ideas and believed that for the development of
the infant, early contact with their mother was essential. She observed that
depressive moods of the mother during the first 2 years after birth could lead to
depression in the child. Thus, we believe Freud intuitively set the stage for the con-
temporary clinician, contributions from attachment theory and developmental
research is a major contributor to a move toward a two-person relational
perspective.
2.6 Object Relations Theory
Melanie Klein (1882–1960)
From the 1940s to the 1960s, many psychoanalytic theorists increasingly recog-
nized the importance of the child’s early interactions with primary caregivers and
how these developmental experiences were crucial to the formation of the child’s
ego functions. As a result, in the 1940s, a natural transition from ego psychology to
object relations theory evolved. Melanie Klein was analyzed by Ferenczi (Chap. 3),
who may have influenced her theories due to his work with children. Klein, a stu-
dent of Sigmund Freud, is thought to be the first object relations theorist. Klein
noted that internalized “objects” were at the center of a person’s emotional life
(Klein 1932). “Object relations” refers to the capacity to have stable and rewarding
relationships based on the internalization of the early childhood representations of
others in the form of “objects.” However, internalization of the early childhood
objects is not a mere imitation of their attributes; rather, what is internalized is that
which is filtered by the child’s desires, wishes, and needs (Delgado and Songer
2009). That is, the internalized objects are attributed an individualized significance
which may resemble the real person object, although it is not always the case. Klein
posits that the infant, as part of a normative developmental phase, from birth to
4 months old, possesses a primitive fear. She refers to this period as being in the
paranoid position, in which internalized representations of caregivers are experi-
enced as part objects that are split into “good” and “bad” objects (e.g., the loving,
nurturing mother and the depriving mother). For example, a child with an innate
tendency to have primitive anxieties may internalize an emotionally available parent
as depriving and critical and may resist the parents attempt to comfort and contain
the child’s anxieties. In the early stages, the child maintains the self and object split
to avoid the distress in recognizing that there are aggressive and depriving aspects
of the self as well as of the other. Then, from 4 to 12 months old, the child learns to
integrate and tolerate the idea that a person has both “good” and “bad” parts and
enters a phase that Klein describes as the healthy depressive position (Klein 1932).
Having psychologically achieved the depressive position, the child proceeds to
develop a capacity of concern for others and guilt about one’s actions and thoughts
about others, with desire for reparation (Winnicott 1965). Klein believed that indi-
viduals who are unable to work through the depressive position in their childhood
continue to struggle to relate to others in adult life.
In her psychoanalytic work with children, Klein’s interpretations were made
early in the treatment and were described by Kleinian analysts as being “deep,” with
2.6 Object Relations Theory 27
the aim of containing the primitive feelings of hate and destructiveness projected
unconsciously onto the analyst from unresolved conflicts in the paranoid position.
The goal of the psychoanalytic treatment was to help the child achieve the depres-
sive position with the integration of hate and love, a more integrated state of mind.
Klein’s interventions were aimed at working through the early intrapsychic conflicts
and anxieties that prevented the child from the use of stable ego functions.
Klein emphasized that through play, the child expressed their unconscious sexual
and aggressive fantasies toward split objects. She considered play as equivalent to
the free associations of the adult patient. Klein believed that the transference neuro-
sis could occur in children as young as 2.5 years old, as they were in the early stages
of the formation of superego and the Oedipus complex at this age. Klein believed
that the oedipal conflict developed during the oral phase, when the struggle for the
possession of the libidinal object—mother or father—was taking place.
Klein, like Hug-Hellmuth, provided children with toys, houses, animal figures,
and cars, which she believed allowed for the representation of people that existed in
the child’s life. Klein was attentive to the fantasies of birth, the primal scene, and of
aggressive wishes for destruction. Klein departed from Anna Freud’s belief that the
parents needed to be educated on how to support their child during the psychoanaly-
sis. Klein felt that this was not necessary and, in fact, felt that working with parents
would interfere with the treatment.
Donald Winnicott (1896–1971)
In Donald Winnicott’s The Capacity to Be Alone, the British pediatrician and psy-
choanalyst introduced the concept that to be alone is not the same as to be lonely
(Winnicott 1958). Rather, the capacity to be alone is the foundation for a sense of the
self with growth-promoting introspective thought, imagination, and creativity. The
capacity to be alone, he further noted, is a prerequisite for true intimacy, which is the
ability to share openly and fully with another human being while maintaining a sense
of oneself as separate from the other and not wholly dependent upon them. Winnicott’s
psychosocial view was that the family and society were crucial as instinctual energy
in psychosexual, emotional, and social development. He did not entirely abandon
drive theory, and his theories were built on Freudian one-person foundations
(Winnicott 1971). Winnicott is also known for the concept of “containment and hold-
ing,” which is similar to Wilfred Bion’s concept of “container and contained,” (Ferro
2005) which had a profound influence in object relations psychoanalytic theory.
An 8-year-old boy needs a holding environment

To the psychotherapist’s surprise, an 8-year-old child demanded that his
mother bring him to his psychotherapy appointment even though he had been
feeling tired and likely had a cold. He entered the session and promptly laid
on the couch and said, “I don’t know why, but I really feel better being sick
here. You know my feelings better than my parents.” He proceeded to sleep

for 10 min, and after waking he felt somewhat better and was able to resume
his play in the session. It was as if the boy had read Winnicott’s paper The
Capacity to be Alone (1958) and conveyed: “I can be alone in your presence.
I feel safe and emotionally held by you at a preverbal level.”
Another important contribution to the work with children was Winnicott’s (1953)
description of the first not-me possession by the infant, a “transitional object.” This
allowed the child to transition from the first oral relationship with the mother’s
breast to a true object relationship. The transitional objects were typically in the
form of a blanket, a doll, or a stuffed animal. He stated, “They are tangible—can be
held onto, grasped, hugged. They lessen the stress of separation and soothe the
infant,” adding, “the transitional object may therefore stand for the ‘external’ breast,
but indirectly, through standing for an ‘internal’ breast.” He further described “tran-
sitional phenomena,” which were behaviors that served the same function as the
transitional object (see Chap. 6). Winnicott (1953) identifies himself as an object
relations theorist in his statement, “I have introduced the terms ‘transitional object’
and ‘transitional phenomena’ for designation of the intermediate area of experience,
between the thumb and the teddy bear, between the oral erotism and true object-
relationship, between primary creative activity and projection of what has already
been introjected, between primary unawareness of indebtedness and the acknowl-
edgement of indebtedness (‘Say: ta!’).”
Margaret Mahler (1897–1985)
Margaret Mahler was a psychoanalyst interested in the research of the infant–mother

dyad in young disturbed children. Her research took place during the 1960s, and she
is known for the seminal book The Psychological Birth of the Human Infant (Mahler
et al. 1975). Her team designed research models that allowed for the observations of
the interactions between toddlers and their mothers and the impact of early separa-
tions of children from their mothers. Mahler’s work continues to be important in
traditional one-person psychoanalytic theory, as it gives importance to pre-oedipal
and early childhood attachments in the form of rapprochement and separation–indi-
viduation as intrapsychic processes, although the concepts are commonly thought to
represent behavioral constructs.
Mahler’s groundbreaking theory of separation–individuation was her most
important contribution to the development of psychoanalysis. She described the
separation–individuation process as occurring between 4 and 36 months old in dis-
tinct subphases: practicing and rapprochement. The terms “practicing” and “rap-
prochement” continue to be used in the psychodynamic formulations of children
with psychological problems and are also used in the description of important pro-
ductive moments during the course of psychotherapy.
2.6 Object Relations Theory 29
Mahler’s contributions, along with Winnicott’s, emphasized the importance of

the infant being held physically and psychologically by the caregiver. Mahler and
Winnicott lived in a period during which infant research was strongly influenced by
object relations theory. Thus, their work received similar reaction to that of the work
by Bowlby, and the mainstream psychoanalytic community did not believe that the
observations of interactions between mother and infant captured the inner life of the
child’s internalized object representations and the fantasies that ensued.
Peter Blos (1904–1997) The Second Individuation Process

of Adolescence
Peter Blos is recognized for his psychoanalytic developmental theory of adoles-

cence. Blos described four preconditions for the adolescent character formation: (1)
the processing of residual trauma from childhood experiences, (2) the development
of sexual identity, (3) the resolution of negative oedipal complex, and (4) the second
individuation process (Blos 1968). His most recognized contribution was the con-
cept of “the second individuation process of adolescence” (Blos 1967), based on
Mahler’s original separation–individuation phase of the infant (Mahler et al. 1975).
The second individuation process is characterized as a phase in which the adoles-
cent psychologically negotiates how to separate from the unconscious reawakening
pressures of the internalized representations of the parents from childhood, due to
the fear of loss of their support. Upon completing this process, the object relations
of the adolescent become stable, with clear boundaries, and the adolescent becomes
more “resistant to cathectic shifts” (Blos 1968). Moreover, Blos believed that
the adolescent’s breakup with internalized objects made possible the quest for
“extrafamilial love” (Blos 1967). It should be noted that not all theorists agreed with
Blos’ view of adolescent psychological development; some argued that individua-
tion occurs during childhood and that a second phase is not needed (Schafer 1973).
Personality Disorders in Children and Adolescents
Paulina Kernberg (1935–2006)

Paulina Kernberg, a child psychiatrist and psychoanalyst known for her work with
children and adolescents with character pathology, believed that the diagnosis of bor-
derline personality in adolescents should be considered from descriptive, structural,
and dynamic points of view (Terr and Kernberg 1990). She stated, “If we were to have
no concept of childhood personality and personality disorder, child psychopathology
would simply be a listing of symptoms and behaviors without an overall framework of
interrelated symptoms and personality traits; we would have an accumulation of bricks
without any mortar” (Kernberg 1990). Moreover, she emphasized that the main criteria
for personality disorders in children was the presence of primitive defenses such as
splitting, denial, omnipotence, and projective identification, with lapses in reality test-
ing. She believed that psychodynamic psychotherapy could help adolescents if it
helped achieve the resolution of aggressive and interpersonal skills deficits. The sui-
cidal behavior was the main goal to be addressed within the relationship to the psycho-
therapist (Kernberg 1983, 1989). She also posited that narcissistic character pathology
can exist in childhood and that family dynamics contributed. Further, Kernberg believed
that narcissistic pathology in children reflected a pathological formation of the self,
used for defensive purposes. She cautioned on the unique countertransference dilem-
mas in treating children with character pathology. She is also recognized for her contri-
bution to the Practice Parameter for Psychodynamic Psychotherapy with Children:
American Academy of Child and Adolescent Psychiatry (Kernberg et al. 2012).
Efrain Bleiberg (1951–)

Efrain Bleiberg a child psychiatrist and child psychoanalyst supported Kernberg’s
contention that children with personality disorders exhibited distinctive patterns
relating to and thinking about others and themselves, including traits such as ego-
centricity and inhibition (Bleiberg 1994, 2004). Kernberg added that these patterns
endured across time and warranted the designation of a personality disorder,
regardless of age. Bleiberg also stated, “Borderline youngsters require a constant
stream of emotional ‘supplies’—someone’s love and attention, sex, drugs, or
food—to protect them against overwhelming feelings of dyscontrol, hyperarousal,
and aloneness” (1994).
A case from a traditional one-person object relations perspective

Cory was a Taiwanese 8-year-old girl adopted as an infant by a Caucasian
family from the Midwest. When there were threats of separation from her
adoptive mother, they would trigger a disruption in her contact with reality, as
well as rage outbursts, both at home and in school. She had created a fantasy
about her biological mother being an Asian princess. At times she seemed to
believe the fantasy was real and would lash out when people failed to recog-
nize her entitlement to royal prerogatives. In her dreams and play, the princess
was replaced by a witch, whose appearance combined Asian and Caucasian
features. This witch would mistreat her, and her only choice was to strangle
the witch (Bleiberg 1994).
Bleiberg (1994) masterfully described Cory’s problems from an object relations

perspective: “Cory’s attempt to produce a perfect, magical union, while keeping
safely apart the dangerous, rageful, and frustrating aspects of herself and others,
often fell apart in the face of separation or the threat of loss of control. The collapse
of such fantasied scenarios is one of the triggers of self-mutilation and suicidal ges-
tures.” He added, “The psychological landscape of these youngsters can sometimes
be glimpsed only through the lens of psychological testing.” Cory’s psychological
testing revealed rigid and primitive defenses: egocentric and arbitrary interpretation
of reality, with disturbances in ego functions, unmodulated experience of affects
and drives, and marked disturbances in the experiences of self and others.
2.7 Self-Psychology 31
Two-Person Relational Psychology View: Object Relations
In Bleiberg’s description of Cory, a two-person relational clinician would consider

that the behavior and emotional reactions are typically seen in children 4–6 years
old, according to developmental milestone norms (see Appendix A). Thus, there
may be innate deficits in cognition that interfere with Cory understanding the expe-
riences with others as they are influenced by poor and maladaptive self-regulatory
schemas based on cognitive misperceptions of his environment. That is, an infant’s
innate forms of temperament and cognition serve as the foundation for internal
working models of attachment to develop and allow cocreating experiences of the
self with others. As such, object relations in a two-person relational model occur at
an implicit level in the form of a complex nonconscious meaning-making process
stored in nondeclarative memory (Chap. 3) and not the result of Freud’s instinctual
drives or Klein’s objects. Concepts such as introjection, projection, projective iden-
tification, and splitting are in the traditional one-person psychology domain, as they
do not account for the psychotherapist’s intersubjectivity when relating with the
patient (see Chap. 6). In the work with Cory, the two-person relational psychothera-
pist would consider making use of here-and-now experiences to improve her per-
ception of his reality. Due to Cory’s likely cognitive limitations, active work with
her family in developing a realistic behavioral plan at home and school would be
imperative.
2.7 Self-Psychology
Heinz Kohut (1913–1981)
Like Freud, the American psychoanalyst Heinz Kohut based his theory of self-
psychology on inferences made during the treatment of adult patients. He hypothe-
sized that narcissistic disorders of the self were due to childhood parental empathic
failures (Kohut 1971). Kohut believed that treating disorders of the self, required a
therapeutic empathic reparation by the analyst of the patient’s maladaptive func-
tions (e.g., idealizing, mirroring, and twinship “self-object”).
Anna Ornstein (1927–)
Anna Ornstein, a child psychiatrist and psychoanalyst, is a prolific writer with

regard to the self–selfobject unit needed to provide an empathically responsive envi-
ronment for the child. She stated: “Kohut’s discovery of selfobject transferences
alerted child therapists to those parental functions which, became of their silent
presence, by and large, have been taken for granted. With these discoveries, we are
now in a position to recognize those clinical conditions in children that are the con-
sequences of the absence or partial failure of certain specific parental responses to
the child’s ordinary narcissistic developmental needs for affirmation, validation,
and a feeling of merger with the omnipotence and power of the parent” (1981).
Ornstein believed that deficits in specific areas of parenting were the reason for the
child’s psychopathology (Ornstein and Ornstein 2005).
Ornstein proposed child-centered family treatment as “a method of treatment in
which the depth-psychological understanding of the child is not sacrificed but in
which the insights that the therapist gains into the inner world of the child (some-
times through play and sometimes through a therapeutic dialogue) are ‘translated’
to the parents.” The psychotherapist would encourage the parents to foster empathic
and therapeutic interactions in their home to the help the child regulate fears, wishes,
and anxieties, rather than the manifest behavior (1984).
In Ornstein’s (1981) paper, she presented clinical vignettes “from the three rep-
resentative age groups in childhood: preschool, latency, and adolescence.” The
vignettes demonstrated her view of the theory of the self, which unfolds within its
psychological (self-object) environment. She emphasized that this provides the
child psychotherapist with a theoretical framework that facilitates the understanding
of the psychological conditions in an in-depth manner rather than on a descriptive
level. She added that problems of the development of the self cannot be categorized
as either neurotic or psychotic conditions and that parental empathy is “the sine qua
non of the execution of parental self-object functions.” The remobilization of these
functions in the treatment will help the parents to become empathic toward the
symptomatic child.
In one such vignette, Ornstein (1981) described the case of a 7-year-old boy who
was to be expelled from school unless his mother agreed to seek treatment for him.
He had uncontrollable behaviors at school, which included threatening teachers and
peers with pencils. The mother had divorced the boy’s father when the boy was
2 years old and had remarried. In psychotherapy, the boy approached the play ses-
sion with caution and would not elaborate on his fantasies. On one occasion, the
psychotherapist had promised to keep the child’s papier-mâché snake safe. When
the boy returned the following day, he did not find his snake and became irritable
and destroyed the things he made in prior sessions, insisting there was nothing good
about them. The psychotherapist told the child that the snake had disappeared and
probably had been destroyed by a careless janitor. She proceeded to interpret that
the child’s anger at her was due to her failure in protecting what they had made
together. Further, she told the mother that her son’s provocative behaviors uncon-
sciously served to protect him from recognizing that he wished other people would
demonstrate that they cared about him.
Ornstein made use of both self-psychology and object relations theory to
understand the boy’s reaction to the lost snake. In using self-psychology, the
psychotherapist serves as the boy’s self-object, mirroring and providing reassur-
ance that he is valued in spite of her losing his snake. In contrast, in using object
relations theory, the psychotherapist views herself, in the transference, as repre-
senting the child’s internalized depriving bad object representations, depriving
him from comfort and empathy when distressed by the loss of his transitional
object.
2.8 Summary 33
Two-Person Relational Psychology View: Self-Psychology
Many of the school of self-psychology describe themselves as being aligned with

both traditional one-person psychology and two-person relational psychology.
However, as Fosshage (2003) notes, “In my view, both self-psychology and rela-
tional psychoanalysis are at their best in addressing different domains of relational
experience, each offering important understandings and guidelines for facilitative
responses.” Although Fosshage attempts to highlight the similarities, he minimizes
the differences not only in theory but also in technique.
In the case of the 7-year-old boy described by Ornstein, from a two-person rela-
tional perspective, the lack of ownership by the psychotherapist for the loss of the
boy’s snake is troublesome. This implicitly conveys a sense that the psychotherapist
is not responsible for the hurtful feelings the child is experiencing. The loss of the
snake was real. For a two-person relational psychotherapist, this moment provides
an opportunity to model to the child how to apologize for failures: not being able to
protect his snake. Additionally, the psychotherapist can provide a corrective emo-
tional experience in asking the child to forgive the psychotherapist for being care-
less and would appreciate if they could together cocreate a new snake. This could be
followed by a discussion on how to best protect the new snake. In the current era of
readily available smartphones or tablets to take photographs, a two-person rela-
tional psychotherapist may consider asking the child’s mother to use such a device
to take a picture of the snake, providing a retrievable here-and-now experience
between the child and psychotherapist at a later time, if needed. These are a few of
the many possibilities that may have been pursued between patient and psycho-
therapist to provide a corrective emotional experience (see Chaps. 3, 5, and 11).
Stolorow (1994) captures the differences between self-psychology and two-
person relational models as such: “How does the concept of an intersubjective field
differ from the concept of a self–self-object relationship? An intersubjective field is
a system of reciprocal mutual influence. Not only does the patient turn to the analyst
for self-object experiences, but the analyst also turns to the patient for such experi-
ences, and a parallel statement can be made about the child-caregiver system as
well…. More important, subjective world is a construct that covers more experien-
tial territory than self.”
2.8 Summary
In this chapter we provide the reader with a critical foundation in the field of child
and adolescent psychoanalysis and psychodynamic psychotherapy, which has radi-
cally changed over the past 50 years, anchoring the remainder of this book in a two-
person relational psychology model. We openly note that we do not intend to
provide the reader with a complete review of all the contributors to child psycho-
analysis and psychotherapy; rather, we limit our review to those that became pillars
of the traditional one-person psychology model and how their contributions
influence the transition to a two-person relational psychology for the current child
and adolescent psychiatrist and psychotherapist.
In this chapter, we define the concept of traditional one-person psychology as the
psychodynamic clinical model in which the analyst’s or psychotherapist’s task is to
discover the patient’s unconscious conflicts that have held them back from having a
successful and happy life. The one-person psychology model relies on the patient
to transfer early, unresolved introjected wishes and feelings about their parents
or caregivers onto the analyst or psychotherapist. Therefore, in a traditional one-
person model, transference is considered a critical element for psychotherapeutic
change to occur. Traditional one-person psychology over the years collectively
became what Pine (1988) described as psychoanalytic pluralism. Pine deftly states
“Psychoanalysis has produced what I shall refer to as ‘four psychologies’—the psy-
chologies of drive, ego, object relations, and self. Each takes a somewhat different
perspective on human psychological functioning, emphasizing somewhat different
phenomena.” We proceeded to describe the influence each of the four psychologies
in a traditional one-person model: drive, ego, object relations, and self, in the con-
text of their contributions to child psychoanalysis and child psychodynamic psycho-
therapy which was firmly grounded on the principle tenets of adult psychoanalysis.
The goals of treatment were the inquiry and the uncovering of the child’s inner
conflicts that created maladaptive patterns that led to a developmental interference
in their emotional growth and the working through of their conflicts in order to
achieve a healthier state. Further, we provide the reader a two-person relational view
of each of the four psychologies, setting the stage for the remainder of this book,
solidly anchored in a two-person relational psychology model.
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Two-Person Relational Psychology
for the Child and Adolescent Relational 3
Psychotherapist
There is no such thing as an analysand apart from the relationship with the analyst and no such
thing as an analyst apart from the relationship with the analysand.
—Thomas Ogden
Attachment theory and infant developmental research have confirmed the ubiquitous
nature of the innate bidirectional mode of communication that exists in everyday
human interactions. From birth, the infant learns to make meaning of the experi-
ences with its caregivers in order to develop internal working models of attachment
that reflect implicit patterns of stable or unstable mental representations of self and
others. When the internal working models of attachment are created in a secure and
stable manner, it allows the child to understand and predict the intent of others in
their environment, and it implicitly becomes a survival-promoting tool allowing for
proximity with others, establishing a psychological sense of “felt” security
(Bretherton 1985; Sroufe and Waters 1977). Further research has provided a better
understanding of how cognitive and memory systems shape a person’s experiences
when interacting with others in what are called moments of intersubjectivity—the
dynamic interplay between two people’s subjective experiences (Chap. 5).
Intersubjective experiences allow for “being with” and “getting” another person’s
state of mind and their intentions. It is this dynamic interplay of subjectivity that,
when things go well, leads to adaptive models of relating with others. These models
are stored in nonconscious and nondeclarative memory systems in what is known as
“implicit relational knowing,” which begins to be represented before the availability
of language (Lyons-Ruth et al. 1998). Intersubjectivity promotes a cohesive and
more flexible way of reflective abilities to know what works for healthy social reci-
procity with implicit aspects of morality. Rustin and Sekaer (2004) aptly observe:
“Experience, in an average expectable environment, enables genetic programs to
unfold and puts the fine tuning on the genetic framework. From this new perspective
the brain itself is relationally constructed.”

DOI 10.1007/978-3-642-40520-4_3
38 3 Two-Person Relational Psychology for the Child and Adolescent
Thus, the advances from attachment theory, infant developmental research, and
intersubjectivity have helped recognize that problematic and unstable early attach-
ment experiences have a role in the development of mental health problems in chil-
dren and adolescents. As a natural result, two-person relational psychology emerged
as a theory of the mind that provided a path for the application of concepts derived
from attachment theory, infant developmental research, and neurosciences in the
practice of psychodynamic psychotherapy. As such, the notion of a two-person rela-
tional model of psychodynamic psychotherapy shook the foundations of traditional
one-person psychoanalytic theory. Holmes (2000) suggests that attachment theory’s
“most significant contribution to contemporary psychoanalysis could be to help it
accept the death of its founder…. Bowlby can help us let Freud go.” We suggest not
letting Freud go, but rather acknowledging the important role he had in how two-
person relational psychology evolved from the traditional one-person theories.
In two-person relational psychology, the psychotherapist takes an active role to
first become an ally to the patient’s subjectivity and implicit relational knowing
during the session. As Adler-Tapia (2012) states, “Psychotherapy needs to account
for the significant contribution of early attachment to mental health and behavioral
issues.” That is, the intersubjective experience becomes a construct of the patient
and psychotherapist’s personalities—temperament, cognition, cognitive flexibility,
and internal working models of attachment—brought into the context of a here-and-
now therapeutic relationship. It is through this bidirectional process that allows the
patient to implicitly, over time, become an ally to the psychotherapist’s healthier
and more adaptive way of interacting with others. In essence, the psychotherapist
provides a new emotional experience for the patient, which is stored in the patient’s
nondeclarative memory at an implicit level.
In this chapter, we provide a review of the trajectory of two-person relational
psychology to give the reader an in-depth understanding of the importance and
applicability it has to the clinical work with children and adolescents in
psychodynamic psychotherapy.
3.1 Two-Person Relational Psychology
Making the Case for a New Paradigm
Over the last 30 years, with the emergence of a two-person relational psychology,
there has been a significant shift in the understanding of a person’s psychological
problems, from intrapsychic and object relations conflicts to problems of tempera-
ment, cognition, affective attunement, cognitive flexibility, and intersubjectivity (the
complex interactions of the self, influenced by other persons, detailed in Chap. 5).
This shift has led to psychotherapeutic interventions that are significantly different
than those of a traditional one-person model—the archaeological discovery of an
unconscious conflicted buried past. A two-person relational model relies on open
bidirectional, here-and-now subjectivities that are continually modified by the real-
ity of both persons—intersubjectivity. As expected the notion of a two-person,
3.1 Two-Person Relational Psychology 39
relationally-based psychodynamic model of psychotherapy was not received well

by all clinicians in the traditional one-person psychoanalytic circles, as it challenged
the legitimacy of its tenets. Friedman (2010) reflects, “The chasm dividing classical
and relational approaches is both wider and deeper than is acknowledged by psycho-
analysts who attempt to either reconcile or minimize the differences between them.”
The two-person relational model has gradually become a concept that most psy-
chodynamic psychotherapists must contend with. Spezzano (1993, 1996) suggests
that “the phrase two-person psychology has become shorthand for our recognition
that a new paradigm has taken a firm foothold in American psychoanalysis.” This
method is widely spoken about in clinical circles, and many clinicians have found
the freedom of being “authentic and real” with the patient as liberating from the
traditional one-person approach. Two-person relational psychotherapy, in one form
or another, is now practiced by a majority of mental health practitioners (Norcross
et al. 2002). The two-person relational model has served as an umbrella for several
forms of psychotherapies that endorse enactments and self-disclosures that fre-
quently occur unknowingly, although at times can be well timed —mindfulness,
dialectic, cognitive, patient centered, etc. Further, in the two-person relational
model, the psychotherapist as an authentic and real person may implicitly disclose
aspects of him or herself without quite knowing what has been revealed.
In spite of the appeal of the two-person relational model, we have had colleagues
who over the years have outwardly moved toward a contemporary two-person
relational approach in their clinical work, although in reality they continue to be
loyal to traditional one-person theory concepts and technique principles (Chaps.
2 and 6). They cautiously share that they do not want to throw out the baby—
traditional one-person psychoanalytic concepts—with the bathwater, traditional
one-person psychoanalytic technique. We find an example of this dilemma in our
colleague and friend, Andrew Gerber, illustrated in his commentary Neurobiology
of Psychotherapy – State of the Art and Future Directions (Gerber 2012) in the out-
standing book Psychodynamic Psychotherapy Research: Evidence-Based Practice
and Practice-Based Research (Levy et al. 2012). Gerber is of the opinion that the
intersection of neurobiological research and psychoanalysis “is fertile and grow-
ing…. That would have delighted Sigmund Freud.” He proposes four unifying prin-
ciples. In the first, he suggests that the description of psychopathology lies in a
set of continuous trait and state variables representing the content and structure
of an individual’s mental life. In the second principle, Gerber asks for a concil-
iatory stance, inviting the traditional one-person model clinicians to make mend
with their own struggles in accepting that “the origins of most psychopathology
are understood best as an interaction between inherited/genetic factors that lead
to psychological traits, strengths, and vulnerabilities on the one hand and envi-
ronmental factors, particularly experience, on the other” (italics ours). As such,
two-person relational psychologies always include two “one persons.” His third
principle emphasizes that psychological processes are best understood as a com-
bination of cognitive, affective, and social categories. Finally, in his forth unifying
principle, he seems to plea to the traditional one-person psychoanalytic community
to accept their limitations: “The mechanism(s) of action in psychotherapies of all
kinds, including psychoanalysis and psychodynamic psychotherapy, overlap more

than current clinical theories describe, thus beginning to explain the widespread
finding that there are multiple effective ways to treat psychiatric illness with talk
therapy” (italics ours). Gerber is implicitly moving the psychoanalytic movement
toward a more integrative process—“we now have the opportunity to integrate mul-
tiple perspectives in our theory and research”—in line with two-person relational
psychology, and concludes with “It is the task of psychotherapy to help the patient
find a set of narratives that are most useful for him or her. In psychodynamic think-
ing, this is often described as ‘co-construction,’ whereas in cognitive therapy, it may
be thought of as ‘cognitive restructuring.’”
Although we mostly agree with Gerber’s principles and efforts for further dialogue
among the divergent forms of psychotherapy, we caution his efforts toward an overly
conciliatory stance with traditional one-person psychology clinicians as it attenuates
the differences. The traditional one-person clinician believes that psychotherapy is
effective when the inner conflicts of the child or adolescent are discovered and under-
stood: through recognition of maladaptive ego defenses, the presence of transference
manifestations (i.e., remembering and repeating), or by discovering object relations
conflicts, which are amenable for being worked through by verbal insight-oriented
suggestions or interpretations. Although the two-person relational psychology has
built on the traditional one-person model, it has evolved to an approach that relies on
the nonverbal, implicit cocreation of new experiences in the form of enactments and
self-disclosures that frequently occur unknowingly, although at times can be well
timed, to move along the psychotherapeutic relationship. The result of this is provid-
ing new and healthier nonconscious relational neuronal pathways in the here and now
with the active and genuine psychotherapist—corrective emotional experiences—
and later implicitly used when interacting with others (Fig. 3.1). Gaines (2003) sug-
gests promoting new, more adaptive relational experiences, saying the “thoughtful
use of therapist self-disclosure is an important tool for child and adolescent.” In two-
person relational psychology, the terms “cocreate” and “intersubjectivity” are sine
qua nons to the theory and technique. They reflect the active participation by both
patient and psychotherapist in the encounter, with continuous and novel moment-to-
moment changes due to each other’s subjective experiences.
Altman (1994) masterfully captures the differences between the two models: “As
I argue, child psychoanalysts of all schools has been moving in the direction of a
relational, two-person or multiperson psychoanalytic model in response to the dif-
ficulties encountered in work with children on a drive theoretical basis. However,
child analysts have done so while avoiding a clean break with drive theory. The
result has often been a collage of one-person and two-person elements, which
results in an internally inconsistent theoretical model with confusing implications
for psychoanalytic technique. Specifically, a drive-based, one-person model directs
attention away from the impact of the here-and-now interaction on patients.” As
Hoffman (1994) states, “there is a feeling of ‘throwing away the book.’” We believe
that is better stated as “let’s not forget that the original (one-person) book also has a
second (two-person) part.” The mechanisms of therapeutic action may be different,
but they still rely on an interaction of one and two person factors.
3.2 Historical Background of Two-Person Relational Psychology in Adults 41
New Emotional Experiences
IF
Child/Adolescent Psychotherapist
• Meaning making (++) • Affective attunement (+++)
• Mirror/echo neurons/ Internal working • Emotional availability (+++)
default mode network models • Social referencing (+++)
• Social referencing (+++) of attachment • Temperament (easy/flexible)
• Temperament • Cognition
• Cognition • Cognitive flexibility (+++)
• Cognitive flexibility
Co-create now moments Ruptures (Non-declarative)

Implicit relational knowing
New more adaptive emotional
experiences
Co-created moments
Repairs
of meeting
Fig. 3.1 Schematic representation of two-person relational psychotherapy representing the psy-
chotherapist and patient. New emotional experiences occur in the intersubjective field (IF), the
overlap of subjective experiences. Number of (+) denotes degree of strength in this dyad
In Chap. 6, “Deconstruction of Traditional One-Person Psychology Concepts,” we

take a bold approach that we believe is much needed but cautiously avoided by most.
In that chapter, we discuss in detail the steadfast terms from traditional one-person
psychologies, followed by their deconstruction when viewed through the lens of a two-
person relational psychology. We then further clarify the reasons why these everyday
traditional one-person concepts have transformed to terms that attend to discoveries
from developmental research, neuroscience, attachment, and temperamental theories
to the clinical work of a contemporary two-person relational psychotherapist.

Psychology in Adults
The origin of two-person relational psychology in adults dates back to the 1900s in
Europe by Sigmund Freud’s dissenting colleagues and students. It is mostly believed that
two-person relational psychology took hold in the United States during the last 30 years.
Herein, we will briefly provide the reader with the historical evolution of the emergence
of the two-person relational psychology model in the landscape of the adult psychothera-
pist, followed by the subsequent influence for the child and adolescent psychotherapist.
Freud’s Dissenting Colleagues
Freud began with a small and closed group of colleagues loyal to his psychoanalytic
theories and formed the Wednesday Psychological Society, which later became the
Vienna Psychoanalytic Society. Among some of its members were Wilhelm Stekel,
Paul Federn, Alfred Adler, Otto Rank, Sándor Ferenczi, Ian Suttie, Karl Abraham,
and Carl Jung. Over time, conflicts aroused, and Adler, Jung, and Rank broke away
from Freud’s drive theories and formed their own societies. This was followed by
the departure of Ferenczi, Stekel, and Suttie, who introduced the idea that the ana-
lyst needed to be a real and active participant in the process in order to help the
patient feel understood. Though their progressive ideas had the potential of extend-
ing the psychoanalytic movement to greater scientific inquiry, they instead were
ostracized from prominent psychoanalytic circles for questioning Freud’s psycho-
analytic theories and advocating changing neutrality to an empathic bidirectional
relationship that allowed for gratifying the patient’s wishes in certain situations. The
early dissenters provided the seeds needed to give birth to what later became two-
person relational psychology.
Sándor Ferenczi (1873–1933)

Sándor Ferenczi was considered the heir to Freud’s Psychoanalytic Society (Fig. 3.2).
He later became critical of Freud’s authoritarian and patriarchal stance, as well as his
centerpiece of psychoanalytic technique, neutrality. Ferenczi encouraged a certain
degree of flexibility and emotional availability of the analyst with the patient and
encouraged the gratification of certain wishes in the form of empathy. In retrospect,
it is clear that Ferenczi had set the stage for two-person relational psychoanalytic
psychology to emerge. In Berman’s (1999) masterful review of Ferenczi legacy, he
states, “He was ahead of his time, and our generation finds him more understandable
than his own.” Soon after, others in Freud’s circle openly agreed with Ferenczi’s
view, the importance of the analyst as a real person and not as transference object,
now considered the sine qua non in two-person relational psychology. Most of the
dissenters from that period were strongly influenced by the work of Ferenczi, who
pioneered the analyst’s authenticity, emphasizing the mutuality of the relationship
between psychoanalyst and patient (Aron and Harris 1993). Both Ferenczi and Rank
believed that therapeutic change occurred when the analyst provided supportive
experiences rather than only by the interpretation of the transference.
For nearly a half century, the politics in the psychoanalytic community sup-
pressed much of Ferenczi’s ideas; however, there has been a recent rediscovery
about the importance of his work. In an excellent review of Ferenczi’s theoretical
concepts and clinical practice, Rachman (1999) called him a “clinical genius of
psychoanalysis.” Ferenczi was not simply deviating from his mentor, Freud; he was
offering an alternative theory to understand the human mind. In his seminal work
The Confusion of Tongue Between Adults and Children (1933), Ferenczi stated that
negative early childhood experiences (e.g., parental depravation and empathic fail-
ures) could lead to adult psychopathology. Ferenczi’s contributions to psychoana-
lytic theory and technique include: (1) the introduction of empathy into the analytic
Fig. 3.2 Sándor Ferenczi

and Sigmund Freud (Image
from The Sandor Ferenczi
Center at The New School for
Social Research (New York,
NY)
relationship, (2) the importance of noninterpretative behavior by the analyst, (3)

the function of experiential and emotional dimensions in the analytic therapy, (4)
analyst self-disclosure, and (5) pioneering mutual analysis (Rudnytsky et al. 2000).
To date, the first four contributions remain very much among the main tenets of the
two-person relational model of psychodynamic psychotherapy.
William Stekel (1868–1940)

William Stekel was known as Freud’s most distinguished pupil (Wittels 1924).
Stekel’s early contributions to psychoanalysis and child psychoanalysis while in
Freud’s circle are described in Chap. 2. Subsequently, though, Stekel strongly criti-
cized Freud’s analytic method: “Orthodox analysis, which demands that man
remember all occurrences as far back as childhood, has set up an impossible task for
itself—impossible to accomplish in the way it is being handled. We can call ortho-
dox analysis the passive analysis (Stekel and London 1933). The analyst commands
his patient to tell everything which passes through his mind. These revelations are
then explained and associated. The same method is employed in the interpretation
of dreams, Freud’s passive analysis.” Furthermore, he had strong words against

Freud’s prohibition in giving advice to patients and believed it was necessary to
assist pedagogically and to guide patients during the sessions. He said of Freud’s
method, “No wonder that a treatment of this kind requires endless time and patience
on both sides, on the part of the physician and that of the patient” (Stekel and
London 1933). Stekel recognized that when the analyst took an active role during
the analysis, the patients would feel safe and more open to reveal their conflicts.
Ian Suttie (1898–1935)

Ian Suttie posited that the infant had the innate capacities and wishes for human “com-
panionship.” In his masterful and little known book The Origins of Love and Hate
(1935), Suttie stated: “Formally, the tentative theory I have formed belongs to the group
of psychologies that originates from the work of Freud. It differs fundamentally from
psychoanalysis in introducing the conception for an innate need-for-companionship,
which is the infant's only way of self-preservation. This need, giving rise to parental
and fellowship ‘love.’” Suttie was interested in the emotional bond between infant and
mother and the impact it had on adult psychopathology. Montagu (1953) writes,
“Where the cornerstone of the Freudian system is sex, in Suttie’s it is love.” Sadly,
Suttie died at the age of 46, although the legacy of his work at the Tavistock Clinic in
London later influenced John Bowlby, the father of attachment theory.
British Relational Theorists
Charles Rycroft (1914–1998)

It was not until the 1950s that Charles Rycroft, a British psychoanalyst, left the
Freudian psychoanalytic movement of Europe and openly questioned the scientific
credentials of psychoanalysis and became dismayed by the bitter rivalry between the
Kleinian and Freudian camps (Rycroft 1985; Holmes 1998). He too questioned the
psychoanalytic approach of the detached observer and emphasized the importance of
the real relationship between the psychotherapist and patient as crucial and curative.
Though he was also dismissed from traditional psychoanalytic circles, Rycroft rein-
vigorated the ideas of two-person relational psychology through his prolific work in
popular press, including The Observer and The New York Review of Books.
Jeremy Holmes (1943–)

Jeremy Holmes is a contemporary British psychoanalyst whose instructive books The
Search for the Secure Base: Attachment Theory and Psychotherapy (2001) and Exploring
in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy (2010)
make use of Bowlby’s concept of internal working models. Holmes proposed that psy-
chotherapists need to take an active role in order to help adult patients break the negative
cycle of self-defeating experiences. He believes that when patients and psychotherapists
mutually cocreate a coherent new narrative of their experiences with others, they learn
to manage their affects more effectively. He adds, “What good therapists do with their
patients is analogous to what successful parents do with their children” (Holmes 2001).
American Relational Theorists
In the United States, there also were some dissenters who broke from the mainstream
of Freud’s drive theory and the restrictive psychoanalytic techniques, specifically
the emphasis on analytic neutrality and psychic determinism (Chap. 6). The dis-
senters founded the William Alanson White Institute (WAWI) in 1946. The WAWI
was strongly influenced by the work of Ferenczi, and its members included Harry
Stack Sullivan, Clara Thompson, Erich Fromm, Frieda Fromm-Reichmann, David
Rioch, and Janet Rioch. Currently, WAWI is one of the leaders in the advancement
of two-person relational psychology and has among its faculty member’s distin-
guished writers Philip Bromberg, Jay Greenberg, and Donnel Stern.
Harry Stack Sullivan (1892–1949)

Harry Stack Sullivan is thought to be among the original important figures in
American psychiatry. He departed from Freud’s drive theory and Klein’s object
relations theory and was considered a Neo-Freudian psychiatrist and psychoanalyst
whose main contribution to the psychoanalytic movement was the interpersonal
theory and interpersonal psychotherapy. He proposed that the most important con-
tributor to the formation of a person’s personality was the interpersonal relation-
ships created in early childhood within the context of society and culture (Barton
1996). Sullivan believed that a person “can never be isolated from the complex of
interpersonal relations in which the person lives and has his being” (Sullivan 1940).
Jay Greenberg (1933–) and Stephen Mitchell (1946–2000)

The shift from Freud’s one-person psychology to a two-person relational psychol-
ogy occurred over several decades, and it was not until 1983—with the publica-
tion of Jay Greenberg and Stephen Mitchell’s seminal book Object Relations in
Psychoanalytic Theory—that the differences and overlaps between relational
and drive models were outlined. Greenberg and Mitchell were trained under the
influence of Harry Stack Sullivan, the founder of the interpersonal theory of psy-
chiatry (Sullivan 1953). Greenberg and Mitchell’s (1983) departure from Freud’s
traditional drive theory led to the distinct two-person psychology concept of relat-
edness—referring to the analyst and patient—that represented a change in psycho-
analytic thought. They stated, “Relations with others constitute the fundamental
building blocks of mental life.” The psychodynamic theories that ensued were a
clear departure from the traditional one-person model that considered the neutral-
ity of the analyst to be a necessary component in facilitating the development of
the transference neurosis onto the analyst. The contemporary two-person relational
psychology model proposes a bidirectional form of treatment that features the
mutual participation of the psychotherapist and the patient in a real relationship,
with attention to here-and-now cocreated moments that are recognized as thera-
peutic in and of themselves. Greenberg and Mitchell saw the relational models as
diverging from the traditional Freudian conceptualization of human motivation and
the nature of the mind. So as to not recreate bitter conflicts, such as those that Freud
had with his dissenters or the heated disagreements between the Anna Freudians
and the Melanie Kleinians, Greenberg and Mitchell were wise in taking a rather
conciliatory approach when conveying their concepts to the psychoanalytic com-
munity (King and Steiner 1991). Ultimately, with Mitchell’s (1988) book Relational
Concepts in Psychoanalysis: An Integration that the relational movement took hold
in the United States.
By 1991, Mitchell had become the most prolific and influential relational psycho-
analyst in the field and was instrumental in helping to launch the International
Association for Relational Psychoanalysis and Psychotherapy. He also became the
founding editor of Psychoanalytic Dialogues: The International Journal of Relational
Perspectives, which remains a well-respected international publication for the con-
temporary psychoanalytic and psychodynamic community. Sadly, Mitchell died at
the age of 54, and in honoring his work, his colleagues founded The Stephen Mitchell
Center for Relational Studies in New York City in 2010. It continues to be an active
educational and clinical center that counts many well-respected two-person rela-
tional psychoanalysts among its faculty, including Lewis Aron, Beatrice Beebe,
Jessica Benjamin, Adrienne Harris, James Fosshage, Paul Wachtel, and Jay Frankel.
Pearlman and Frankel (2009) reflect on the relational movement, saying it “gained its
first institutional foothold when it became a separate official ‘orientation’ within the
New York University postdoctoral program in psychotherapy and psychoanalysis in
1988.” For an eloquent and detailed description of two-person relational psychology
and attachment theory in psychotherapy of adults, we refer the reader to Buirksi and
Haglund (2009), DeYoung (2003), Wachtel (2010), and Wallin (2007).
Paul Wachtel (1940–)

Paul Wachtel is a psychologist and psychoanalyst and cofounder of the Society for the
Exploration of Psychotherapy Integration (SEPI). The central themes of his writings
focus on the theory and practice of two-person relational psychotherapy, which he elo-
quently distinguishes from the traditional one-person model. He posits that what tran-
spires during a psychotherapy session goes beyond the patient and psychotherapist
subjectivities. He emphasizes that the clinical encounter is best viewed from a fully
contextual approach: accounting for the patients’ and psychotherapist’s experiences of
each other as implicitly being influenced by earlier relationships, as well as implicit
social and cultural forces. He is best known for his books Relational Theory and the
Practice of Psychotherapy (2008), Inside the Session: What Really Happens in
Psychotherapy (2011), and Cyclical Psychodynamics and the Contextual Self (2014).

Psychology in Child and Adolescent Psychotherapy
We have provided the reader a review of the historical background of the two-person
relational psychology pioneers in the treatment of adults with psychoanalysis and
psychodynamic psychotherapy. We now proceed to provide an outline on how, over
the last 20 years, two-person relational psychology began and was incorporated into
the psychodynamic psychotherapy of children and adolescents.
3.3 Historical Background of Two-Person Relational Psychology 47
The importance of the two-person relational model in working with young

children has expanded over the last two decades, largely due to the advances in
developmental psychology and neuroscience. Developmental research has placed
the early experience of the infant with its caregiver at the center of understanding
developmental and relational difficulties, as well as later formal psychopathology in
children and adolescents.
Although the two-person relational model of psychodynamic psychotherapy
is gaining traction in clinical practice, it continues to remain largely elusive in
child and adolescent psychiatry training programs. Newly minted child and ado-
lescent psychiatrists currently are mostly focused on learning traditional one-
person model psychotherapy, evidence-based treatments, cognitive behavioral
therapies, and new psychopharmacological interventions. We also note that the
rich findings from developmental research and the eloquent writings regarding
two-person relational psychotherapy in children and adolescents have been pri-
marily limited to the literature available to relational psychoanalysts, psycholo-
gists, and social workers. Unfortunately, this inherently limits the exposure of
the child and adolescent psychiatrist in training to these useful concepts. It is our
hope that the trainee, newly minted child and adolescent psychiatrist, or psycho-
dynamic psychotherapist finds this book helpful in increasing their knowledge of
two-person relational psychology and its application to their day-to-day clinical
work.
American Two-Person Relational Child

and Adolescent Psychotherapists
We will now briefly review the main authors that have influenced our journey as
child and adolescent relationalists. These authors have been brave in sharing
their work, even though it was seen by some as “not psychodynamic,” claims we
clearly disagree with. As Gabbard and Westen (2003) state: “We would suggest
deferring the question of whether these principles or techniques are analytic and
focusing instead on whether they are therapeutic. If the answer to that question
is affirmative, the next question is how to integrate them into psychoanalytic or
psychotherapeutic practice in a way that is most helpful to the patient.”
James Anthony (1916–)

James Anthony, a well-respected child psychiatrist and child psychoanalyst who,
although largely anchored in a traditional one-person model in his work with chil-
dren and adolescents, also noted the importance of innate and contextual factors that
need to be considered in their treatment. In his extraordinary paper Communicating
Therapeutically with the Child—published in 1964 in the Journal of the American
Academy of Child and Adolescent Psychiatry (JAACAP), a mainstream journal for
child and adolescents psychiatrists—he emphasized the psychotherapist’s need to
learn about the child’s outside world realities.
To understand some children, you need to know especially about their unoccupied, unsched-
uled hours when they are lonely and bored. Knowing how he spends his time and how he
wastes his time will provide us with two important facets of the child’s life (Anthony 1964).
In contemporary two-person relational psychotherapy with children and adoles-

cents, it is understood that a child has approximately 100 waking hours a week and
that only 1 or 3 hours of psychotherapy during the week are “a drop in the bucket” if
not accompanied by knowing what the child spends his time on and the realities of
his environment. In the two-person relational model, the patient is viewed through
the lens of the contextual. That is, the here-and-now interactions with a child or ado-
lescent are influenced not only by the context of the interaction with the psychothera-
pist but also by what the patient chooses to share within the context of their
environment. Anthony makes the case for the child and adolescent psychotherapist to
humbly recognize his limitations when solely relying on information obtained during
the psychotherapy sessions, which is more commonly the case in a traditional one-
person model. Anthony openly agrees with Anna Freud in that the child analyst who
relies exclusively in the inner world, risks missing out on his patient’s activity con-
cerning his equally important environmental circumstances (Anthony 1986).
A child who isolates

Alex, an 11-year-old boy with an easy/flexible temperament, well-developed
cognitive flexibility, and secure internal working models of attachment (Chap. 8),
had begun to isolate in his room and avoid his family and friends. He was a good
student and was doing well in school. He was brought to the psychotherapist by
his parents to help with his “isolation from the world.” He played well during the
initial two sessions at age-appropriate games, although the psychotherapist noted
the subjective and palpable anxiety in the boy. The psychotherapist’s intersubjec-
tive experience allowed him to understand the boy’s subjective desire to share his
struggles, as well as his fear in doing so. To this, the psychotherapist decided to
genuinely say, “I really think we can figure out what bothers you. My idea is that
if we go through what you do during the day before you go to your room and
isolate, we can figure out where the problem is.” The boy, somewhat embarrassed,
responded, “I don’t want to talk about it.” The psychotherapist respected the boy’s
wish of not wanting to talk about his isolation and wondered if it would be easier
if the boy wrote down everything he did during the day and brought these notes to
the next appointment. The boy seemed relieved and agreed it would be easier,
although he wanted reassurance that his parents would not see his notes until he
had shared them with the psychotherapist, to which the psychotherapist agreed.
In the following appointment, the boy gave the psychotherapist a sheet of
paper with details of what occurred between sessions. He had written, “I hear
voices during school, at home, and when I am with my friends. In the eve-
nings I go to my room because I do not want my family and friends to know I
hear them. Please help me feel better.” His parents had thought that he just
needed space and did not know about the severity of his symptoms.
3.3 Historical Background of Two-Person Relational Psychology 49
This example captures what Anthony had in mind: to accept that children have a
world with many experiences that influence and shape many aspects of their person-
alities. The two-person relational psychotherapist in this example is active, present,
and uses his intersubjective experience to recognize the child’s distress. Rather than
continuing with an active line of questioning or comments to the effect of “I know
you are worried and it is hard for you to tell me” (essentially saying, “I know you
are hiding something from me”), he respects that the child is not ready to share his
worries. He also discloses his interest in the child’s life outside of the office as much
as that in his office, demonstrating that daily experiences are important, which may
include success that can be supported in addition to his worries. As Wachtel (2012)
reminds us, “We do not adequately understand the meaning or implications of what
is transpiring in the consulting room without understanding in considerable detail
what happens in the patient’s daily life; conversely, our understanding of the events
of his daily life is likely to be far less accurate and perceptive if it is not informed by
the complex intersubjective exchange between patient and therapist in the consult-
ing room.” He later adds, “the two approaches each offer valuable and important
elements that must be included to achieve a maximally effective therapeutic effort.”
Further, the two-person relational psychotherapist will work with the child’s par-
ents, as he may learn about situations that may be relevant to the child’s life and
important to bring into the process.
Additionally, Anthony’s paper was clearly ahead of his time. He gave importance to
the interface between the findings from attachment theorists and developmental research-
ers to the practice of psychodynamic psychotherapy with children and adolescents, which
is the essence of a two-person relational model of psychotherapy. Anthony reflects:
The child’s capacity to communicate is closely related to the success or failure of his first
communication environment when he was learning the language of gesture, of expression,
of minimal cues, of kinesthetic communication, and, most important of all, of words. The
various types of mother–child relationship favor or disfavor the development of a need to
communicate with another person for the sake of the immeasurable satisfactions that it
offers.
It is clear, however, that in the majority of cases that Winnicott would call “good-enough,”
the warm, sympathetic, empathetic, patient, and uniquely and mutually satisfying coupling
of mother and infant brings about a good-enough level of communication that persists
throughout life. This communication model would be an ideal one to strive after when we
need to further communication, as we do in therapy.
In essence, he agrees with Levenkron (2009), who states that attending to pros-
ody is a “rich vehicle for the expression of implicit relational knowing. Gestures,
body language, sighs, eye movements, facial expressiveness, breathing and tone,
cadence, rhythm and emphasis are among the many prosodie carriers of meaning.”
Herein, in spite of Anthony’s introduction of two-person relational psychology con-
cepts, it has taken nearly 20 years for two-person relational psychology in child and
adolescent psychotherapy to take hold.
Cohen (1997) adds to Anthony’s vision, “The shift in child work—theoreti-
cally and clinically—to a more equitable balance between internal and external
factors represents a shift that many would see as an extension of previous work
but that others would see as a dilution….. Still, there are those who see this shift
as a dilution, even a crisis for child psychoanalysis. There is the concern that
focusing on the external world (e.g. working too much with parents) potentially
undermines what has been considered the heart of psychoanalytic work: the abil-
ity to work with the transference and other aspects of unrecognised meanings and
structures.”
Neil Altman (1946–)

Neil Altman is a psychologist and psychoanalytic psychotherapist recognized for
his clinical work in relational child psychotherapy. As with the 1983 publication
of Jay Greenberg and Stephen Mitchell’s book Object Relations in Psychoanalytic
Theory, which allowed the relational movement in adults to take hold in the United
States, the publication of the seminal book Relational Child Psychotherapy (Altman
et al. 2002) allowed the relational movement to take hold in child and adolescent
psychoanalysis and psychotherapy. This book makes great strides in integrating
concepts of two-person relational psychology in working with children. Altman
(1994) states: “Child analysts, I suspect, have been working a great deal with the
immediate interactions with their patients. Yet, in their efforts to preserve a one-
person model, there is a risk of their attention being led away from the impact their
own actions and interpretations on their child patients. A fully relational approach
to child analysis would take account of such impact.” Notwithstanding, a limita-
tion of their book is that the authors limit their work to diagnostic formulations and
clinical work with infants and elementary school-age children and not with ado-
lescents. In a later paper, Altman (2004) states, “With few exceptions, the child’s
psychoanalytic world was, until recently…seemly unaffected by the relational turn
in the literature.”
Other Two-Person Relational Child and Adolescent

Psychotherapists
Other important contributors to two-person relational child and adolescent psycho-

therapy are Richard Briggs, Kenneth Barish, Jay Frankel, Daniel Gensler, Monica
Lanyado, and Pasqual Pantone.
The authors define contemporary two-person relational psychodynamic psychother-

apy as a rich and complex process that involves a child or adolescent and his or her
psychotherapist, who through a process of mutual understanding of here-and-now
moments of intersubjectivity cocreate corrective experiences that are stored in non-
conscious nondeclarative memory systems, which are needed for successful clinical
3.4 Two-Person Relational Psychodynamic Psychotherapy 51
work (Fig. 3.1). Although the patient’s and the psychotherapist’s subjectivities are
mutually influenced, the influences are not symmetrical. The asymmetry refers to the
psychotherapist’s personal healthy attributes that allow him or her to be guided by the
intersubjective experiences provided by the patient in the here-and-now moments of
their interactions. Additionally, the asymmetry allows the psychotherapist to nudge
the patient, by carefully timed enactments and self-disclosures, to move along the
process in what are called moments of meeting, which may also occur spontane-
ously and unknowingly. Herein, together, the patient and psychotherapist cocreate
new “corrective emotional experiences” (Alexander et al. 1946; Hoffman 2006).
Moment of meeting with an adolescent

A 16-year-old adolescent male begins two-person relational psychotherapy
for his depression. He shares with the psychotherapist that he is worried his
father will not understand that he no longer wishes to participate in high
school sports and would like to dedicate his time studying for his college
admission exams to pursue a career in journalism. The psychotherapist inter-
subjectively experiences that the patient’s efforts to follow his dreams are
being held back by his father’s pressure for him to pursue sports and by his
depression. The psychotherapist enacts and self-discloses, “I have an idea and
I would like your input about whether you think it may help. What do you
think about inviting your father to our next session? I wonder if my help can
lead to a better solution between the two of you.” With a visible sense of relief
and affectively feeling understood, the patient states that his father (a high-
level engineer) needs help understanding how difficult it is for an adolescent
to struggle with depression and that his father would trust “a doctor’s opinion.”
A moment of meeting was cocreated.
Basic Principles of a Two-Person Relational

Psychodynamic Psychotherapy Process
In a two-person relational psychodynamic psychotherapy process, there is inherent

emphasis on the importance of the active participation by both patient and psycho-
therapist during the encounter, with continuous and novel moment-to-moment
changes due to each other’s subjective experiences (Aron 1990). The subjective expe-
riences occur in the intersubjective field between patient and psychotherapist, and the
changes occur at an implicit level. Cappas et al. (2005) suggest that a two-person
relational psychotherapy process integrates seven principles:
• Genetics and environment interact in the brain to shape the individual.

• Experience transforms the brain.
• Memory systems in the brain are interactive.
• Cognitive and emotional processes work in partnership.
• Bonding and attachment provide the foundation for change.

• Imagery activates and stimulates the same brain systems as does real
perception.
• The brain can process nonverbal and unconscious information.
Meanwhile, the Boston Change Process Study Group (BCPSG 2010) conceptu-
alizes the two-person relational model of psychotherapy to be based on five basic
premises:
• The dyadic nature of the therapeutic process

• Fittedness and directionality in the therapeutic process
• Sloppiness and creative negotiation in the therapeutic process
• Increasing inclusiveness of the therapeutic process
• Vitalization in the therapeutic process
Both conceptual views help the two-person relational psychotherapist under-

stand the complexities in providing a here-and-now sense of mutuality needed to
cocreate a corrective emotional experience for the patient (Table 3.1). Further, both
views attend to the patient’s innate and acquired strengths. As Wachtel (2011) states,
“Effective psychotherapeutic effort must have an equally clear vision of the patient’s
strengths. It is on those strengths that change is built, and failure to see them clearly
can make change extremely unlikely.” For example, from the time a person begins
the day showering, brushing their hair, and eating breakfast, through the times he or
she takes the children to school, calls a friend, completes work, and goes to the store
to buy the ingredients to prepare dinner, to the time when he or she serves dinner,
leaves the children with a babysitter, and goes to a movie with their spouse, their
psychological functioning is difficult to distinguish from that of any other person,
and these mundane moments are precisely the crucial building blocks upon which
change is created (Wachtel 2011).
Table 3.1 Broadly accepted tenets of two-person relational psychotherapy

The central, innate motive of mental life is to seek relatedness with others
Early childhood implicit relational patterns of interaction manifest within the psychotherapy
process in the form of intersubjective experiences between the psychotherapist and the patient
Change occurs at the implicit level in the form of nonconscious moments of meeting that lead
to the development of new neuronal pathways and more adaptive patterns of interaction
The psychotherapist must be aware of his or her emotional states, to effectively attune to the
patient and provide the intersubjective field necessary for moments of meeting to occur
Co-construction of new reparative enactments is fundamental to the healing process and
therapeutic change, new emotional experiences
Insecure attachment in childhood disrupts healthy emotional and relational development
3.5 Two-Person Relational Experiences Are Contextual 53
3.5 Two-Person Relational Experiences Are Contextual
We are in agreement with Wachtel, and feel the essence of two-person relational
psychology, that experiences between two or more people are contextual. We
propose that in two-person relational psychotherapy, the concept of “contextual”
represents three different aspects: realities within the environment that trigger a
person’s anxiety; interactions with another person that implicitly trigger anxiety;
and here-and-now moments in the psychotherapeutic process during which, in
the intersubjective field, the patient unknowingly and implicitly is trying to
engage the psychotherapist into a relational pattern that is contextually familiar
(Wachtel 2010).
A traditional one-person model maintains that a patient’s symptoms or relational
difficulties represent ego defense mechanisms to manage intrapsychic drive or
object relation conflicts. The clinician becomes the objective observer of the
patient’s maladaptive defenses, develops a diagnostic formulation of the intrapsy-
chic pressure for such behaviors, and later, through clarifications or interpretations,
provides the insight needed for the patient to return to a healthy developmental
track. In essence, a traditional one-person model psychotherapist does not give
equal importance to the realities of the contextual as to his or her objectivity. We
recognize that a person using a traditional one-person model may resort to distanc-
ing when in doubt about how to proceed during a moment in the clinical encounter,
which generally takes the form of silence, withholding answers, or asking the well-
worn question, “What do you think?”
Realities in the Environment That Trigger a Person’s Anxiety
We begin with an example that can help shed some light on delineating the context
of the situation in which the person experiences anxiety. Consider a person who is
an avid hiker and frequently takes trips to rugged terrain where hiking poles are
needed. Although this hiker (one of the authors of this book) is typically eager to
climb moderate to challenging hills, he becomes anxious about slipping or falling
when descending. On one occasion, while descending a steep rocky section with
a friend, they stop and laugh upon seeing some other hikers descending rapidly
without using hiking poles. The friend says, “Don’t you wish we could descend like
them? They have a steady foot like goats.”
Considering this example as psychodynamic psychotherapists, we may utilize
Freud’s concept of psychic determinism to an extreme in understanding everyday life
situations that are anxiety laden. From this vantage, it could be said that if the two
friends separately sought a psychoanalyst to better understand their fear in descend-
ing, the psychoanalyst may consider the fear due to unresolved intrapsychic conflicts
triggered by the steep descent, and that by having access to their free associations
or dreams—the traditional one-person archaeological excavation—the repressed con-

flicts that led to the inhibition in descending could be uncovered and later worked
through. In contrast, when the avid hiking author discussed the difficulties of descend-
ing steep terrain with a physical therapist, who knew plenty about the differences in
body mechanics, she deftly captured, in non-psychoanalytic terms, the reason for the
anxiety about descending: “Our genes define us; your body mechanics are lousy for
descending in treacherous terrains. Some individuals are genetically predisposed to be
able climb and descend with dexterity and others, like both of you, can only do one or
the other well.” She proceeded to share the complex aspects of body mechanics (i.e.,
balancing, positioning of feet, coordination, etc.) that contribute to having abilities or
limitations. As Freud stated, “Anatomy is destiny” (1924).
We provide this example to serve as a reminder to the reader that when the tradi-
tional one-person concept of psychic determinism is used to understand anxiety-
laden daily-life experiences, it can be limiting. In this hiking example, the traditional
one-person psychotherapist may have thought that the unconscious forces held the
clue to the person’s fear in descending. It may be of interest that in dream analysis
the fear of heights in men was once thought to be indicative of psychic conflict
regarding fear of success due to castration anxieties. (We happily note that the hik-
ing author’s psychoanalyst attests that the castration anxieties were thoroughly
worked through, even though the author continues to fear steep descents.)
In contrast, contemporary two-person relational psychology understands that
people have certain attributes and limitations as a result of their genetic blueprint,
which influence how they respond to event in their environment at an implicit level;
their response is not influenced by a conflicted unconscious. In the example of the
hiking friends, it is clear they were aware of their inherent abilities and limitations
in descending. Further, since the experience is shared in vivo (sharing subjectivities
in the here and now), it becomes the context for their anxiety. They may implicitly
understand, “We are in this together and we can laugh because we both know we
can descend slowly and carefully,” alluding to nature and nurture factors. In con-
trast, if the person hiking were unable to share the experience with a friend in the
same context, “being in the same shoes,” the anxiety may have been managed much
differently and influenced by implicit relational knowing (Chap. 5). That is, the
person hiking may have been overwhelmed, feeling unable to share the experience,
and may have chosen not to descend the trail.
A situation that is familiar to all of us is that of the innate and contextual dif-
ferences among siblings. Differences in abilities and limitations among siblings are
ubiquitous. One child may be skilled in sports, while the other is clumsy in sports but
excels in music. A two-person relational model encourages the psychotherapist to
consider the sibling differences as a result of the interactions of nature and nurture in
many complex ways, and not due exclusively to their unconscious drives and parental
object representations. Understanding this in terms of the patients, genetic differences
can influence the abilities and limitations of their psychological functioning. With this
in mind, in the case of the siblings, if the parents are not skilled at sports or music, they
will need to implicitly learn how to attune with the affective states of their children in
a manner that promotes curiosity and excitement supporting their talents. At the most
basic level, the parents will need to intuitively learn how to share their excitement
within the context of the situation—loudly in sports and quietly in musical events.
Interactions with Another Person That Implicitly Trigger Anxiety
In considering the interactions between two people, we have made the case through
this book that infant developmental research has elucidated that the infant’s meaning-
making experiences with other people are many and ultimately influence personality
development (Chap. 5). That is, the child’s implicit relational knowing takes into
account a person’s attachment experiences evoked by the different people they have
interacted with through their life span, relationships of relationships (Emde 1989).
Wachtel adds, “It attends to what each party to the exchange or to the relationship is
doing and feeling at any particular moment, and it asks what each person’s participa-
tion in the attachment relationship at any given moment is in response to and what it
evokes in the other.” In contrast to a traditional one-person model that may see inter-
personal difficulties as solely due to the patient’s intrapsychic conflicts with others,
in a two-person relational model, the nature of the context of the interaction is essen-
tial to consider. As Wachtel (2010) aptly states, “The contexts in which we find our-
selves are very largely contexts that we have ourselves contributed to creating, that
we have cocreated with those who participate with us in that context.” Used clini-
cally, the psychotherapist will need to maintain a keen ear for the interpersonal expe-
riences a child and adolescent patients describe as challenging.
The 12-year-old child that excels at school

The parents of a 12-year-old child brought her in for a psychiatric evaluation
after she had been difficult and obstinate. The child was bright, excelling at
school academically, and was well liked by peers. The clinician intersubjec-
tively experienced the child as pleasant, bright with an easy/flexible tempera-
ment, and easy to engage in playful here-and-now moments. In contrast, while
the clinician was interacting with the child, the parents were outwardly criti-
cal of their daughter and demonstrated poor capacity to provide the emotional
availability needed by their daughter. When the clinician inquired about what
the parents considered their daughter’s obstinate and difficult behaviors to be,
they shared that she had been disrespectful because she would not ask them to
attend her sporting events and that she preferred spending time at her friends’
homes and did not like to have friends over to their home. While her parents
were sharing their view, the child looked at the clinician and in a nonverbal
manner implicitly was saying, “See why I don’t want to have my friends
around my parents,” which the clinician intersubjectively understood.
This example helps illustrate the fact that, in many occasions, a child or adoles-
cent may have difficulties interacting with certain people. When viewed from the
lens of the contextual, this knowledge allows the psychotherapist to appreciate that
the here-and-now intersubjective experience may fail to capture what it is like for
the patient in those “live” difficult moments with others (see section on limitations
in Chap. 1). The example also brings the contextual aspects to the office, where the
clinician has a front-row seat to the bidirectional interactions and is able to
understand the vantage point of both parties: In this case, the clinician noted that the
parents had a difficult/feisty temperament and a dismissive attachment style with
deficits in social reciprocity, while their daughter had the attributes needed (i.e., an
easy/flexible temperament, a good ability for social reciprocity) to seek the emo-
tional attunement from other family members in early childhood, and later from
teachers. The clinician understood the child when using the intersubjective experi-
ence of the child and parents.
The Patient Unknowingly and Implicitly is Trying to Engage

the Psychotherapist into a Relational Pattern that is
Contextually Familiar
Wachtel (2010) reminds us of the unique proclivities that each member brings into
a psychotherapeutic dyad: “We begin to think that this is the way the person ‘is,’
when it is more accurate to say that this is the way he is with me (and, moreover,
how he is with me when I am acting in a particular way, and he may not be that way
even with me when I am being different).” Wachtel, like Anthony, emphasizes the
importance in understanding that psychotherapy is a fully contextual process.
The 7-year-old child has problems playing

The parents of a 7-year-old child brought their son in for a psychiatric
evaluation due to him seeming unhappy and having difficulties playing with
family and peers. After gathering pertinent information from the parents,
the clinician proceeded to see the child without the parents present. The
child was friendly and seemed eager to play. The clinician suggested they
play Connect Four, a developmentally appropriate game for his age, to
which the child agreed. Within a few moves, the child became irritable with
the clinician and said he no longer wished to play any games. Internally, the
clinician thought, “Why do you make it so difficult to play with you,” which
was not the typical reaction when the clinician had previously played with
young children. The clinician recognized that he had unknowingly begun to
implicitly give nonverbal cues to the child about his exasperation. The child
had been struggling in figuring out how to play Connect Four. Using a con-
textual lens, the clinician took a step back and recognized that his intersub-
jective experience was something familiar to the child, the idea that “it is
difficult to play with you.” The clinician used this change of perspective to
shift his approach and attune to the child’s needs. The clinician recognized
some of the child’s cognitive limitations and suggested they play a different
board game, one that was more appropriate for a younger-aged child. The
child felt reassured in the intersubjective field and said with some excite-
ment, “I like this game.”
This example helps to highlight the fact that some children and adolescents may
have difficulties interacting with others due to temperamental and cognitive weak-
nesses in spite of healthy and emotionally available parents and family. The exam-
ple brings the contextual aspects to the office, where the clinician becomes an active
participant of the relational patterns the patient unknowingly sets up with others.
As is commonly said, actions speak louder than words.
Uncertainty in Two-Person Relational Psychotherapy
When considering two-person relational psychotherapy, we have often been

asked by trainees and experienced psychotherapists (specifically those anchored
in traditional one-person psychology), “Aren’t we all relational?” It is not uncom-
mon for the term “relational” to be understood in its narrow form, as being an
empathic and active listener to the patient’s discourse. The differences between
being relational and being empathic lie on whether the psychotherapist allow the
patient to subjectively become, in a bidirectional transaction, aware of the emo-
tions and states of mind in the psychotherapist. We agree that traditional one-
person psychology allows for the psychotherapist to demonstrate some degree
of empathy, the ability to share the feelings that another person experiences,
although it limits the patient to become aware of the emotions and state of mind
of the psychotherapist. Mitchell (1993) and Bromberg (2009) clarify that being
relational occurs when there is an authentic and genuine process of empathic
attunement between the people involved.
The girl that wants the psychotherapist’s toy

An elementary school-age child at the end of a psychotherapy session wished
to take home the toy she had been playing with. A traditional one-person psy-
chotherapist empathically explained why the child would not be allowed to
take the toy. The psychotherapist then asked the child about her wishes for
taking the toy, and then added that by not taking the toy, it would be available
in the next session. Further, the traditional one-person psychotherapist
explored the intrapsychic meanings as to why the child wished to take the toy
from the office, breaking the frame of the process. The psychotherapist may
have chosen to interpret that the child displaced onto the toy their wish to take
the psychotherapist with them—with the toy serving as a transitional object
(Chap. 6)—if confident that such a notion was the case for the child. To this,
Beebe and Lachmann (2003) eloquently caution against this and state, “Too
great a tilt toward an intrapsychic view of the organization of experience
underestimates the contributions of the partner and the environment, and the
intrauterine interactive organization of infant ‘biology’” (also see Chap. 5).
In contrast, in a two-person relational psychotherapeutic process, the psycho-

therapist may reflect on how he or she felt about the patient’s request before any
response is given. If the relational psychotherapist intersubjective experiences the
child’s request to take the toy due to feelings of deprivation or loneliness, which
the child routinely experiences at his home, allowing the child to take the toy could
serve as a new corrective emotional experience stored nonconsciously and in non-
declarative memory, similar to a song or memento. Viewed differently, the relational
psychotherapist may intersubjectively experience the child as demanding and may
gently state, “You know, that toy is important to me, and I wonder if we can agree
for you to enjoy playing with it here with me.” The goal of the relational psycho-
therapist is to provide the child a new experience in which she can begin to value
that here-and-now mutuality, “We both want the toy.” Herein, traditional one-person
psychotherapy limits the freedom to open the intersubjective field for back-and-forth
subjectivities that serve as a guide for the psychotherapist on how to best proceed. In
two-person relational psychotherapy, the possibilities for new experiences are influ-
enced by the patient’s and psychotherapist’s subjectivities, which are numerous and
complex. Further, Rustin and Sekaer (2004) add: “Findings strongly suggest that
memory is an intersubjective event based on an amalgam of the internal encoded
experiences of the patient and the external retrieval cues provided by the analyst and
external events. Patient and analyst co-construct memories each time, expanding and
extending the neuronal networks. In each recollection the memory is constructed
anew and is slightly transformed…. The neuroscience of memory explains how this
happens.”
Anxiety in the Two-Person Relational Psychotherapist
The complexity of the two-person relational process has led trainees and experi-
enced clinicians to pose several questions:
• Can I use traditional one-person neutrality when I don’t know what I should say
or do, and later use a relational model when I feel I understand the patient?
• Can I maintain my neutrality and ask questions in a Socratic method?
• Can I make use of interpretations to help the patient develop insight about their
problems?
• Do I have to self-disclose? I am a very private person and would rather not
disclose.
• What are appropriate boundaries in a relational approach?
Typically, these questions are followed by statements: “Relational psychotherapy

makes me nervous. Without guidelines about what is important to address or know-
ing what amount of self-disclosure is appropriate, it is easy to be overwhelmed.”
These statements represent anxieties that not only are expected, they are helpful
reminders to the two-person relational psychotherapist of the sloppiness and cre-
ative negotiations of shared subjective experiences (see Chap. 5).
3.6 Critiques of the Two-Person Relational Model 59
We would reassure our colleagues that a two-person relational approach requires

extensive reading with an open frame of mind to new concepts from developmental
research and neuroscience, and as is said, practice makes perfect. We invite the
reader to review the clinical examples in Chaps. 10, 11, 12, and 13 in order to have
an intersubjective feel for the process.
3.6 Critiques of the Two-Person Relational Model
There has been considerable criticism of the two-person relational model by some
psychoanalysts and psychotherapists since the time the concepts of “corrective
emotional experience,” “cocreativity,” and “intersubjectivity” entered the landscape.
Mills (2005) states, “What perhaps appears to be the most widely shared claim in
the relational tradition is the assault on the analyst’s epistemological authority to
objective knowledge.” Mills further critiques relational psychoanalysis, saying,
“It has opened a permissible space for comparative psychoanalysis by challenging
fortified traditions ossified in dogma, such as orthodox conceptions of the classical
frame, neutrality, abstinence, resistance, transference, and the admonition against
analyst self-disclosure.” Prominent figures such as Wasserman (1999) reminded the
psychoanalytic community how a traditional one-person model posed the greatest
value when the psychoanalyst or psychotherapist maintained neutrality. By main-
taining such a receptive posture, “the facts” of what the patient is truly experiencing
may be discovered, “ideally uncontaminated by anything coming from the analyst.”
For Freud (1900), the “unconscious is the true psychical reality.” Even a traditional
figure such as Wasserman, though acknowledging that the role of the psychoanalyst
is to primarily help the patient discover a buried past, in fact supports a key tenet of
two-person relational psychology, as he writes: “The analyst always actively influ-
ences what he discovers empathically. Specifically, the analyst’s theoretical biases
always shape what he empathically understands” (1999). For further critiques or the
two-person relational model, we refer the reader to the work by Jon Mills (2005)
and Morris Eagle (2003).
The authors have not been immune to the negative perception. We have col-
leagues who state, “New words for the same thing; just another way of looking at
things we already know.” Others have said, “Why change things if the old model is
working well?” Further, within the psychoanalytic community, some have gone as
far as considering the two-person relational model “not psychodynamic if you pro-
mote enactments” or a form of “wild analysis” (Schafer 1985).
These comments are misguided. They typically represent personal impressions of
the two-person relational psychology concepts and theory rather than a careful review
of the literature. Fossage (2003) deftly captures the dilemma a student of two-person
relational psychotherapy faces: “to ‘get’ another approach requires extensive reading
and living and breathing it within a community where a good deal of communication
takes place verbally. In addition, each approach houses a wide range of differences in
theory and practice, creating more confusion. Hence, misunderstandings from the
‘outside,’ not to mention from the ‘inside,’ are inevitable and frequent.”
We agree with Fossage: A two-person relational approach requires extensive

reading and living within a community open to new concepts, which at present is
scarce in most child and adolescent training programs, departments of child psy-
chiatry, and child psychodynamic psychotherapy programs, which we hope this
book contributes to help correct.
3.7 Summary
In this chapter, we have demonstrated how the advances from attachment theory, infant
developmental research, and intersubjectivity have led to a two-person relational psy-
chology that emerged as a theory of mind that provided a path for the application of
concepts derived from attachment theory, infant developmental research, and neurosci-
ences in the practice of psychotherapy. As such, the notion of a two-person relational
model of psychotherapy shook the foundations of traditional one-person psychoana-
lytic theory. We provide a reader the steps taken by two-person relational theorists and
psychotherapists to establish broadly accepted tenets of two-person relational psycho-
therapy for children and adolescents. There is general agreement that: the central innate
motive of mental life is to seek relatedness with others; early childhood implicit rela-
tional patterns of interaction will manifest within the psychotherapy process in the
form of nondeclarative intersubjective experiences between the psychotherapist and
the patient, rather than cognitive and verbal interactions and that change occurs at the
implicit level in the form of nonconscious moments of meeting that lead to the develop-
ment of new neuronal pathways of the more adaptive patterns of interaction. The psy-
chotherapist must be aware of his or her emotional states, to effectively attune to the
patient and provide the intersubjective field necessary for moments of meeting to occur.
Ultimately co-construction of new reparative enactments is fundamental to the healing
process and therapeutic change, corrective emotional experience (Table 3.1).
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Key Pioneers of Two-Person
Relational Psychology 4
There can be no knowledge without emotion. We may be aware
of a truth, yet until we have felt its force, it is not ours. To the
cognition of the brain must be added the experience of the soul.
—Arnold Bennett
This chapter reviews some of the leading experts who have contributed to the field
of child and adolescent two-person relational psychotherapy through their research.
The list is by no means complete as it would be beyond the scope of this book to
include all of those who contributed to further expand the understanding of the
complexities of infant development. We limit this review to the authors who pur-
sued infant–caregiver research—the “baby watchers,”—and spawned the concepts
most applicable to the two-person relational psychodynamic psychotherapy of chil-
dren and adolescents.
We have organized this chapter into three sections. We begin by focusing on
those researchers who were directly involved in developmental research studies,
followed by those who have synthesized vast amounts of empirical research from
neuroscience and summarized the relevance to the clinical work of the psychothera-
pist. We end by reviewing the developmental researchers who were instrumental in
formulating what are now known as the attachment and temperament theories.
4.1 Developmental Psychology Researchers
Developmental psychology refers to the scientific discipline that studies the biologi-
cal, social, and cultural factors that affect development and advance the knowledge
and theory of development of children and adults across their life span. Developmental
theorists have been keenly aware that a key aspect in social interactions is the ability
of one person to understand the mental states of others.
René Spitz (1887–1974)
René Spitz, a psychiatrist and psychoanalyst best known for his systematic observa-
tions and video recordings of the interactions between infants and their mothers,

DOI 10.1007/978-3-642-40520-4_4
64 4 Key Pioneers of Two-Person Relational Psychology
preceded many of the attachment theorists (Palombo et al. 2012). Spitz studied the
infant’s relationship to their caregivers. He found that infants who were hospitalized
and did not have direct exposure to their mothers or caregivers developed what he
coined hospitalism, characterized by anaclitic depression and a failure to thrive syn-
drome, based on the infant’s reaction to maternal deprivation. Moreover, he was
among the first psychoanalysts to use the research laboratory to affirm the impor-
tance of a child’s need for social interactions with other humans as essential for the
child’s survival and biopsychosocial development. It is important to note that his
work occurred nearly 10 years before Bowlby’s writings on attachment theory.
Further, another important contribution is the findings from observations of planned
separations between the mother and the infant in prison nurseries. His findings
proved that early loving caregiving were internalized at an early age by the infant
and that later separation had devastating consequences for the infants, i.e., grief and
depression. Thus, what had become standard practice, that adoption was best when
it occurred after the first year of life, changed to promote early adoption when pos-
sible, to facilitate the bonding needed for affective reciprocity and ego development
(Emde and Hewitt 2001).
Robert Emde (1935–)
Robert Emde, a psychiatrist and psychoanalyst, was a student and mentee of René
Spitz during Emde’s residency at the University of Colorado. He wrote that he “got
hooked in beginning a career in infant research and psychoanalytic thinking about
the importance of the mothering for early social-emotional development” (Emde
2009). He continued Spitz’s work with regard to mother–infant dyads and later
developed a distinguished research program for the systematic analysis of video
recordings of the interactions between infant and mother or caregiver. Their research
highlighted the infant’s need for social referencing and affective attunement by the
caregiver. Emde’s team believed that there was a need for “mutuality” between care-
giver and child for survival and emotional growth, indicating “the development of
the self and the development of the other did not develop separately but were two
sides of the same coin.”
Emde’s team posited that social referencing was a form of active emotional com-
munication thought to mediate behavior when the infant is confronted by a situation
of uncertainty. For Emde (1980, 1983, 2000), emotional availability referred to the
“receptive presence” of the parent to the child’s emotional signals. It connoted a
type of presence and availability that had a great deal in common with the way a
psychotherapist “is there” for a patient (Biringen and Easterbrooks 2012).
Emde is recognized in the field of psychoanalysis for his role in integrating the
information gathered from research about childhood development with psychoana-
lytic theory. He suggested that the adherence to conflict-based drive theory limited
the understanding of the child, in that it failed to recognize the value of the new
findings from developmental research. In his paper “From Ego to ‘We-Go’:
Neurobiology and Questions for Psychoanalysis,” he used the term “we-go,”
4.1 Developmental Psychology Researchers 65
which—as a concept—led contemporary psychoanalysts to begin to view Freud’s

ego as a concept that did not take into account the intersubjectivities and mutuality
between the infant and the “other.” The term “we-go” had been credited posthu-
mously to George Klein (1967). Emde writes that, in 1987, when presenting his
“From Ego to ‘We-Go’” paper at a plenary address at the International Psychoanalytic
Association annual meeting, he mentioned that psychoanalysis was in need of the
theory of we-go to supplement the theory of the ego, and “it resulted in somewhat
of sensation.” His contributions led to a surge in the interest of two-person relational
psychology influenced by infant developmental research by many of his psychoana-
lytic colleagues. Emde traced the origins of the shared we-go to the beginnings of
social referencing during the second half of the first year of life.
Emde is also known for a classic study in which healthy 3- and 4-year-old
middle-class children were initially asked to play with toys in the presence of a
researcher. Each child’s mother then entered the room and brought her child two
new toys and would let her child know her wish that the new toys should not be
played with after she left the research room. The mother then left the room, and the
researcher challenged the prohibition given by the mother by tempting the children
to play with the new toys. Surprisingly, a number of children resisted the tempta-
tion, to which Emde states, “We came to the realization that these children had
developed an executive sense of ‘we’ of the significant other being with them, giv-
ing them an increased sense of power and control.” He goes on to say: “The self is
a social self. Moreover, research indicates that from infancy, innately given brain
processes support social reciprocity and the development of “we-ness”” (Emde
2009).
Further, Emde and his team believed that the infant’s autonomous self existed
within the context of a social connectedness to the other and had the capacity to
develop a rudimentary moral compass for empathy with others. For example, in an
experiment they noted that as early as 3 years old, children had parental prohibitions
internalized. When facing a challenge in their play, these children accessed and
abided by these internalized rules. The team added that when 3- to 4-year-olds in
their control group were read stories that conveyed moral dilemmas, the children
“understood and struggled with the dilemmas, with many achieving pro-social out-
comes” (Oppenheim et al. 1997).
Daniel Stern (1934–2012)
Daniel Stern, a psychoanalytically trained psychiatrist, was also a prominent infant

researcher best known for his book The Interpersonal World of the Infant (1985).
His detailed observations of the mother–infant interactions in the research labora-
tory led him to bridge infant developmental research to the practice of psychody-
namic psychotherapy and psychoanalysis (Emde 2013). Early in his research, he
departed from Mahler’s separation–individuation theories (Mahler 1974), and with
the information gathered from his infant observations, he proposed that for the
infant to organize a coherent and core sense of self, it would need to successfully
develop four interrelated senses of self-experience. He observed that the infant’s

self-experience senses began within the first 2 years of life and progressed as such:
The process starts with the emergent self, continues through the core self and the
subjective self, and then finalizes with the verbal self. Primary attachment figures
played a critical role in helping the infant with this process, and the developmental
achievements in each phase persist over the child’s life span. During the period of
the subjective self (in the 7- to 15-month-old range), the child becomes aware that
his thoughts and experiences are distinct from those of others, and with proper
attunement by the primary caregivers, the child can cocreate dialogue with others
that requires the use of mirror neurons. This allows the child to participate in another
person’s actions without having to imitate those actions. He termed this as “affec-
tive attunement” and described it as “the performance of behaviors that express the
quality of feeling of a shared affect state without imitating the exact behavioral
expression of the inner state.”
Stern noted that in the case of a caregiver who suffers from depression and is
unable to provide the affective attunement needed by the child, the child would be
deprived of positive intersubjective experiences. This would interfere with the
child’s development, which could lead to the child being unable to connect emotion-
ally with others or make sense of another person’s action in any meaningful way.
Stern’s important contribution, which influenced the writing of this book, is the
concept of intersubjectivity, defined as “the capacity to share, know, understand,
empathize with, feel, participate in, resonate with, enter into the lived subjective
experience from another” (Stern 2004, see Chap. 5). For Stern, intersubjectivity
occurred in the implicit and preverbal domain. He felt that intersubjectivity was
used in a continuous manner, and it expanded as the infant grew.
Moreover, Stern believed that what was implicit occurred in the “nonconscious”
realm, a term Stern preferred over unconscious, because nonconscious resides in a
dynamic system that is nonsymbolic and nonverbal and does not need to be
repressed.
The Boston Change Process Study Group (BCPSG)
The Boston Change Process Study Group was created in 1995 by a small group of
psychoanalysts, developmental researchers, and psychoanalytic theorists who pro-
posed that here-and-now intersubjective experiences observed in infant studies shed
light on how change could be facilitated by psychotherapy and psychoanalysis. The
original members of the BCPSG were Nadia Bruschweiler-Stern, Karlen Lyons-
Ruth, Alexander Morgan, Jeremy Nahum, Bruce Reis, Louis Sander (deceased),
Daniel Stern (deceased), and Edward Tronick (no longer part of the group). The
group was strongly influenced by Stern’s work in infant research. They made great
strides in developing theoretical models that relied on the understanding of deeper
psychodynamic levels of meaning based in implicit forms of representation, co-
constructed by a person’s intentions during their interactions. Since its inception,
the group has published several seminal papers and books. In addition, they asserted
that the therapeutic relationship itself, even in the absence of interpretation, was
sufficient to promote a therapeutic change. They were also proponents of the co-
constructed exchanges that occurred at the implicit domain and came to constitute
implicit relational knowing with significant psychotherapeutic effects.
The BCPSG explains that when making reference to implicit relational knowing,
the group is not referring to the infant’s cognitive function, but rather to the physi-
ological and later to the social/behavioral regulation carried out between the infant
and its caregiver, an act that is remembered by the infant. They see the earliest forms
of biological regulation in the infant emerge for the basic capacity of adaptation:
“The fact that these earliest forms of biological regulation are stored in memory
systems, have mental concomitants and are psychologically meaningful has been
intuitively grasped by some, but is not widely understood. Through representing
these dyadic regulatory exchanges, the human infant moves from being a physiolog-
ical to being a psychological being” (Nahum 2000).
Further, they describe what they believe are the reasons why the implicit domain
has significant relevance to psychotherapeutic encounters: “Implicit processing
consists of the representing of the relational transactions that begin at birth and
continue throughout life. Such implicit processing guides the moment to moment
exchanges that occur in any interaction, including the psychoanalytic situation. All
the things that are the stuff of the interactive flow, such as gestures, vocalizations,
silences, rhythms, constitute this moment to moment exchange, which we refer to
as the local level”.
L. Alan Sroufe (1941–)
L. Alan Sroufe is best known for his work on the Minnesota Longitudinal Study of
Parents and Children, which began in 1975 and is currently in its 38th year. The
project’s researchers follow a sample of 267 first-time mothers who enrolled in the
study during the third trimester of their pregnancy. They have followed these moth-
ers and their children to monitor the course of the child’s individual development
and to discern the factors that lead to good and poor outcomes. They have studied
the subjects at different points in their lives and across diverse settings, including at
their home, in social relationships, and at school.
Sroufe’s team conceptualized attachment as a dyadic emotion-regulation pro-
cess, in which infants are not capable of regulating on their own and therefore
require their caregiver in this process. How the infant ultimately learns how to regu-
late their emotions will depend heavily on how the caregiver regulates his or her
own emotions. The research from the project demonstrated a high correlation
between the caregiver’s attachment status and the attachment status of the infant
with that particular caregiver. Sroufe and colleagues’ research viewed a child’s
behavior as a product of their past history within the context of the current environ-
ment. Further, his team proposed that parallel assessments of a child’s early experi-
ences and the influences of their environment predicted psychopathology better
than either alone. Sroufe’s research articulated a general model of development and
psychopathology: “Within attachment theory, psychopathology is viewed as a

developmental construction, resulting from an ongoing transactive process as the
evolving person successively interacts with the environment. Individual transforms
environment but also is transformed by it…. Patterns of infant-caregiver attachment
and other aspects of early experience may have a special role in the developmental
process via their impact on basic neurophysiological and affective regulation”
(Sroufe et al. 1999). Sroufe believed that when children are able to safely express
their emotional and physical needs, they developed better self-regulatory skills. Not
surprising, children who grow up in chaotic environments have better outcomes
when their attachment to caregivers is positive than those in which the caregivers are
an extension of a chaotic environment, and the children are more prone to relational
trauma. Children with histories of anxious attachment are more likely to have prob-
lems in adolescence or adulthood than are securely attached children.
Edward Tronick (1942–)
Edward Tronick is a developmental researcher and clinical psychologist at the

University of Massachusetts and former member of the Boston Change Process
Study Group. He collaborated with pediatrician T. Berry Brazelton in creating the
Neonatal Behavioral Assessment Scale and Touchpoints tool, which is designed to
interpret what newborns are communicating through their behavior. He is best
known for the “still-face experiment” and the “mutual regulation model.” In his
still-face disruptions, Tronick’s work has led to significant contributions of how
mental health clinicians think about biopsychosocial states of infant consciousness,
the process of meaning making, and how and why we engage with others in the
world. His work contributed to the understanding of the infant self-regulation pro-
cesses when maternal scaffolding is temporarily and abruptly unavailable. During
the experiment, infants initially signal to the mother hoping to get her to resume her
normal behavior. When this fails, the infants express negative emotion and use self-
regulatory behaviors. When the experiment is over, for the next few minutes there is
a continuation of the infants’ negative mood and a reduction in visual regard of the
mother (Tronick 1989). In the model of mutual regulation, Tronick states, “In our
view, the infant–adult meaning-making system is a dyadic, mutually regulated com-
municative system in which there is an exchange of each individual’s meanings,
intentions, and relational goals—what we call the mutual regulation model.” He
adds that it does not necessarily lead to pathology: “The infant of a depressed
mother might become exceedingly sensitive to her emotional state in order to read
her better and to better regulate the interaction. Such sensitivity may be useful when
the infant interacts with others” (Tronick 1989).
Tronick’s current research focuses on infant memory for stressful events and the
epigenetic processes affecting behavior. His research utilizes the still-face and other
stress paradigms, as well as multiple other measures, including ERP (event-related
potentials) and EEG (electroencephalography), salivary cortisol, alpha amylase,
and skin conductance, in addition to behavior measures. Tronick was instrumental
in making his findings accessible to the pediatric community and the lay public,
emphasizing the importance of early mother–child interactions to promote the
development of the infant’s emotional capacities.
We suggest the reader take the time to view the helpful YouTube videos of
Tronick’s still-face experiment.
Andrew Meltzoff (1950–)
Andrew Meltzoff is an American psychologist internationally recognized for his

research on infant and child development. His discoveries about infant imitation
have revolutionized our understanding of early cognition, personality, and brain
development. The seminal work by Meltzoff occurred in the 1970s, when his team
demonstrated that infants had rudimentary forms of imitative behavior early in their
development. Later, his team suggested that a key form of learning that occurs early
in life is through imitation. Another important theme that emerged from his devel-
opmental research is the functional link between imitation, empathy, and social cog-
nition, in particular the ability to develop a theory of mind (Meltzoff 2007). Meltzoff
(2011) masterfully states, “We are not born social isolates. We are fundamentally
connected to others right from the start, because they are seen as being ‘like me.’
This allows rapid and special learning from people. I can learn about myself and
potential powers by watching the consequences of your acts, and can imbue your
acts with felt meaning based on my own self-experience. This propels infants
beyond what they see or know innately. Social cognition rests on the fact that you
are like ‘me,’ differentiable from me, but nonetheless enough like me to become my
role model and I your interpreter.”
Colwyn Trevarthen (1931–)
Trevarthen is a professor of child psychology and psychobiology at the University

of Edinburgh and vice president of the British Association for Early Childhood
Education. He originally trained as a biologist before going on to study infancy
research at Harvard in 1967. As Seligman eloquently states about Trevarthen, “He
has distinguished himself for more than four decades as one of the most inventive
and rigorous explorers of infant development and its implications” (Seligman
2009). Trevarthen has been an influential contributor to matters of intersubjectivity,
which he believes begins immediately after birth. He states about intersubjectivity,
“We are born to generate shifting states of self-awareness, to show them to other
persons, and to provoke interest and affectionate responses from them. Thus starts
a new psychology of the creativity and cooperative knowing and meaning in human
communities” (Trevarthen 2011). His current research concerns how rhythm and
expressions of musicality in movement help communication with children and may
assist the parents, teachers, and psychotherapists who provide care to young
children.
Peter Fonagy (1952–)
Peter Fonagy is a British psychoanalyst and clinical psychologist best known for his
efforts in integrating concepts between attachment theory and psychoanalytic the-
ory. He is recognized for the concept of mentalization, the ability to interpret behav-
ior as meaningful and as based on the mental states and psychological makeup of
both the self and others, such as desires, needs, beliefs, reasons, and feelings. The
infant’s ability to mentalize supports the self-regulation capacities. Some have said
this is akin to “holding mind in mind” (Allen et al. 2008). Fonagy developed a
mentalization-based treatment (MBT) that is rooted in attachment theory and based
on the idea that people who lack the ability to mentalize—caused by an absence of
affective attunement during early childhood—can use this treatment to improve
their mentalization skills. Among his most recognized contributions are his books
Attachment Theory and Psychoanalysis (2001) and Affect Regulation, Mentalization,
and the Development of the Self, with Target, Gergely, and Jurist (2002).
Fonagy’s work regarding the importance in the capacity to mentalize as having a
significant impact in the emotional development of the infant and in the treatment of
patients with borderline personality disorder.
4.2 Developmental Psychology Synthesizers
Allan Schore (1943–)
Allan Schore is known as a clinician–scientist who has provided an extensive syn-

thesis of data from the field of neuroscience (neurobiology, behavioral neurology,
and neuropsychology) and developmental infant research, integrating these with
social, biological, psychological, and psychoanalytic theory. He also developed a
theoretical model of a regulatory theory integrating data and models from a wide
range of different fields. He hypothesizes that attachment theory represents a regu-
latory theory and sees the environment as having a significant impact on the brain
development of the infant, particularly during critical periods in early childhood. He
believes, “Since the human face is a central focus of these transactions, studies of
right brain appraisals of visual and prosodic facial stimuli, even presented at tachis-
toscopic levels, may more accurately tap into the fundamental mechanisms that are
involved in the processing of social-emotional information.” He later states, “This
‘neocortical network,’ which ‘modulates the limbic system’ is identical to the right-
lateralized orbitofrontal system that regulates attachment dynamics. Attachment
models of mother–infant psychobiological attunement may thus be used to explore
the origins of empathic processes in both development and psychotherapy, and
reveal the deeper mechanisms of the growth-facilitating factors operating within the
therapeutic alliance” (Schore 2000a). He defines attachment as the interactive regu-
lation of biological synchronicity between organisms and says, “Future directions
of attachment research should focus upon the early-forming psychoneurobiological
mechanisms that mediate both adaptive and maladaptive regulatory processes”
4.3 Developmental Theory and Theorist’s 71
(Schore 2000b). He further proposes that when ruptures of the attunement process
between the infant and the primary caregiver occur and there is lack of repair of the
rupture, it results in impaired development of the right hemisphere, which contrib-
utes to the inability to regulate emotions adequately, leading to an impaired rela-
tional capacity. In his work with the pediatric community, Schore emphasizes that a
mother’s right brain has an active role in the infant’s right brain capacities in
Schore’s effort to promote early childhood interventions in the medical office to
prevent negative outcomes from attachment problems (Schore 2005).
Schore’s work about his regulatory theory, where he explains his views about
environmental factors having a significant impact in the brain development of the
infant.
Daniel Siegel (1957–)
Daniel Siegel, a developmental synthesizer like Schore, is known for his book The
Developing Mind: How Relationships and the Brain Interact to Shape Who We Are
(2001), in which he reviews and integrates the extensive research from theories of
interpersonal neurobiology and attachment. He advocates the use of mindfulness—
a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and
surrounding environment—as the central idea of his interpersonal neurobiology to
enhance mental well-being. His work synthesizes theoretical concepts from multi-
ple disciplines. Siegel’s book Mindsight: The New Science of Personal
Transformation (2010) offers the public an easy-to-read in-depth exploration of the
power the mind has to promote well-being. He also has written parenting books that
explore the application of the “mindsight” approach to parenting and explore how
brain development impacts teenagers’ behavior and relationships.
Siegel’s work about the mindsight approach.
4.3 Developmental Theory and Theorist’s
We will now proceed to review the main authors who contributed to developmental
theories, keeping in mind that it is not an extensive review, but rather is limited to the
authors who have contributed to the authors’ understanding of the landscape in two-
person relational psychodynamic psychotherapy with children and adolescents.
Attachment Theory
The attachment bond a child establishes with his or her caregiver is essential for
their safety, security, and protection. Similar, human attachment behaviors and emo-
tions were also displayed by rhesus monkeys in Harry Harlow’s (1905–1981) 1958
experiments. Harlow observed rhesus monkeys in the research laboratory during
Fig. 4.1 Harry Harlow’s classic 1958 experiment in which terry cloth and wire “monkey mothers”
(left) were offered to infant monkeys. Infant monkeys preferentially spent time with the cloth
“mother” (right) (Image from Classics in the History of Psychology)
their first year of life that were reared by two “surrogate mothers”—a bare wire
model with a bottle for feeding and a wire model covered with terry cloth without a
bottle (Fig. 4.1). The monkeys spent more time cuddling with the cloth mother and
would only seek the bare wired mother when hungry (Harlow 1958). Bowlby, like
Harlow, proposed that attaching to caregivers was innate and instinctive, character-
ized by specific behaviors, such as seeking proximity with the attachment figure
when upset or threatened (Bowlby 1999; Harlow 1958).
Attachment theory at its core is a two-person relational psychology. Slade (1999)
recognizes the relevance: “In essence, attachment categories do tell a story. They
tell a story about how emotion has been regulated, what experiences have been
allowed into consciousness, and to what degree an individual has been able to make
meaning of his or her primary relationships.” Although attachment is a complex
process, it is important precisely because it serves to organize core developmental
experiences. Sroufe (2005) deftly captures the importance of the organizing
4.3 Developmental Theory and Theorist’s 73
principle for the infant: “Infant attachment is critical, both because of its place in
initiating pathways of development and because of its connection with so many
critical developmental functions—social relatedness, arousal modulation, emo-
tional regulation, and curiosity, to name just a few. Attachment experiences remain
vital in the formation of the person.” Attachment is in essence a dynamic and a
contextual process, which clinically underscores the influence patient and psycho-
therapist attachment patterns exert on each other. Bowlby (1999) proposed that the
quality of the attachment predicts the ability to relate to many others, to establish
trust, to form and retain friendships, and to engage in mutually satisfying emotional
and physical relationships.
John Bowlby (1907–1990)
John Bowlby, a British psychiatrist and psychoanalyst, is best known for his contribu-
tions to our understanding the process of attachment. As such, he is considered the
“father of attachment theory.” Delgado and Strawn (2014) believe “Bowlby may have
preferred to be known as the ‘the primary caregiver of attachment theory,’” which
would reflect his belief that an infant needs to develop a relationship with at least one
primary caregiver, regardless of gender, for healthy psychological development to
occur. Bowlby, an analyst himself, departed from traditional psychoanalytic school of
thought when he posited that infants had an evolutionary, innate wish for close, shared
experiences with their primary caregivers for survival, growth, and development
(Bowlby 1999). He felt this urge was biologically rooted and distanced himself from
Freud’s drive theory, which placed emphasis on sexuality and aggression as innate
drives. Bowlby notes that early in life, the infant creates attachment behavioral sys-
tems that help it assess whether its caregiver is available not only physically but emo-
tionally. He further suggests that the quality of the attachment between the infant and
the parent or primary caregiver is a powerful predictor of a child’s later social and
emotional facility (Benoit 2004). The caregiver strongly influences how the infant
develops the capacity for emotional regulation of their feelings, creating an “internal
working model of social relationships” that serves as a template when relating to oth-
ers (Bowlby 1999). Attachment theory subsequently provided a longitudinal view on
how early dyadic relationships, with mother or primary caregivers, shape the quality
of emotional relationships the child has with others throughout its lifespan.
Mary Ainsworth (1913–1999)
During the 1960s and 1970s, developmental psychologist Mary Ainsworth (1913–
1999), influenced by her communication with John Bowlby, began to experimen-
tally evaluate his basic formulations through studies of infant–parent pairs in
Scotland and Uganda (Ainsworth et al. 1978). Her work led to the foundation of
different descriptions of patterns of attachment between infants and caregivers
based on observable traits of the mother and the infant during times of separation
and reunification: (1) secure attachment, (2) avoidant attachment, and (3) anxious
attachment (Ainsworth et al. 1978).
Mary Main (1943–)
Ainsworth’s work was later expanded by Mary Main (1943–), a researcher who
introduced the concept of “disorganized attachment,” which was instrumental in
understanding the experiences of children exposed to chaotic and unpredictable
environments and their tendency to seek the same type of interactions (Main 2000).
Main is coauthor of the Adult Attachment Interview (AAI) which uses question-
naire and interview to assess attachment status of adults. In the sixth year of follow-
up of her AAI research, the classifications of the adults were found to match the
infant’s Strange Situation classification with their parent 5 years before. Not surpris-
ing, secure parents had secure infants; dismissing parents had avoidant infants; pre-
occupied parents had ambivalent infants; and disorganized parents had had
disorganized infants (Main et al.1985).
Lev Vygotsky (1896–1934)
Lev Vygotsky is best known for his sociocultural theory of psychological develop-
ment. He hypothesized that the development of an individual is determined by their
experience within a group of other people’s activities. The child interactions with
other people are internalized, after which the social and cultural values of the group
also became personal values (Vygotsky 1978).
Vygotsky coined the concept of the zone of proximal development, “the distance
between the actual developmental level as determined by independent problem
solving and the level of potential development as determined through problem solv-
ing under adult guidance, or in collaboration with more capable peers” (Vygotsky
1978). Vygotsky believed that when a student is at the zone of proximal develop-
ment, if supported by a skilled teacher for a learning task, it will provide the student
the nudge necessary to master the task.
Adoption Policies
The works by Harlow, Bowlby, Ainsworth, Main, and Vygotsky in attachment and
sociocultural theory helped influence current adoption policies. The current policies
support early adoption to help meet the child’s emotional needs and prevent the
detrimental effects of the institutionalization of children or the extended time living
in foster homes.
4.4 Temperament Theorists
“Temperament” refers to the “stable moods and behavior profiles observed in

infancy and early childhood” (Thomas et al. 1960). The concept of temperament
came to the forefront in developmental psychology and child psychiatry in the
1960s and 1970s (Thomas et al. 1960). Although there have been many
References 75
classificatory schemes, Thomas and Chess (1999) are recognized for their landmark
scientific contribution to the study of temperament. Their seminal work has achieved
general consensus in that its expression has been consistent across situations and
over time. In their study, Thomas and Chess longitudinally evaluated 141 children
over 22 years, from early childhood until early adulthood (1977, 1982, 1986).
The work of Thomas and Chess confirmed what the British psychoanalyst and
father of attachment theory John Bowlby (1907–1990) had hypothesized: A child’s
temperament influences how the child is experienced by their parents and signifi-
cantly shapes how the parents interact with the child (Bowlby 1999). This way of
thinking, where an active and bidirectional relationship exists between the child and
caregiver, represented a significant point of divergence from the previously accepted
understanding of the infant as a passive recipient and product of his or her environ-
ment (Mahler 1974). In essence, the child began to be seen as a full contributor to
the “goodness of fit” (Thomas and Chess 1999) between the child and the parents
or caregivers. Thomas and Chess were proponents for the theory and practice of
psychiatry to take full account of the individual “uniqueness,” a strong contributor
to the goodness of fit (Thomas and Chess 1970). Furthermore, temperament in
infancy and early childhood is influenced not only by heredity but also by environ-
mental experiences (Emde and Hewitt 2001). As a consequence, temperament is
recognized as pivotal to our current understanding of attachment theory. A review of
the literature regarding child temperament reveals that much research has evolved in
developmental psychology since the early work of Thomas and Chess 30 years ago,
although some controversies remain (Zentner and Bates 2008).
Jerome Kagan is an American psychologist and researcher considered to be one
of the most influential psychologists of the twentieth century. He posited that an
infant’s temperament is stable over time and that behaviors of infants were predic-
tive behavior patterns later in life. He did extensive work on temperament and emo-
tion. Kagan and his research team found that certain children’s behavioral inhibitions
can be predictors of similar characteristics in adults (Moehler et al. 2008).
4.5 Summary
In this chapter we reviewed some of the leading experts who contributed to the field
of child and adolescent two-person relational psychotherapy through their empirical
research. The list is by no means complete as it would be beyond the scope of this
book to include all of those who contributed to further expand understanding the
complexities of infant development.
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come. Paediatr Child Health 9(8):541–545
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developmental psychopathology. Dev Psychopath 24:1–8
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developmental change. Oxford University Press, Oxford
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cal perspectives. Analytic Press, Hillsdale, pp 407–474
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level of representation. Monogr Soc Res Child Devel 50(1/2):66–104
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subjective mind of a newborn human being. Infant Child Dev 20:119–135
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Key Concepts in Two-Person
Relational Psychology 5
Distorted developmental psychic programming can be repaired

through psychotherapeutic experiences.
—Eric Kandel
The empirical study of infants and toddlers confirmed what Bowlby (1969) and
Winnicott (1971) had believed: that the infant was indeed a “social being.” This
hypothesis inspired a generation of developmental researchers to search for the neu-
robiological underpinnings of childhood psychological growth and behavioral
issues. Today, there is little debate that the human brain is a social organ (Cozolino
2010). The changes undertaken by the brain from infancy to adulthood are mediated
by the processes of emotional availability, attachment, affect regulation, and cogni-
tion, which all play a central role in two-person relational psychotherapy. Cozolino,
a developmental neuroscientist, writes, “A therapist attempts to restructure neural
architecture in the service of the more adaptive behavior, cognition, and emotion”
(2010). Additional research has demonstrated that infants have an innate bias toward
self-regulation and mastery and work to create coherence of their perceptual experi-
ence and maintain organization of their happenings (Sameroff 1992; Emde 1992).
As such, we currently are in an era in which the importance of what happens during
infancy, stored as relational schemas in nondeclarative memory systems, can be
nonconsciously retrieved by the patient and changed through here-and-now new
emotional experiences with the psychotherapist (Litowitz 2005). This is in contrast
to Gilmore and Meersand (2014), who in their very much traditional one-person
psychology book on child and adolescent development regrettably state, “Although
we concur that certain basic interpersonal, emotional, and biological needs must be
met in infancy for development to proceed, we do not see infancy as the preeminent
developmental moment” (italics ours). Therefore, we provide the reader the neces-
sary information from infant developmental research to help elucidate that infancy
is in fact a preeminent developmental moment.

DOI 10.1007/978-3-642-40520-4_5
80 5 Key Concepts in Two-Person Relational Psychology
Table 5.1 Key concepts Meaning-making processes

of two-person relational
Affective attunement
psychology
Emotional availability/social referencing
Temperament
Internal working models of attachment
Intersubjectivity
Real relationship
Present moment
Now moments
Fuzzy intentions and sloppiness
Moments of meeting
Mentalization
Corrective emotional experience
IF
Child Parent
• Meaning making (+++) • Affective attunement (+++)
• Mirror/echo neurons/ • Emotional availability (+++)
Internal working models
default mode network • Social referencing (+++)
of attachment
• Social referencing (+++) • Temperament
• Cognition • Cognitive flexibility
Many now moments Everyday ruptures

Healthy development
Frequent “Aha!”
Many Repairs
Moments of meeting
Fig. 5.1 Schematic representation of intersubjective experiences between child and parent in the
context of a secure attachment. Healthy development and maturation occur through intersubjective
field (IF) which is the overlap of their subjective experiences. The number of (+) denotes degree of
strength in this dyad
In this chapter, we present the reader a structured overview of the key concepts
from developmental research that influenced the development of child and adoles-
cent two-person relational psychology and psychodynamic psychotherapy
(Table 5.1). We have attempted to organize these key concepts loosely on how they
evolve in a healthy and securely attached infant (Fig. 5.1). Few of these concepts are
5.1 Meaning-Making Processes 81
standalone and many that overlap in terms of clinical usefulness and will be grouped
together. We conclude this chapter with several case examples to demonstrate the
use of these important key concepts clinically.
5.1 Meaning-Making Processes
“Meaning making” is the process of how people make sense of their subjective
experiences within the context of their relationships to others. During the first few
months of life, an infant’s biopsychosocial development will be constructed from an
amalgam of layered and complex meaning-making processes, which will influence
how they will make sense of themselves and their experiences with others. Tronick
(1989) reminds us that developmental research has expanded the way we under-
stand how infants organize their behaviors in the context of stimulating events, such
as emotional expressions of the face, voice, gaze, and the psychophysiology of self
and others. He writes:
…these processes include motor activity, emotions, temperamental reactivity, mirror
neurons, cortical processes, and processes such as the dampening of the hypothalamic–
pituitary–adrenal axis and the kindling effect of trauma on neuronal groups.
Damasio et al. (2000) adds that such internal meanings represent a “core biopsy-
chosocial state of consciousness” for the infant. Such processes can have a profound
impact on the developing infant, as it has been proposed that they represent a central
mechanism that constructs both typical and pathological outcomes (Tronick and
Beeghly 2011). The process of meaning making allows a person to construct mental
models that ground their understanding in a deeply personal and unique fashion.
Growing evidence suggests that these meaning-making processes continue through-
out life (Kegan 1994). That is, a person’s representational models are fine-tuned in
perpetuity as they make sense of the meaning, affect, and intentions of others within
the intersubjective field. Further, research has documented that infants have an
innate bias toward self-regulation and mastery and to create perceptual–experiential
coherence and organization of their happenings (Emde 1998). Developmental
research demonstrates that during the first few months of life, children rely almost
entirely on perceptual clues from others, which can help them identify temporospa-
tial, “amodal” qualities (Stern 1985), such as rhythm, intensity, sequence, affect,
and tone in their interactions with others. Toward the end of the first year of life,
verbal–symbolic clues begin to gain ascendancy, leading to the construction of rep-
resentational models with symbolic qualities.
Developmental researchers Stern and Emde found that the infant’s brain is
designed to make meaning of what goes together in reality. Dodd (1979) and
Trevarthen (1977) demonstrated that infants as young as 3 months old can experi-
ence distress when there is a discrepancy between reality and their mental represen-
tation of the event. For example, when an image of their mother’s face is on a
television screen and her voice is delayed by a few milliseconds, the infants detect
the discrepancy, remaining upset until the discrepancy is corrected. In a review of
infant research, Bleiberg (1994) states, “Infants (1) develop fairly realistic
spatial-temporal models of reality and use them to anticipate what reality will be
like, and (2) present a readiness to activate affective responses of anxiety when
reality fails to match their mental model of it.”
More recently, developmental researcher Andrew Meltzoff (2007) has found that
infants can represent other people as “like me” and that their imitation of bodily
movements is a meaning-making process that establishes a connection between self
and other. Meltzoff and Brooks (2007) state, “Imitation shows a sharing of actions.
This action, sharing is present at birth and tells us much about the intersubjectivity
that infants bring to their first encounters with others.” Further, Meltzoff and Brooks
(2007) share that the duplication of the action patterns, mannerisms, and gestures
humans use to communicate is part of the fabric of human communication and runs
in the background, fostering emotional cohesion in everyday interactions, often
times outside of explicit awareness. Thus, Meltzoff’s research experiments in
essence define the goals of a two-person relational psychotherapist, “Human par-
ents often act as good therapists, mirroring (and interpreting) the infant’s thoughts,
feelings, and behaviors.” We would clarify that the two-person relational psycho-
therapist’s mirroring and interpreting occur at the implicit nondeclarative level,
which allows moving forward the psychotherapeutic process and creating new and
more adaptive developmental pathways (Meltzoff 1999).
Ed Tronick, a developmental researcher, who was a member of the Boston
Change Process Study Group, designed the “still-face experiment,” in which moth-
ers would present a “still” face to their infants in the midst of play (2007). Healthy
infants, after being presented with their mother’s nonresponsive facial expression,
would at first continue to smile and gesture (learned implicitly during the interactions
with his mother), attempting to reengage with her. However, when the mother con-
tinues with her still face, the infants became upset and would resort to vigorous
verbal and motoric attempts to elicit their mother’s response. If not successful, they
would become despondent and withdrawn. Tronick (2007) explains the infant’s
reaction: “The (in)-action of the still-faced mother precludes the formation of the
dyadic state of consciousness because there is no exchange of meaningful affect and
action with the infant, no creation of meaning.” The meaning-making process has
neural underpinnings and is further discussed in Chap. 7.
In this section, we briefly discuss mirror and echo neuron systems, which are
believed to play fundamental roles in imitation in infants and in understanding with
regard to conspecifics. This system, which is localized in the frontoparietal regions,
has been described by Rizzolatti and Craighero as a system responsible for the
“neural basis of a mechanism that creates a direct link between the sender of a mes-
sage and its receiver [and allows] actions done by other individuals become mes-
sages that are understood by an observer without any cognitive mediation” (2004).
In infant research, infant attachment outcomes at 1 year can be predicted based on
the degree of interactive coordination of vocal rhythms between mothers and infants
at 4 months (Jaffe et al. 2001).
Literature supports that the mirror neuron system is complex and intertwined in
electrophysiological terms with the scaffolding in degrees of functionality
(Iacoboni and Dapretto 2006). Mirror neurons are a particular class of visual motor
neurons, and it seems natural that an audiovisual neuron system develops
5.2 Affective Attunement 83
to understand object-related actions. This encompasses a visual mirror neuron

system and an auditory (echo neuron) system that allows for the understanding of
the sound that accompanies the actions as in language; “object-related actions are
not sufficient to create an efficient intentional communication system” (Rizzolatti
and Craighero 2004).
However, over the last decade, more than a dozen “mirror neuron” areas that
involve Brodmann area 9 have been identified, including in the inferior frontal
gyrus, premotor cortex, primary visual cortex, cerebellum, and the limbic system,
and these structures are functionally connected (Molenberghs et al. 2012). Thus,
while the distinction may seem semantic, the extant and accumulating neurostruc-
tural and neurofunctional data argue that it is better to consider these “mirror
neurons” within larger structures and regions that participate in coordinated reflec-
tive functions and reciprocally modulate one another, rather than as isolated, auton-
omously functioning regions (see Chap. 7 for a more comprehensive discussion).
5.2 Affective Attunement
Affective attunement is known as the sharing and alignment of internal states that
occur during the interaction between the mother and infant, usually around the
eighth month in the domain of intersubjective relatedness to others (Stern 1985,
2005). Stern (1985) gives an example of an infant stretching and extending his
fingers to reach a toy. During this moment, a mother may recognize her son’s
concentrated facial expression and may begin to utter encouragement, “uuuh…
uuuh!” signaling implicit encouragement by the crescendo of her voice. The
mother’s accelerating vocal respiratory effort matches the infant’s accelerating
physical effort. In a securely attached relationship, affective attunement largely
consists of implicit processes and is seemingly automatic. Stern reflects on this
process:
It is a matching, more than an imitation, that is cross-modal, each partner using a mode of
expression different, unconsciously* the most often. The reference for the match is the
internal state and not the external behavioral act. Attunement is felt like an unbroken
process in the time and leads to define a new quality of feeling, vitality. The quality of the
relation of attunement determines probably the ulterior level of the intersubjective
relatedness of the ability to ‘be-with’, to share.
*Stern’s use of the term “unconscious” is not Freud’s conflicted unconscious but rather
a dynamic nonconflicted unconscious also referred to by the Boston Change Process Study
Group as “nonconscious.”
We would draw the reader’s attention to Stern’s careful delineation that suc-
cessful affective attunement is based on the internal state and not on an external
behavioral act. Stern then ties the quality of this attunement to the level of intersub-
jective relatedness, which is the ability to be with and implicitly share experiences
with others. Emde and Hewitt (2001) consider the affective system as psychobio-
logical dispositions with both organizing and communicative functions. Affective
attunement is cross-modal and encompasses both verbal and nonverbal communica-
tions. Interactions encompass much more than a shared lexicon; they are strongly
influenced by vocal tonality and intensity, and observable movements like touch-
ing, laughter, and singing are stored in preverbal amodal understanding, becoming
precursors to affective regulation (Barsalou 2010). Ultimately, these various forms
of expression should provide a sense of “I get what you need.”
In clinical practice, the two-person relational psychotherapist’s affective
attunement refers to the authentic and genuine responses given to the patient. Unlike
empathy, the relational psychotherapist is not only reflecting on the patient’s
subjective state but also conveying his or her own internal perspective to the patient.
Thus, in two-person relational psychodynamic psychotherapy of children and
adolescents, there must be concerted attention made to matters of emotional
availability and affective attunement, which play a critical role in psychotherapeutic
change. Diener and colleague state, “The more therapists facilitate the affective
experience/expression of patients in psychodynamic therapy, the more patients
exhibit positive changes” (Diener et al. 2007), and concludes, “Research indicates
that contemporary psychodynamic therapies place greater emphasis on encouraging
experience and expression of feelings compared with cognitive behavior therapies.”
According to Safran and Muran, “After approximately a half century of psycho-
therapy research, one of the most consistent findings is that the quality of the thera-
peutic alliance is the most robust predictor of treatment success” (2000).
Earlier, we described a typical example of a successful affective attunement
between mother and her infant boy reaching for a toy. In contrast, when the primary
caregiver does not provide appropriate affective attunement in the early months of
life, the infant is at increased risk to develop poor self-regulatory abilities, which
become the precursor to a variety of insecure attachment patterns. On one hand,
consider an infant boy whose mother is very anxious and has difficulty tolerating
the child’s struggle in reaching for a toy. Instead, she reaches and gives the toy to the
child and thereby prevents overt signs of distress, which make her anxious. This
mother does not provide the emotional availability needed for the child to have a
sense of vitality in his exploration and impedes the development of self-regulatory
functions. Alternatively, a mother may be dismissive of the child reaching for a toy,
and the child will learn that he or she cannot rely on his caregivers, and later others,
for appropriate affective attunement. This will also lead to difficulties with self-
regulation and interrelatedness. Taking this scenario a step further, if the mother is
critical and laughs at the boy when he reaches for the toy, and if this is typical of
their mode of interaction, it is reasonable to consider that the child will develop a
disorganized attachment style. All of these examples illustrate implicit patterns of
relating that will likely over time form internal working models of insecure attach-
ment, which is a considerable risk factor for maladaptive interpersonal behavior and
formal psychiatric disorders.
5.3 Emotional Availability and Social Referencing
Emotional availability is a comprehensive construct based on the integration of find-

ings from developmental research and attachment theory. This construct is influ-
enced by both caregiver and child. Healthy emotional availability can be evident by
5.3 Emotional Availability and Social Referencing 85
mutual interest and openness within the dyad of child and parent. This may include
a range of positive and negative emotions.
Social referencing serves to expand emotional availability by introducing a sense
of shared meaning about events. Emde (2000) discovered that there is a need for
“reciprocity” between caregiver and child for emotional growth and the ability to
ultimately enjoy mutually fulfilling and healthy relationships. For Emde (1998),
emotional availability referred to the “receptive presence” of the parent to the child’s
emotional signals. Emotional availability is a vital aspect of the infant–caregiver
relationship before the onset of social referencing (Emde and Easterbrooks 1985).
Further, it connotes a type of presence and availability that has a great deal in com-
mon with the way a psychotherapist “is there” for a patient (Biringen and
Easterbrooks 2012).
Social referencing is a critical milestone in typical child development that refers
to the process in which a child looks to a caregiver in an emotionally ambiguous
situation in order to obtain clues on how to interpret and resolve the situation.
Successful social referencing results in a capacity to self-regulate behavior, gain
reassurance, and understand how to proceed (Oppenheim et al. 1997). Bleiberg
(1994) in reviewing infant research literature states:
Beginning in the second half of the first year of life, infants respond to a novel or uncertain
situation—that is, one for which they lack an internal model—in a predictable fashion:
They search the caretaker’s face for clues to resolve the uncertainty. If the caretaker’s face
signals encouragement, the infants explore with pleasure. If, however, the caretaker betrays
anxiety, they become inhibited and distressed.
The visual cliff experiment is a well-recognized paradigm for studying how social
referencing can regulate behavior and was used by Emde and Easterbrooks (1985) to
assess the effect of maternal emotional signaling on 1-year-olds. In this experiment,
infants were placed on a special table in which a transparent tabletop appeared to end
and fall off between the infant and the mother. Remarkably, the majority of infants
will cross the cliff in the face of apparent danger if the mother demonstrates a posi-
tive facial display. Conversely, when the mothers displayed a fearful face, none of
the 17 infants crossed. The observation of social referencing appears to have real-
world implications. In a study, Dickstein and Parke (1988) found that when marital
satisfaction was stable, infants would equally use their father and mother as social
referencing targets. Some research suggests that there is correlation between the
security of attachment and maternal referencing (Klinnert et al. 1986). Dickstein
et al. (1984) found a strong relationship between infant temperament measures and
social referencing capacity, rather than attachment patterns.
As demonstrated by the visual cliff experiment, negative expressions by caregiv-
ers can regulate infant behavior similarly to how positive expressions do so. When
infants look at parents or caregivers and notice anxious or fearful expressions, they
can develop maladaptive, problematic behaviors over time. As an example, starting
school is generally an exciting time for parents, even though there may be some dif-
ficulty in allowing the child to separate. Though parents may be implicitly anxious,
they understand they need to mitigate the child’s inherent anxiety, through facial
and emotional expressions that provide reassurance to the child of the new endeavor:
Table 5.2 Key aspects of development for the relational child

In utero, the infant begins to develop internal working models according to the sounds/voices
that he or she hears
After birth, the infant develops meaning making of sounds, smells, touch, and facial
recognition, within implicit nondeclarative memory systems
During infancy, psychological attunement to the emotionally available parent creates internal
working models of attachment
Intrinsic attributes of the child (e.g., temperament and cognition) affect the goodness of fit
with the parent
Social reciprocity between child and parent is influenced by each others’ internal working
models of attachment
The child’s capacity for social referencing allows him or her to distinguish emotionally
available family members
Development occurs within a cultural context
“everything will be fine.” However, if parents or caregivers consistently provide

fearful or anxious emotional expressions, the child may begin to refuse to go.
Additionally, the child may be eager to go to school and rely on school personnel to
provide the social referencing needed for reassurance.
Importantly, Emde (1992) also reminds us that social referencing processes have
largely been studied from the point of view of the infant and have neglected the
caregiver’s side of the process. Observations of caregiver social referencing may
help further knowledge and develop programs to promote maternal sensitivity and
caregiver emotional response essential for the child’s growth. Additionally, the two-
person relational psychotherapist emotional availability is also essential for the
patient and family’s growth, as they will implicitly and nonconsciously make use of
the psychotherapist’s more adaptive relational knowings.
Several authors have thought of these early referencing patterns in social con-
texts as initially being dyadic. However, toward the end of the first year, looking
behavior becomes increasingly referential—or coordinated between many people—
with relationships influencing relationships. The emergence of referential looking is
of particular interest because it is a major milestone in the infant’s development of
social cognition. It is a marker that the infant has an understanding, however primi-
tive, that other people have intentions directed toward the outside world. These pro-
cesses will grow increasingly more sophisticated and become the underpinnings of
theories of the mind, emerging by the third year (Hala 1997; Striano and Rochat
2000). Up to now, most studies of infant–caregiver interactions suggest that multi-
ple influences are likely to contribute to the emergence of individual differences in
social referencing (Table 5.2).
5.4 Temperament
The concept of temperament has traditionally had limited use in the larger mental
health community. In contrast, early childhood educators, developmental
psychologists, and pediatricians have routinely embraced the concept of
5.4 Temperament 87
temperament. Temperament can be broadly defined as observable and persistent

behavior patterns in early childhood that distinguishes one child from another.
These patterns remain relatively consistent over situations and time. Many spe-
cific patterns of behavior have been identified (McCrae et al. 2000; Windle and
Lerner 1986) with several useful classification schemes used across the lifespan.
Thomas and Chess are credited with the modern concept of temperament. In
Thomas and Chess’ New York Longitudinal Study of 141 youth (Thomas and
Chess 1982), they described temperament as having four general styles: 45 %
were classified as “easy or flexible,” 15 % “slow-to-warm-up,” 10 % as “difficult
or feisty,” and 35 % as “mixed,” a combination of the three, which remained con-
sistent at 22-year follow-up (Thomas and Chess 1999). Though we discuss tem-
perament in greater detail in Chap. 8, we will briefly visit this concept as it relates
to two-person relational psychology.
Behavioral inhibition is another important temperamental construct that should
be clearly assessed prior and during the therapeutic process. In their pioneering
work, Kagan and colleagues (1986) characterized behavioral inhibition as the ten-
dency of children, when presented with an unfamiliar circumstance, to restrict
speech and play and retreat to an object of attachment. These observations were not
restricted to behaviors, but indeed, physiological differences such as higher and
more stable heart rates were found in children who were classified with extreme
behavioral inhibition. Such temperamental traits in infancy have repercussions later
in life. Through a series of studies, Biederman and colleagues found that infants
with high levels of behavioral inhibition were at high risk for the later development
of childhood anxiety disorders and comorbid psychiatric conditions (Biederman
et al.1993, 2001).
Though temperament is presumed to have a biologic basis, environmental influ-
ences in a child’s early life may lead the child to selectively develop some traits over
others necessary for adaptation. For example, two well-established temperamental
traits, emotional reactivity and self-regulation, may be strongly influenced by a
child’s early environment (Bronson 2000; McLaughlin et al. 2010). Temperamental
traits may also be broadly shaped within a cultural and socioeconomic context
(Bornstein and Cote 2009; Paulussen-Hoogeboom et al. 2007). Thus, temperament
is a multifactorial process, including contributions from genes, neurobiology,
observable behavior patterns of interaction, and culture. Ultimately, temperamental
traits play an important role within any therapeutic relationship.
Temperamental differences between individuals, especially within the parent–
child and psychotherapist–patient relationships, can play a critical role in the qual-
ity of interpersonal interactions. As Roffman and Gerber (2012) state, “Genetics
and temperament are two important (and likely related) areas of research that are
undoubtedly relevant to the variability of patient outcome in psychodynamic treat-
ment, and ultimately to our understanding of the mechanisms of psychopathology
and therapeutic change.” We would encourage psychotherapists to consider not only
the child’s or adolescent’s temperament but also that of the primary caregivers.
In keeping with the two-person relational perspective, it is also important for the
psychotherapist to reflect on his or her own temperamental style, as it will also
contribute to the goodness of fit with the patient in the intersubjective field.
5.5 Internal Working Models of Attachment (IWMA)
The principal tenet of attachment theory is that people have an innate predisposition
to form close emotional bonds with others to assure survival. Bowlby (1969)
proposed a construct, known as internal working models, to describe the mental
representation of the self and others formed by early childhood relational experi-
ences. In typical development, stable internal working models are formed to under-
stand and predict the intent of others within a certain context and environment,
conferring a survival benefit to maintain proximity to caregivers and establish a
sense of “felt” security (Bretherton 1985; Sroufe and Waters 1977). Bowlby noted
that early in life, the infant creates attachment behavioral systems that help assess
whether the parent or caregiver is available not only physically but also emotionally.
The parent or caregiver strongly influences how the infant develops the capacity for
emotional regulation of their feelings, creating an internal working model of attach-
ment (IWMA), which serves as a template when relating to others (Benoit 2004).
Further, the quality of the attachment between the infant and the parent or caregiver
is a powerful predictor of a child’s later social and emotional abilities (Benoit 2004;
Bretherton et al. 1990).
The empirical evidence of the impact of caregivers’ behavior on infants’ behavior
and development has steadily accumulated since Bowlby’s original proposition
(Cassidy and Shaver 2008). In addition, individual patterns of attachment appear to
remain relatively stable and persist over time (Grossmann and Grossmann 2005;
Mikulincer and Shaver 2005; Sroufe 2005). In an elegant study, Johnson and col-
leagues (2010) found evidence of internal working models during a replication of
the Strange Situation experiment. The infant participants and their mothers were
observed watching an animated presentation involving either a secure or an insecure
caregiver. Three unique patterns of expectations emerged: (1) secure infants demon-
strated a desire for comfort and had an expectation of caregiver comfort, (2)
insecure-resistant infants expected to be comforted but did not expect comfort from
the caregiver, and (3) insecure-avoidant infants neither expected comfort for them-
selves nor expected comfort from the caregiver. Johnson and colleagues came to the
following conclusions:
These results constitute direct positive evidence that infants’ own personal attachment expe-
riences are reflected in abstract mental representations of social interactions…. These
representations can now be traced as they emerge, well before existing behavioral measures
of attachment can be employed.
Their data supports Bowlby’s original claims that infants form internal working
models of attachment-relevant behavior, and these models are associated with
infants’ own behavior.
In recent years, neurodevelopmental research has begun to uncover the underpin-
nings of how IWMA are formed (Schore 2005). The attachment quality between a
child and caregiver is multifactorial, and the developing IWMA subsequently allows
for social referencing, affective attunement, implicit relational knowing, and
intersubjectivity.
5.5 Internal Working Models of Attachment (IWMA) 89
Attachment Patterns: Secure, Insecure-Ambivalent/Anxious,

Insecure-Avoidant/Dismissive, and Insecure-Disorganized
Developmental research experiments have delineated four attachment patterns that

warrant further discussion given the central role they play in determining the
patient’s and psychotherapist’s ability to interact with each other.
Secure Attachment
Secure attachment between the infant and caregiver develops when there is an
implicit sense of safety, emotional availability, social referencing, and reciprocity
within the relationship. The parent or caregiver provides the affective attunement
necessary to help the child learn to manage normal and growth-promoting periods
of disruption, such as the time between feedings, diaper change times, first visit to
the pediatrician, and when setting limits.
The parent or caregiver may choose to provide affective attunement in the form
of holding, soothing with touch, rhythmic rocking, or singing with a melodic voice.
This provides the child with a coherent, implicit, nonconscious, and cohesive narra-
tive over time. The child begins to value attachments, whether pleasant or temporar-
ily unpleasant, over time and is able to develop other early forms of social reciprocity
(Meins et al. 2002). Children with secure attachment in the Strange Situation exper-
iment were easily comforted after a brief separation from their mothers and then
resumed exploration and play (Ainsworth and Bell 1970).
In general, secure attachment has a protective tendency, even under stress.
Children with secure attachment have physical and psychological skills that will
allow them to manage normal periods of distress or relationship rupture while main-
taining their core sense of self and their core beliefs about others (Edwards et al.
2006). Nevertheless, at times, even a securely attached child will be unable to toler-
ate and manage certain unexpected life events. In Chap. 12, we discuss this in par-
ticular by reviewing a case of a school age child who is overwhelmed with his
father’s terminal cancer.
Insecure-Ambivalent/Anxious Attachment
An ambivalent/anxious form of insecure attachment occurs when the infant or tod-

dler experiences anxiety due to a parent’s or caregiver’s inconsistent emotional
availability. In the Strange Situation experiment, these infants were highly dis-
tressed by separation and had difficulty being consoled after reunion, and they
demonstrated resistance to the parent’s wish for reengagement (Ainsworth et al.
1978). From the perspective of the parent or caregiver, most commonly the anxiety
conveyed to their child is based on their subjective experience of not being compe-
tent as a parent or resenting being in a responsible position. What develops within
this dyad is a relationship that is characterized by superficiality and the implicit
need for self-reliance. As the child grows older, he or she may hover close to neigh-
bors, teachers, and peers but will fail to convey a sense of hoped reciprocity as the
result of self-doubt and anxiety about rejection. Ultimately, this is an enactment of
the original pattern established by the ambivalent/anxious parent or caregiver
(Sroufe et al. 1999).
Insecure-Avoidant/Dismissive Attachment
The avoidant/dismissive type of attachment develops when the toddler grows in

constant fear due to the unpredictability of the quality of the relationship with the
parent or caregiver and cannot develop a stable internal working model of social
relationships (Bowlby 1969). As the child grows, he or she shows a tendency toward
passivity in the presence of the parent or caregiver and avoids the expression of
affect in order to prevent the imagined or real rejection from the parent or caregiver.
In the Strange Situation, these infants showed little distress at separation from the
parent and then actively ignored the parent upon reunion (Ainsworth et al. 1978). In
other words, children who develop avoidant/dismissive internal working models
have stored in implicit nondeclarative memory the pattern of distancing themselves
from others, which may proactively prevent feeling hurt when ignored.
As an example, a mother while walking toward and waiting for the elevator is
quiet, with a scowl face, and does not interact with her two children, ages 2 and
4 years of age, in spite of their attempts to engage with her. Once in the elevator, the
mother continues to be silent and does not engage with other friendly people reach-
ing out to her affectively. The children have learned to avoid and dismiss engaging
with other people in the elevator who demonstrated willingness for some degree of
social reciprocity. Further, the elementary school aged child with an avoidant/dis-
missive type of attachment often rejects closeness and help offered from teachers to
complete assignments. The child is generally independent and self-reliant, avoids
peer interactions, and spends more time alone watching TV or playing video games.
When the child becomes an adolescent, he or she may prefer to play video games
and spend time alone and also may resort to illegal substance use to help with the
feelings of loneliness. They have heightened self-doubt about whether they will be
of any interest to other people.
Insecure-Disorganized Attachment
Main and Solomon (1990) originally introduced the term “disorganized attach-
ment” to describe a series of 55 infants who did not fit either a secure, anxious, or
avoidant attachment style within the Strange Situation experiment. Though this
cohort of infants did not share any broad, patterned attachment behaviors, Main and
Solomon observed that these infants shared “bouts or sequences of behavior which
seemed to lack a readily observable goal, intention, or explanation.” Subsequently,
a careful examination of the infant–mother dyads revealed that the mothers in these
5.6 The Contextual Nature of Attachment 91
dyads had themselves suffered from attachment traumas, i.e., physical or emotional
child maltreatment (Ainsworth and Eichberg 1991). Winnicott (1971) similarly
found there was a narrow window in which an infant could tolerate a rupture with a
primary caregiver, such as an absence, but if that window were too wide, the experi-
ence of the infant would result in distress and confusion. Repeated ruptures within
the dyad would devolve into a disorganized pattern of attachment that may general-
ize to other social interactions and the development of poor capacity for social
reciprocity.
Disorganized attachment patterns appear to be strongly related to the effects of
enduring relational trauma that intrudes into the interpersonal life of a child. The
term developmental trauma is apt to describe the complexities of relational trauma
in childhood and the devastating consequences it has throughout their life span
(van der Kolk 2005). When children experience neglect or abuse by people respon-
sible for their well-being, it is deleterious to their self-organization and can broadly
affect the cognitive, physiological, emotional, and relational domains (Hertsgaard
et al. 1995; Hesse and Main 2000). It is not surprising that there is often a history
of abandonment or trauma in these children, who then grow to be frightened or
hostile toward commitment in relationships and perpetuate cycles of incoherent life
discourse. These children are unable to develop the self-regulatory functions
needed to establish closeness with others and to envision a positive future. The
preschool age child who angrily pushes his or her mother away after a brief separa-
tion and the mother who is unable to provide comfort but instead similarly responds
with anger are assumed to indicate an insecure and disorganized form of attach-
ment (Pietromonaco and Barrett 2000). As discussed by Schore (2000), relational
trauma can persist into adulthood in the form of additional risk of repeated trauma
and dissociative experiences. Herman (1997) offered the term “complex trauma” to
delineate trauma that involves repeated and chronic abuse, instead of a single trau-
matic event that can cause posttraumatic stress disorder (PTSD). Some have sug-
gested that this may represent an early precursor to borderline personality disorder
(Holmes 2004).
5.6 The Contextual Nature of Attachment
As we have described previously (Delgado and Strawn 2014), when two people
interact with each other, the attachment patterns observed are specific to those two
people. It is not necessarily a representation of attachment patterns that may be
exhibited when with others. For example, a child may be dismissive of the
psychotherapist in his office, and the psychotherapist may feel the need to make
extra efforts to connect with the child, although neither behavior is the typical mode
of interaction for them. Their interaction has been guided by the here-and-now
intersubjective experiences of each other. The child, who may have a history of
secure attachment, could still implicitly fear sharing his struggles with the death of
a parent to avoid reexperiencing the sadness and anger of the event. In contrast, the
relationally informed psychotherapist implicitly is reminded by the child’s anxiety
in relating, of his own childhood difficulties tolerating others’ dismissiveness, and

nonconsciously and unknowingly attempts to speed up the process by actively
encouraging the child to talk about the traumatic event, without recognizing that the
child’s reluctance is well founded. Although both the child and psychotherapist
typically use a secure form of implicit relational knowing when interacting with
others, during the session the child uses dismissive behaviors and the psychothera-
pist, anxious behaviors, and both cocreate a disruption (i.e., a now moment, see
below under Intersubjectivity) that will need to be repaired by the psychotherapist.
The psychotherapist will ultimately recognize the child’s subjective anxieties in the
here-and-now intersubjective field and may choose to enact and self-disclose (Chap.
6) that as a child himself, experiencing negative feelings was difficult and that
sometimes playing a game helped create a reprieve from the intensity of the feel-
ings. He may then proceed to invite the child to play to implicitly convey, “I under-
stand that you are uncomfortable in here with me. You do not need to tell me what
worries you. Let’s play and cocreate a positive experience for you in the here and
now.” Wachtel (2010) eloquently captures this dilemma:
We begin to think that this is the way the person “is,” when it is more accurate to say that
this is the way he is with me (and, moreover, how he is with me when I am acting in a par-
ticular way, and he may not be that way even with me when I am being different). Thus, a
fully contextual or two-person conceptualization of attachment not only attends to how the
person varies in the attachment experiences that are evoked with one person or another; it
also requires us to ask what is happening that leads the person to relate and to perceive and
experience in a secure fashion, in an ambivalent or avoidant fashion, etc. It attends to what
each party to the exchange or to the relationship is doing and feeling at any particular
moment, and it asks what each person’s participation in the attachment relationship at any
given moment is in response to and what it evokes in the other.… What is really being
measured is a depiction of the person’s average or modal attachment status, not a measure
that is unvarying through the days and weeks and years; our understanding of the person’s
“central tendency” must be complemented by an understanding of the exceptions like inpa-
tient, the office of the therapist, the persistence of the child’s attachment behavior contrib-
utes to the continuity of the child’s environment just as the continuity of the environment
contributes to the persistence of the attachment status.
Therefore, it is necessary for the two-person relational psychotherapist to be an

active participant in the child’s or adolescent’s subjective experiences in order to be
fully immersed and affected from the “inside out” of the attachment patterns as they
are played out. It is within this intersubjective field that cocreation takes place and
the psychotherapist can carefully plan how to effectively provide a new emotional
experience in the patient’s own nondeclarative language, thus creating new neuronal
pathways that improve a sense of identity and regulate affect. For example, props
may be used, such as soothing (transitional) objects, toys, etc., to prevent feelings of
abandonment and to foster a feeling of connection. Wachtel (2010) describes this
process as helping patients to learn to implicitly seek “accomplices” more akin to
the healthy psychotherapist and not repeat prior maladaptive attachment patterns
(Chap. 3).
5.7 Fundamental Principals of Two-Person Relational Psychotherapy 93
This is in contrast to traditional one-person psychology, which has as its basic

tenet the goal of helping the patient understand their dysfunctional unconscious
conflicts, ego weaknesses, object relations problems or self-object functions through
the repetition of transference paradigms with the psychotherapist to allow for
interpretations to make the unconscious conflict conscious (Chap. 2).
5.7 Fundamental Principals of Two-Person Relational

Psychotherapy: Implicit Relational Knowing
and Intersubjectivity
Implicit Relational Knowing
The concepts of implicit relational knowing and intersubjectivity go hand in hand as

fundamental principals in two-person relational psychology and psychodynamic
psychotherapy. We define implicit relational knowing as the processes of social
interaction and attunement that are largely nonverbal, based on nondeclarative
memory systems (Table 5.3) and outside conscious experience (Lyons-Ruth et al.
1998). Though we discuss intersubjectivity in detail later in this chapter, it can be
briefly defined as the psychological “field” between participants in which subjective
experiences are inextricably intertwined with one another (Dunn 1995). Implicit
relational knowing is a complex process that begins in infancy (BCPSG 2007), and
then, as Nahum (2000) aptly described, “the infant goes from being a physiological
being to a psychological being.” Implicit relational knowing is masterfully described
by Lyons-Ruth et al. (1998):
[Implicit relational knowing] begins to be represented in some yet to be known form long
before the availability of language and continue to operate implicitly throughout life.…
Language is used in the service of this knowing, but the implicit knowing governing intimate
interactions are not language-based and are not routinely translated into semantic form.
Implicit relational knowing cannot be recalled in the explicit declarative mem-

ory system. Procedural nondeclarative representations guide a person on how to
proceed in action and how to do things, and they are not symbolically coded. For
example, when driving a car, we do not have a symbolic representation for suddenly
Table 5.3 Table distinguishing implicit and explicit. Memory is divided into implicit and explicit
processes which differ in origin, neuroanatomic basis, and means of access
Implicit (nondeclarative or procedural) Explicit (declarative)
Present at birth Develops at 2 years of age
Storing of meaning-making process Semantic meaning of language
Affective attunement Autobiographic memories
Involves parahippocampal processing Retrieval of episodic memories
Hippocampal based
stepping on the brakes and steering away when we see a vehicle collision in close
proximity. Further, knowing what others typically would find as embarrassing or
hurtful is also the domain of nondeclarative knowledge. The Boston Change Process
Study Group, of which Lyons-Ruth is a member, emphasized that such implicit
relational knowing is as much affective as it is cognitive (BCPSG 2007):
By implicit knowing in infancy we are not referring to the infant’s cognitive function, but
to the way that physiological and then social/behavioral regulation is carried out between
the infant and its caregiver, and represented and “remembered” by the infant. These earliest
forms of biological regulation emerge from the basic capacity for adaptation in living
beings as it intersects with the deeper biological origins for motivations, which are the
source of the initiatives that trigger exchange. The fact that these earliest forms of biological
regulation are stored in memory systems, have mental concomitants, and are psychologi-
cally meaningful has been intuitively grasped by some, but is not widely understood.
Lyons-Ruth et al. (1998) emphasized the role the concept of implicit relational
knowing has for the two-person relational psychotherapist by pointing out that
“these knowings are often not symbolically represented; they are also not necessarily
dynamically unconscious in the sense of being defensively excluded from
awareness.”
A poignant example may be the nostalgia and pleasure evoked when listening
to a favorite song and experiencing physiological effects, such as “goose bumps.”
The two-person relational psychology would posit that the memories evoked by the
song (e.g., contextualized in the company of loved ones or friends over the years)
are stored and retrieved in an implicit nondeclarative memory system rather than in
the realm of the dynamic conflicted unconscious. In contrast, semantic representa-
tions are those that rely on symbolic representation in language, such as the words
of a book. Further, it is important to note that implicit relational knowings are
influenced by culture and context.
Intersubjectivity
Intersubjectivity is a concept that over the last several decades has been the unifying
pillar to two-person relational psychology schools (Table 5.4). Clinically, intersub-
jectivity has been defined as “the capacity to share, know, understand, empathize
with, feel, participate in, resonate with, enter into the lived subjective experience of
another” and “interpreting overt behaviors such as posture, tone of voice, speech
rhythm and facial expression, as well as verbal content…which assumes that [the
psychotherapist] can come to share, know, and feel what is in the mind of the patient
and the sense of what the patient is experiencing” (Stern 2004). Furthermore, Dunn
(1995) eloquently defined it as such: “Intersubjectivity embodies the notion that the
very formation of the therapeutic process is derived from an inextricably intertwined
mixture of the clinical participants’ subjective reactions to one another. Knowledge
of the patient’s psychology is considered contextual and idiosyncratic to the particu-
lar clinical interaction. This interactional nexus is considered the primary force of
5.7 Fundamental Principals of Two-Person Relational Psychotherapy 95
Table 5.4 Three theorists’ conceptualizations of intersubjectivity

Andrew Meltzoff Colwyn Trevarthen Daniel Stern
Development of Innate, develops at Innate, develops at Develops at 6–12 months
intersubjectivity birth birth of age
Perception Cross-modal Cross-modal Cross-modal
Relational schema Complex, pre- Complex, pre- Complex, develops at
symbolic, motivated symbolic, motivated 6–12 months and is
and intentional positive and intentional symbolic: a theory of
emotion, playfulness, separate minds
intimacy, and bonding
Regulation of self Social mirroring Mutual regulation Mutual regulation model
model of of communication
communication (two-way)
(two-way)
Adapted from Beebe et al. (2003)
the psychoanalytic treatment process.” Further, Krause (1997) studied the impact of
facial expressions in a psychotherapeutic process. When the psychotherapist mir-
rored the patient’s affective facial expression, it led to poor outcomes, while when
the psychotherapist’s affective responses did not mirror but rather implicitly and
intersubjectively moved the process toward a feeling of hopefulness, it predicted
better outcomes.
The ability to make use of the process of intersubjectivity subsumes that the
infant has been successful in organizing experiences in which he can have subjec-
tive experiences of others and recognizes that during the interaction, the other’s
experience is different than his. As described throughout this chapter, the organizing
experiences by the infant require that certain processes serve as growth-promoting
building blocks; these include meaning-making processes, amodal perceptive
capacity for affective attunement and social referencing, innate temperamental attri-
butes conducive for subjectivity, and secure internal working models of attachment.
The infant’s self-regulatory abilities and self-representations are influenced by the
schematic representations, in implicit form, of the interactions with their emotion-
ally available parents, caregivers, and family members. Further, the schematic rep-
resentations are influenced by the context of their culture. The process of
intersubjectivity allows the infant, and later the child, to know how to influence the
interactions and negotiate discontinuities when in the presence of others (e.g., dis-
agreement about what the child should wear to a family event). Intersubjectivity
promotes a cohesive and more flexible way of reflective abilities to know what
works for healthy social reciprocity with implicit aspects of morality. In a longitu-
dinal study, Emde and colleagues (1987) found that by 24 months, infants presented
evidence of internalized rules for “don’ts” as well as for “dos,” as long as their
parents were present and could be referenced (Emde et al. 1987).
Children and adolescents who have genetic, biological, or relational impairments
(e.g., autism, traumatic brain injuries, intellectual disabilities) that interfere in their
ability to intersubjectively share, know, and enter into a live subjective experience
of another person benefit from psychotherapeutic interventions tailored to their

basic needs. These children and adolescents do not benefit from the theory of mind
interventions, which require some form of cognitive and relational abilities (see
Chap. 8 for a review of which children benefit from behavioral and cognitive forms
of psychotherapy).
5.8 Real Relationship, Present Moments, Now Moments,

and Moments of Meeting
The following paragraphs represent a summary of important two-person relational

concepts pioneered and developed by Stern and the Boston Change Process Study
Group (BCPSG). We end this section briefly using these terms in composite clinical
case vignettes to elucidate their applicability to clinical work.
Real Relationship
The “real relationship” in two-person relational psychodynamic psychotherapy is

defined as the patient’s and the psychotherapist’s here-and-now bidirectional use of
genuine and authentic implicit relational knowings in the intersubjective field
between them (BCPSG 2010). The intersubjective field includes the authentic per-
sonal engagement and affective attunement, sensing each participant’s current “way
of being with each other.” Further, for the psychotherapist, the real relationship also
involves the here-and-now active participation in the form of nonconscious or care-
fully timed self-disclosures and enactments known as now moments (see Chap. 3).
The concept of the “real relationship” permits to differentiate the two-person
relational approach from the traditional one-person model’s approach which relies
on the “therapeutic relationship,” a process in the transference–countertransference
domain where the psychotherapist is an objective observer who uncovers the
patient’s conflicted past. Further, the traditional one-person model relies on the use
of semantic and declarative memory in the form of verbal exchange believed to
represent the patient’s accurate memory of autobiographical experiences that when
worked through lead to insight.
Present Moment, Now Moments, and Moment of Meeting
A present moment is ubiquitous to the interactions of everyday life. Stern (2004)

viewed present moments as those that represent “schemas of ways of being with
another.” Present moments are repeated many times and are weaved together to
move along the relationship with others, and they later become implicitly familiar
relational knowings unique to each dyad. They provide mutual regulation, such as
recognizing when a child wants to play or needs to be fed and greeting our family
5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting 97
Fuzzy and sloppy

Affective attunement unfamiliar anxiety
creating familiar provoking experience
experiences
Present Now
moment moment
Moment of
meeting
New more adaptive emotional experiences implicitly create new adaptive

ways of managing interactions with others.
Fig. 5.2 Present moments, now moments, and moments of meeting
after work. These moments can be considered the building blocks of relationships
influencing relationships and contribute to the formation of internal working models
of attachment. Although implicit relational knowings are not in awareness, they are
distinct from that which is repressed due to intrapsychic conflicts (Stern 2004).
When the interaction between two people is unfamiliar, as in a patient–psycho-
therapist dyad, a disruption of reciprocity occurs and unexpected moments of anxi-
ety emerge. That is, the disruption cocreates a now moment and a decision will need
to be made by both persons on how to return to a mutually regulated experience: a
past–present moment. When the decision is made intersubjectively and one person,
through their implicit and nonconscious actions and behaviors, allows for the anxi-
ety of the now moment to dissipate, this creates what is called a moment of meeting
(Fig. 5.2).
Moments of meeting are unique and infrequent experiences that are jointly
constructed, in the here and now, by patient and psychotherapist. This is elo-
quently described by Lyons-Ruth et al. (1998): “A ‘moment of meeting’ occurs
when the dual goals of complementary fitted actions and intersubjective recogni-
tion are suddenly realized.” Moments of meeting are recognized as the special
moment that most patients remember as being the time the authentic person-to-
person connection with their psychotherapist altered their relationship, in that
they were able to implicitly recognize that they knew what was in each other’s
mind. The moment of meeting is the single most important opportunity for both
participants to bring about implicit relational transformation and either lead to
rupture or repair of the dyad.
The BCPSG (2010) adds:
[A moment of meeting]…requires that each partner contributes something unique

and authentic as an individual in response to a now moment. The response cannot be
an application of technique or a habitual therapeutic move. It must be created on the spot
to fit the singularity of the unexpected situation, and it must carry the therapist’s signature
as coming from his own sensibility and experience beyond technique and theory.
The transformative change that occurs during moments of meeting can best be
understood as concepts drawn from infant research and systems theory. Tronick
(1989) masterfully captured the contributions from developmental infant research
in two-person relational psychodynamic psychotherapy:
Moments of meeting catalyze change in parent–infant interaction as well as in psycho-
therapy. In the process of infant development, the baby’s implicit relational knowing
encompasses the recurrent patterning of mutual regulatory moves between infant and
caregiver.
Thus, the special and unique moments of meeting open the intersubjective field
for patient and psychotherapist to cocreate a more adaptive way of being together,
with the associated change being stored in nondeclarative memory systems repre-
sented in a rearranged implicit relational knowing for the patient. As a colleague
shared, these moments are addictive, and once you experience a moment of meeting
with your patient, you know something important happened. Although there is a wish
to provide more of these moments of meeting to the patient, they cannot be forced.
The adolescent that felt misunderstood.

The lead author described an experience with an adolescent male with diffi-
culties socializing who shared, “I worry that you will think of me just like my
parents do. That I should stop dating Emily because I spend all my time with
her and I don’t socialize like my parents think I should. They don’t get it; she
is an honor roll student, and we have a lot in common. We connect.”
From a traditional one-person perspective, the psychotherapist may have believed

that the statement “you will think of me just like my parents” was evidence of early
transference manifestations: The psychotherapist was standing in for the perceived
critical parent. The psychotherapist may have chosen to explore this further and
states: “You experience me as your critical parent who will not approve of your dat-
ing Emily. You seem to avoid talking about the fact that perhaps you also have some
worries about dating Emily, because you fear you would be agreeing with your
parents, who in fact want to make sure you are happy and not get hurt.” This line of
thinking would be consistent with the diagnostic formulation that the adolescent
was struggling with the second individuation process of adolescence—due to the
unconscious reawakening pressures of the internalized representations of the par-
ents—and feared the loss of their support (Blos 1967). The traditional one-person
psychotherapist would help the adolescent work through his unconscious struggles
through transference and ego defense interpretations. The concept of making the
unconscious conscious implies forms of symbolization and reflection through
language (Litowitz 2005).
In contrast, in a two-person relational model, the real relationship is bidirec-
tional. Both parties are authentic and genuine with each other in the here-and-now
intersubjective field, and both are subject to change by the processes. In using the
same example, the psychotherapist would have experienced the adolescent as being
genuinely happy with Emily. She had provided the reassurance and support he
needed to feel like a competent adolescent: a present moment. In the intersubjective
field, the psychotherapist was also implicitly reminded of times when he was in high
school and his parents voiced disapproval of his choice of college and, later, his
pursuit of a career in medicine. The psychotherapist subjectively recalled that what
proved to be of enormous help was the support of other family members, teachers,
and mentors who recognized his abilities. The psychotherapist proceeded to self-
disclose and enact in the here and now. He shared with the adolescent some of his
parents’ anxiety and doubt about his future, and he openly offered support to the
adolescent. He also wondered if the adolescent had family members or teachers
who were supportive of his dating Emily. The adolescent was outwardly relieved,
and his facial expression demonstrated a sense of “You understand me”—a moment
of meeting. This opened the intersubjective field, and the adolescent, with vitality,
shared his worry about whether his parents would be hurt knowing that in fact his
teachers, cousins, aunts, and uncles were supportive of his dating Emily: “They
know she is a good student, attentive to me and others, and is active in sports.” The
patient, smiling, shared, “My parents are good parents, but they were not happy in
high school. They worry that I will repeat their mistakes. They do not know how
good Emily is to me.” The psychotherapist empathized and shared that “allowing
help from other people can be difficult on your parents.” The patient added, “It’s
good to know that you went through this. I bet your parents are proud of you now.”
To which the psychotherapist replied: “Thanks. There is nothing wrong with parents
wanting the best for you. Sometimes they just need to learn to trust you. I am sure
you have learned a lot from your parents.”
The psychotherapist’s self-disclosing and enacting interventions in traditional
one-person psychology would have been considered problematic. It may have been
viewed as a countertransference enactment in which the psychotherapist gratified
the patient’s unconscious wishes for approval rather than analyzing his doubts and
later interpreting his fear with individuation.
It is important to note that the two-person relational psychotherapist had no way
of knowing that the adolescent was going to elicit the feelings he experienced. In
fact, if the adolescent’s description of Emily would have been made with a different
affective state, tone of voice, gaze, and body posture, the psychotherapist may have
not intersubjectively felt the adolescent was genuinely happy. If that had been the
case, it is conceivable that the psychotherapist’s intersubjective experience, as a real
person, may have been similar to that of the adolescent’s parents—disapproval of
his dating Emily—and may have chosen to explore why the adolescent felt that his
parents were wrong in worrying about his dating Emily. The goal would have been
to provide a more adaptive new emotional experience for the patient—“I wonder if
your parents have a point in worrying.” Herein, in two-person relational psychody-
namic psychotherapy, the possibilities in this case are many and may have had a
different outcome. Some of the factors that may have influenced differently the
here-and-now subjective experiences between the adolescent and psychotherapist
include the adolescent having difficulties with social reciprocity, the relationship
with Emily being less stable, and the psychotherapist being younger or a different
gender, to name a few.
As is aptly concluded by BCPSG (2010):
This is an engaged, interactive, dialogic view of understanding. We need the collaboration
of the other. We cannot understand him by ourselves; we cannot somehow choose, on our
own, to experience exactly what the other experiences. The value of empathy is not at issue.
It is just that in a hermeneutic view empathy is not some kind of monadic immersion in the
experience of the other. It is a process that requires the involvement of the one who is to be
understood.
Fuzzy Intentions and Sloppiness
Sloppiness is a clinical concept coined by the Boston Change Process Study Group.
They define it as a spontaneous, improvisational, unexpected interpersonal event
that “pops up” in interactions with others and can facilitate moments of meeting and
bring about change. This process captures the inherent complex nature of what
occurs in the intersubjective field cocreated by two people. The BCPSG (2010)
states, “We think of co-creation as a self-organizing process of two minds acting
together that takes advantage of the sloppiness inherent in the interaction to create
something psychologically new. What comes into being did not exist before and
could not be fully predicated by either partner. Sloppiness is viewed as allowing the
emergence of creative elements during the interaction.” Sloppiness involves unpre-
dictability of what will occur during any interaction and permitting oneself to be
surprised. For Stern, sloppiness is comprised of three elements: (1) the inexact
nature of trying to express one’s intentions to others; (2) an error-filled process
when trying to infer the intentions of another person thorough their words, behav-
iors, and context; and (3) reading another person’s intentional state is only an
approximation and not an absolute. The BCPSG (2010) views sloppiness “not as
errors or mishaps in the dialogue, but rather as a generator of potentially creative
elements that may alter the direction of the dyad’s evolution in unexpected, even
previously unimaginable ways,” an essential aspect of two-person relational psy-
chodynamic psychotherapy. The BCPSG further adds, “Sloppiness is not to be
avoided or regretted; rather it is necessary for understanding the almost unlimited
co-creativity of the moving-along process” (2010). Returning the above example of
the adolescent’s dilemma with his parents and girlfriend Emily, the intersubjective
experience elicited in the psychotherapist can be considered a moment of
unpredictable sloppiness. This is typically one of the reasons why newly minted and
experienced clinicians initially fear using a two-person relational model of
psychodynamic psychotherapy, as it requires tolerating the unpredictability and
uncertainties of the experiences that occur in the intersubjective field between
patient and psychotherapist.
Mentalization and Intersubjectivity
Mentalization is a well-known concept that describes the ability to interpret

behavior as meaningful and is based on the mental state of both the self and oth-
ers, taking into account desires, needs, beliefs, reasons, and feelings. The term
itself has long-standing roots in the psychoanalytic tradition and, as Target (2008)
notes, “has been long recognized in philosophy and psychoanalysis.” The term
gained popularity when Fonagy, a psychoanalyst and developmental researcher,
associated the term in the context of attachment theory. Some have said that men-
talization is akin to “holding mind in mind” (Allen et al. 2008). It is accepted that
children with a history of being securely attached have good mentalizing abilities,
while those who grew insecurely attached have difficulties in mentalizing and
make use of maladaptive ego defense mechanisms. Mentalization-based treat-
ment (MBT) is a time-limited treatment that is widely recognized as helpful for
adolescents with personality disorders (Bateman and Fonagy 2004; Rossouw and
Fonagy 2012). An example of mentalization is captured by a toddler who is play-
ing a board game with her mother and attempts to cheat. Without prompting, the
child looks at her mother sheepishly to see if the move was noticed. Her mother
returns with a disapproving look—one that the child is able to infer the intent,
desire, and feelings and, while laughing, retraces her piece to the original
location.
The reader at this point may wonder whether there are differences between
mentalization and intersubjectivity. We suggest that mentalization-based theories
contain aspects of both one-person and two-person psychologies, whereas inter-
subjectivity is exclusively a two-person psychology concept. We recognize that
both concepts are “theories of mind” and both are relational theories. Regarding
mentalization, Allen et al. (2008) note, “The concept of mentalizing first emerged
in psychoanalysis: Freud implicitly employed the concept of mentalizing in his
initial neurobiological theory of the development of the mind.” They later add,
“It is no accident that within psychoanalysis, object relations theory has been
especially compatible with focusing on mentalizing in treatment.” They further
clarify that mentalizing in clinical practice “might be viewed as equidistant
between psychodynamic psychotherapy and cognitive therapy.” Although con-
temporary controversies are far from over, we believe that the concept of inter-
subjectivity is more aligned with the practice of two-person relational psychology
psychotherapy than mentalization, which is fundamentally a one-person
concept.
5.9 Corrective Emotional Experience
Alexander and colleagues (1946) coined the term “corrective emotional experience”
to describe the explicit use of the relationship between the clinician and patient to
bring about therapeutic change. They described the process as:
… to reexpose the patient, under more favorable circumstances, to emotional situations
which he could not handle in the past. The patient, in order to be helped, must undergo a
corrective emotional experience suitable to repair the traumatic influence of previous
experiences.
Undoubtedly, the work of Alexander and colleagues set the stage for the integra-
tion of the discoveries from developmental psychology research in two-person rela-
tional psychoanalysis and psychotherapies. In the half century following their work,
a large body of research expanded their fundamental principles, and it became clear
that experiencing and processing painful, poorly resolved emotions within a secure,
affectively attuned relationship could bring about a “new ending” (Bridges 2006).
Thus, a new emotional experience is considered the main goal of two-person rela-
tional psychodynamic psychotherapy across all ages. Two-person relational psy-
chodynamic psychotherapy by definition is the process in which the psychotherapist
helps cocreate a new and corrective emotional experience for the patient.
Alexander and his successors speak frequently of the need for a present and active
psychotherapist and caution against interventions that would repeat the maladaptive
patterns of the patient’s parents or early childhood environment. Alexander, for exam-
ple, carefully distinguishes between a neutral psychoanalyst and one who is objective:
A completely neutral psychoanalyst does not exist in reality, nor would he be desirable.
While it is necessary that the therapist maintain an objective, helpful attitude at all times,
within this attitude lays the possibility of a great variety of responses to the patient.
Spontaneous reactions to the patient’s attitudes are frequently not desirable for the therapy,
since they may repeat the parents’ impatience or solicitude which caused the neurosis and
cannot, therefore, constitute the corrective experience necessary for cure.
The advances in developmental psychology—including attachment theory and dis-

coveries from neuroscience—have bolstered and refined Alexander and French’s orig-
inal ideas. There is broad agreement among relational psychotherapists that “intellectual
insight alone is not sufficient” for therapeutic change (Alexander and French 1946).
Contemporary relational theorists and practitioners now recognize that rather than
needing to remember and work through a specific conflict (Bridges 2006), the new and
corrective emotional experience can occur in the here and now between the psycho-
therapist’s and patient’s subjective experience at an implicit and preverbal level. Said
differently by Fosha (2000), “Emotional processing that leads to therapeutic change is
frequently associated with positive emotions regarding the self, associated with mas-
tery, such as joy, exuberance, and pride, as well as positive feelings toward others such
as gratitude and love.” We note that a new emotional experience does not need to be
corrective; rather, it provides a new and more adaptive way of relating to other people
that over time takes the place of the maladaptive implicit relational schema.
5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy 103
5.10 Key Concepts: Implications for Two-Person Relational

Psychotherapy
We will now proceed to illustrate, in a clinically relevant way, the key concepts
reviewed in this chapter by providing composite clinical examples of four children
who were raised by parents with different attachment styles and in different envi-
ronments. Additionally, the examples are used to convey the importance of assess-
ing dyads of patients and their parents or caregivers through the lens of a two-person
relational contemporary diagnostic interview (Chap. 8). This interview model pro-
vides an integrated developmental approach (biopsychosocial) in understanding
children and adolescents, and it concisely helps develop realistic and practical treat-
ment recommendations.
The basic premise of two-person relational psychodynamic psychotherapy is
that a child or adolescent can benefit from this model of treatment if they have the
temperamental and cognitive abilities, albeit in a rudimentary form, to subjec-
tively know how to interact and “be with” others. Two-person relational forms of
psychodynamic psychotherapy are appropriate for those with easy/flexible, slow-
to-warm-up, or mixed temperaments; cognition of superior to below-average
intelligence; good to fair cognitive flexibility; and secure, anxious, or dismissive
internal working models of attachment as assessed through intersubjectivity by
the child and adolescent psychiatrist or clinician. In cases where the child or ado-
lescent does not have these abilities due to intellectual disabilities, as in autistic
spectrum disorders, traumatic brain injuries, or disorganized internal working
models of attachment, as in the case of Daniella below, formal cognitive testing
and specialized behavioral psychotherapeutic interventions are best considered as
the first choice.
Andrew: A Securely Attached Child
Andrew’s parents had welcomed the news of their pregnancy with excitement.
After his birth, he was raised by his parents with active involvement from
extended family members. In Andrew’s environment, the emotional availability
and affective attunement from others were plentiful, promoting his active mean-
ing-making processes. As a toddler, his parents continued to experience joy in
seeing Andrew make progress developmentally and would implicitly convey,
“We are going to have a lot of fun with each other.” The parents made the adjust-
ments needed to match his temperamental attributes with sensitivity, using
motherese that matched his vocal sounds and body movements: social
reciprocity.
In using Fig. 5.1, we notice that the contributions by both Andrew and his parents
are generally symmetrical, and the intersubjective field is spacious and allows for
many now moments, some of which will result in healthy discontinuities that allow
for new moments of meeting to move along his development in a psychologically
healthy and adaptive manner.

Psychotherapy
Andrew develops well and does not require psychotherapy (unless, of course, he
decides to become a psychoanalyst and is required to undergo personal training
analysis by his Two-Person Relational Psychoanalytic Institute. In Chap. 12 we
review a case of a school age child whose by all standards development was similar
to Andrew’s until the unfortunate diagnosis of his father with terminal cancer—
complicated by the fact that hospice care was provided at his home—and who ben-
efited from a two-person relational psychotherapy process.
Bonnie: A Child with an Ambivalent/Anxious Attachment
Bonnie’s parents received the news of their pregnancy with some excitement,
although they promptly became anxious and worried about how this would nega-
tively affect their life. After Bonnie’s birth, her parents continued to experience joy,
although soon after, they became ambivalent and anxious about their ability as
parents. They implicitly conveyed to Bonnie, “Let us know what you need, because
we do not understand your subjective and nonverbal requests.” Their anxiety
increased their hesitancy in interacting with Bonnie when she naturally requested
their emotional resources through crying, which made it difficult for them to adjust
to Bonnie’s physical and psychological needs. Fortunately, Bonnie’s parents had
easy/flexible temperaments, and when Bonnie was happy and content, they were
able to provide some social reciprocity. Thus, Bonnie’s attempts to develop self-
regulatory abilities were often difficult during negative affective states, as she
needed help in the form of affective attunement and social referencing, which was
dependent on her parents’ fluctuating emotional states. The parents had difficulty
using motherese and being playful with Bonnie through facial gestures, vocal
sounds, and body movements. Fortunately, Bonnie had an easy/flexible tempera-
mental style that implicitly allowed her to reach out to other family members and
friends, when present, who were more receptive and playful with her. Bonnie grew
with some anxiety and had some self-doubt while at home, although she had good
interactions and was happy when other family members, peers, and teachers were
around.
In using Fig. 5.3, we notice that the contribution by both Bonnie and her parents
is generally symmetrical and the intersubjective field is narrow in comparison to
a securely attached child (Fig. 5.1). As such, this narrow intersubjective field con-
tributes many now moments as a result of daily healthy discontinuities, although
the narrow field does not allow for the forming of many moments of meeting to
move along Bonnie’s development in an adaptive manner. In Fig. 5.4 we note that
Bonnie is able to expand her intersubjective field with other people who have
more adaptive modes of interaction, which provides opportunities for moments of
meeting in the form of a new emotional experience (e.g., a two-person relational
psychotherapist).
IF
Child Parent
• Meaning making (++) • Affective attunement (+)
• Mirror/Echo neurons/ Internal working • Emotional availability (+)
default mode network models of • Social referencing (+)
• Social referencing (++) attachment • Temperament
Inconsistent
Ruptures
Now moments
Anxious implicit
relational knowing
Incomplete Some moments

repairs of meeting
Fig. 5.3 Schematic representation of intersubjective experience between child and parent in the
context of an insecure attachment. An ambivalent/anxious attachment forms through the intersub-
jective field (IF) primarily by inconsistent emotional availability leading to superficiality in implicit
relational knowing. The number of (+) denotes degree of strength in this dyad

Psychotherapy
Bonnie can benefit from two-person relational psychodynamic psychotherapy, as

she has some innate abilities for curiosity, exploration, flexibility, novelty seeking,
and creativity in spite of her parents’ anxiety. The two-person relational psycho-
therapist can help her improve her intersubjective field and affective attunement by
demonstrating in the here-and-now implicit nondeclarative experiences’ vitality and
curiosity about Bonnie’s many states of mind. They can cocreate moments of meet-
ing—intersubjectivity—in which she can implicitly learn how to regulate her anxi-
ety in more adaptive manners through a new emotional experience and develop new
forms of implicit relational knowing.
Carlos: A Child with an Avoidant/Dismissive Attachment
Carlos was a child raised by his single mother who lived with her family. She
received the news of her pregnancy with some excitement in having a child, as well
as anger at Carlos’ father for his refusal to be involved during the pregnancy and in
New Emotional Experiences
IF
Child/Adolescent Psychotherapist
• Meaning making (++) • Affective attunement (+++)
• Mirror/echo neurons/ Internal working • Emotional availability (+++)
default mode network models • Social referencing (+++)
• Social referencing (+++) of attachment • Temperament (easy/flexible)
• Cognition • Cognitive flexibility (+++)

experiences
Co-created moments
Repairs
of meeting
Fig. 5.4 Schematic representation of two-person relational psychotherapy representing psycho-

therapist and patient. New more adaptive emotional experiences occur in the intersubjective field
(IF), the overlap of subjective experiences. The number of (+) denotes degree of strength in this
dyad. Bold arrows in the IF represent here-and-now moments of meeting
any of Carlos’ care after birth. After Carlos’ birth, his mother experienced some joy
and implicitly hoped that Carlos would know what she, as a mother, needed: “Show
me that you need me and love me.” Carlos’ mother and grandparents had a limited
capacity for affective attunement and social reciprocity and ignored his overt request
for interaction when crying. Carlos’ mother had a slow-to-warm-up temperamental
style, which made it difficult for her to implicitly recognize her son’s need for her
emotional availability. The family’s lack of cohesion made it difficult for Carlos to
know who would attend to his physical and psychological needs, as their availabil-
ity was inconsistent and unpredictable. Carlos’ attempts to develop self-regulatory
abilities were irregular, as affective attunement was inconsistent and unpredictable.
His mother and family had difficulties in using motherese, and they generally com-
municated with him as if he were an older, self-reliant child. Carlos’ attempts to
make meaning of his interactions with caregivers proved to be difficult; some would
infantilize him, and others would try to “man him up.” Carlos was overtly an
unhappy child and avoided closeness with others. As an adolescent, he related better
with peers who were also lonely and at times used illegal substances.
In using Fig. 5.5, we note that the contributions by both Carlos and his mother
and family are not symmetrical and the intersubjective field is restricted and narrow
IF
Child Parent
• Meaning making (+/–) • Affective attunement (+/–)
• Mirror/echo neurons/ Internal working • Emotional availability (+/–)
default mode network models of • Social referencing (+/–)
• Social referencing (+/–) attachment • Temperament
Few now moments Many Ruptures
Dismissive relational knowing

Limited mentalization
Few repairs Few moments

of meeting
context of an insecure attachment. An avoidant/dismissive attachment dyad is depicted below. A
(+) denotes strengths and (−) denotes weakness in this dyad. IF (intersubjective field) is the area in
which both overlap
in comparison to a securely attached child (Fig. 5.1). As such, this narrow intersub-
jective field allows for more than the usual now moments and discontinuities, which
contribute to his developing an avoidant/dismissive form of attachment and implicit
relational knowing.
In Fig. 5.4 we note that Carlos has expanded the intersubjective field with other
people who have a more adaptive mode of interaction, with the opportunity for
moments of meeting in the form of a new and corrective emotional experience (e.g.,
a two-person relational psychotherapist).

Psychotherapy
Although Carlos has relational difficulties that are similar to Bonnie’s, the psycho-
therapist will need to make a more concerted effort through a two-person relational
approach in psychodynamic psychotherapy to help engage with him, gently point-
ing out when he avoids, which can be expected due to his avoidant/dismissive form
of implicit relational knowing. The two-person relational psychotherapist will also
have to actively and implicitly demonstrate to Carlos how to become curious about
other people’s mental states and promote in the here-and-now healthy exploration
and creativity in spite of his family’s likely critical comments of this.
Daniella: A Child Who Grows in a Disorganized Environment
Daniella was a toddler raised by a single mother. Daniella’s mother received the
news of her pregnancy with anger; Daniella’s father was abusive and had abandoned
Daniella’s mother who had been raised by a series of family members and foster
homes after her own parents abandoned her. When Daniella was born, her mother
treated her more like a sibling with limited understanding of the clear developmen-
tal mismatch. Despite having a large number of close relatives who participated in
caregiving, the environment was harsh and provided inconsistent emotional avail-
ability with poor affective attunement. Although Daniella normally craved for inter-
action with others, she frequently resorted to screeching and aggressive behavior to
gain the attention of her caretakers. Over time, she learned that crying and screech-
ing in fact did elicit attention from adults, albeit in negative form. As such, this
became her implicit relational knowing; the affect and language used by the rela-
tionships in her environment to communicate were disorganized. Rather than expect
nurturing, Daniella learned to walk early, searching for food and learning to care for
herself, a type of survival mode. Many members of the family, including Daniella’s
mother, had difficult/feisty temperaments, which limited their ability to provide her
with self-regulatory skills. When Daniella presented for her first consultation
appointment, she was 5 years old. Her mother’s disgust was apparent. When the
clinician asked about her main concerns, she said, “Well, I wanna know, is she men-
tal or something or just a spoiled brat’, cause that’s what I think. Someone said she
has that opposition thing. She is so clingy and selfish. She’s not talking to me right
now. I am tired; I’m a single parent workin’ 40 h. I’m sick and tired of her.”
This vignette captures a generational pattern of disorganized attachment styles.
In the absence of severe cognitive deficits, Daniella demonstrates an implicit knowl-
edge of her family’s lack of cohesion and disorganized interactions. She could not
reliably predict who would attend to her physical and psychological needs. The
hostile environment did not provide the self-regulatory abilities needed. Rather, it
promoted Daniella to learn that self-reliance is essential to survive in her inconsis-
tent and harsh environment. Daniella will likely end up similar to others in her fam-
ily, characterized by poor affective dysregulation and frequent displays of anger and
relational difficulties.

Psychotherapy
When a child is forced to grow with the real and constant fear of being abandoned
by their caregiver, as in those with a history of disorganized attachment patterns, the
abandonment by the parents is experienced by the child as real possibility. These
same children who have adopted a disorganized internal model of attachment will
Child
IF Parent
• Meaning making-unpredictable
• Affective attunement-poor
• Mirror/echo neurons/
• Emotional availability-minimal
default mode network Internal working models • Social referencing-disorganized
• Social referencing of attachment • Temperament (feisty)
• Temperament
• Cognition (+/–)
• Cognition (+/–)
• Cognitive flexibility (–)
• Cognitive flexibility (–)
Unpredictable now moments Many Ruptures
Disorganized relational knowing

Poor mentalization
Scarce repairs Scarce moments of meeting
context of an insecure attachment. In a disorganized attachment, there is essentially a nonexistent
intersubjective field (IF) and limited emotional availability. The number of (+) and (−) denotes
degree of strength in this dyad. Behavioral, family, and pharmacological interventions are recom-
mended interventions
implicitly repeat these patterns of distancing and abandonment onto their own chil-
dren. Thus, the child with insecure forms of attachment develops chronic meaning
pathways with ever-present anxiety, fear, and threat of abandonment, with little
modeling in experiencing closeness with others. Viewed through the lens of a gen-
erational perspective, it is likely that children with insecure attachments have not
had the benefit of having their parents play games with them, sing songs to them, or
read a story to them in a soothing way. Sadly, they may have had a story read to
them in a threatening way, in which the adult may have felt that frightening their
child was humorous.
If a child grows up in an insecure environment, their maladaptive behaviors
(impulsivity, uncontrollable anger, labile mood, unstable relationships) become part
of their implicit relational knowing, which is repeated nonconsciously. They seek
accomplices of that which is familiar, similar maladaptive behaviors. It is well doc-
umented that what becomes familiar exposes them to relational trauma and at times
sexual and physical trauma. It is not uncommon for children who are yelled at by
their parents to make yelling the internal working model they use when relating to
others (e.g., nonconsciously seeking accomplices to yell at and to be yelled at by).
Herein, in Fig. 5.6 we note that Daniella’s intersubjective field is essentially non-
existent. As such, she would benefit from early childhood behavioral interventions,
case management with in-home services, and formal cognitive testing, rather than a
two-person relational psychotherapy process.
5.11 Summary
In this chapter we provide the reader the necessary information to understand the
origin and meaning of key concepts in two-person relational psychology. The key
concepts reviewed in this chapter have become the new lexicon that allows for the
understanding of the variability of how a person relates to another person, and how
they may relate in a completely different manner with others, based on relational
schemas that are nonconsciously evoked by each person differently. The changes
undertaken by the brain from infancy to adulthood are mediated by the processes of
emotional availability, attachment, affect regulation, and cognition, and they all play
a central role in two-person relational psychotherapy.
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Deconstruction of Traditional One-
Person Psychology Concepts 6
There is no creation without tradition;

the “new” is an inflection on a preceding form;
novelty is always a variation on the past.
― Carlos Fuentes
In the last two chapters, we laid the groundwork to distinguish between traditional
one-person and two-person relational psychologies. The astute reader will recognize
that the terms that are used within each theoretical model may, in fact, ultimately
complicate one’s ability to distinguish between the two psychologies. As Bornstein
(2001) states, “Many psychoanalytic terms and concepts became so widely known
that they evolved into colloquialisms, recognized even by persons with little or no
formal exposure to psychology.” In fact, some of the two-person relational literature
often retains the language of the traditional one-person model. Nonetheless, it is criti-
cal to clarify the differences in the meaning of the terms used in one-person psychol-
ogy, which continue to prevail in the psychotherapeutic lexicon, as ultimately these
terms evolved to represent two-person relational model constructs. In this regard,
there are numerous everyday examples involving clinicians using traditional one-
person psychology concepts to understand another person’s behaviors, as if the clini-
cian clairvoyantly knew the nature of the patient’s unconscious. For example, a
clinician may describe an adolescent girl who dates older men as having “father/
daddy issues,” or a male adolescent who struggles with intense closeness and “needi-
ness” in his relationships as having “mother/mommy issues.” These comments fore-
stall a true understanding of the patient for several reasons. First, the clinician—in
using these terms—assumes that the patient has unconscious intrapsychic conflicts
(e.g., maladaptive behaviors represent ego defense mechanisms against the pressures
from intrapsychic conflict). Second, the clinician fails to take into account the many
aspects of the adolescent’s innate temperament, cognition, and internal working mod-
els of attachment that influenced his or her relational patterns. Third, in the case of the

DOI 10.1007/978-3-642-40520-4_6
116 6 Deconstruction of Traditional One-Person Psychology Concepts
adolescent girl who dates older men, it is important to consider that in early child-
hood, she may have had the emotional availability and affective attunement needed
provided by warm and caring men in her family (e.g., father, brothers, uncles, cousins,
neighbors) and limited affective attunement from the women in her family. As such,
her development occurred in an environment where older men may have represented,
in a nonconscious way, implicit relational knowings, as safe and caring and likely
adaptive. Herein, her wish for closeness to older men to provide the needed affective
attunement may have been adaptive in spite of the age difference, as true compatibil-
ity is not a simple issue of biology or social construct. Fourth, this also forestalls the
fact that for another adolescent, an older man may represent maladaptive childhood
experiences of demanding and abusive men that provided some support to her, seen in
disorganized forms of attachment. Thus, in the case of the adolescent with a disorga-
nized attachment style, her choice of older men reflects a return to maladaptive
implicit relational knowings during adolescence. For the adolescent boy, his clingi-
ness to women may also represent cocreated experiences of safety when close to
women and fearful being close to men as a child, stored in implicit nondeclarative
memory. Further, both adolescents may have temperament or cognitive weakness that
predisposed them to engage in maladaptive behaviors, and, as such, these behaviors
may not be attributable to their parents or to their environment per se. Thus, a two-
person relational model allows for teasing apart the complexities of nature and nurture
through here-and-now experiences between patient and clinician.
Additionally, we have observed the use of traditional one-person psychology
terms (e.g., unconscious, transference) during discussions of two-person relational
approaches, which increases confusion among students, clinicians, and supervisors.
This tendency is described by Fossage (2003), a relational theorist: “Each of us
gravitates toward and develops a theory and practice that resonates deeply with our
subjective experience. For this reason, it is difficult for all of us to really know, to
have a ‘feel’ for psychoanalytic approaches other than the one we practice.” Thus,
the ability to meaningfully discuss two-person relational approaches and apply its
key concepts in a clinically meaningful way requires extensive reading, living, and
breathing of this approach. In order to clarify why we, as authors and two-person
relational clinicians, view the traditional one-person psychology terms as limiting,
this chapter is written to juxtapose case-based conversations of traditional one-
person and two-person relational psychotherapists that will highlight differences in
context and terminology. As such, we provide a list of the common concepts in
traditional one-person psychoanalytic theory and compare these terms with those
from a two-person relational psychology model. We will also explore conceptual
differences from the two psychologies in each of the clinical cases discussed in
subsequent chapters.
At the most basic level, a traditional one-person psychology tenet is to help the
patient understand, within the therapeutic encounter, his or her past intrapsychic
conflicts and object relations (inner life) through his or her transference manifesta-
tions to the objective psychotherapist or by the autobiographic memories shared.
Foangy and Target (2000) remind us that theories are shaped by what the clinician
finds helpful and are intrinsically contaminated by technique and consequently run
the risk of assuming that what is remembered by the patient is true and accurate. By
6.1 Two-Person Relational Psychodynamic Psychotherapy: A Historical Context 117
contrast, two-person relational psychology focuses on both players (i.e., the psycho-
therapist and patient), although not symmetrically. That is, the psychotherapist,
through bidirectional here-and-now experiences with the patient, will cocreate and
model new and more adaptive patterns of interaction with others in the form of a
new emotional experience (Hoffman 2009, see Chap. 5). A two-person relational
psychotherapist is not neutral; rather, he or she makes implicit (nonconscious) or
explicit self-disclosures and welcomes planned and well-thought-out enactments
when believed to help the psychotherapeutic process of his or her patients (Delgado
and Strawn 2014). Another contrast is that a traditional one-person model implies a
conflicted unconscious, whereas two-person relational psychology implies that
there is a dynamic, nonconflicted unconscious stored in nondeclarative memory
systems. This nonconflicted unconscious provides the internal working models of
“how to” implicitly engage in interactions with other people, known as “implicit
relational knowing” (Chaps. 3 and 5).
The reader may then wonder: Are the concepts of the unconscious, transference,
and countertransference helpful? Does the two-person relational model of psycho-
therapy “throw the baby (i.e., traditional psychoanalytic concepts) out with the
bathwater (i.e., traditional psychoanalytic technique)”? In order to answer these
commonly posed questions, we provide a guide for the reader to navigate through
the two models of psychotherapy and the semantic differences. As Aron (1990)
states, “My aim is to extract fundamental clinical concepts from the quasi-biological
drive theory that has dominated both our metapsychology and our clinical theory
and to reexamine the value of these clinical concepts within a relational, contextual,
and intersubjective framework.”
6.1 Two-Person Relational Psychodynamic Psychotherapy:

A Historical Context
For more than a century, traditional one-person psychoanalytic theories dominated

the psychotherapeutic landscape and were used to develop constructs about the
frailties of the human mind, with the notion that unconscious instinctual drives
exerted a role in shaping the introjected representations of the parents—as
“objects”—that served as a relational template for an individual when interacting
with others. A failure to master the instinctual drives would lead to psychological
symptoms, thought to reflect the battle between the urges for gratification of infan-
tile drives and wishes, and the pressures for the repression of these wishes to remain
composed. In this model, common treatment interventions were akin to archaeo-
logical explorations: efforts to uncover deeply buried intrapsychic phenomena (e.g.,
unconscious developmental intrapsychic conflicts and object representations). The
treatment was directed at mastering the pressures from the instinctual drives and
conflicted object relations through the use of healthy ego defense mechanisms. The
psychoanalytic concepts that evolved were used broadly to create diagnostic formu-
lations about conditions such as anxiety neurosis (harsh superego formations),
obsessive–compulsive symptoms (anal level conflicts), and depression (internaliza-
tion of the lost loved object). These psychoanalytic concepts were also applied to
the understanding of conditions and problems of children and adolescents, such as

enuresis, night terrors, toilet-training difficulties, and oppositional and aggressive
behaviors, all of which were believed to result from the compromise of uncon-
sciously repressed intrapsychic conflicts, poorly integrated parental objects by the
child, or poor ego functions.
Over the last 40 years, the emergence of a two-person relational psychology
shifted the understanding of psychological and relational problems. In this regard,
the two-person relational model proposes that a child’s problems result from diffi-
culties of the interplay of multiple complex processes, including temperament,
affective attunement, cognition, cognitive flexibility, internal working models of
attachment, and intersubjectivity—the complex interactions of the relational self,
influenced by other people. This shift fostered the development of treatment inter-
ventions that differed from traditional archaeological inquiries—which focused on
the discovery of a conflicted and buried past—and instead focused on open, bidirec-
tional, here-and-now subjectivities (i.e., the experience of each other’s mental states,
in the context of treatment, that are continually modified by both the patient and the
psychotherapist).
Herein, we provide the background of what have been historically viewed as
conflicting approaches and theoretical orientations, and we attempt to clarify the
reason for the seeming persistence of the conflict that exists between the traditional
drive-based, conflict-based, object relations, one-person psychology theories and
the contemporary relational, intersubjective, co-constructive, two-person relational
psychology theories. Although both theories provide—implicitly or explicitly—a
foundation for shared concepts for communication among psychodynamically ori-
ented psychotherapists within their respective theoretical paradigms, their differ-
ences render them discordant with one another (Delgado and Strawn 2014). In this
regard, while many psychotherapists are more familiar with the traditional one-
person theory and terminology that they learned during their child and adolescent
psychiatric training, and that is routinely used in understanding patients and fami-
lies, they recently developed interventions are more aligned with and guided by
contemporary two-person relational approaches and family systems. These contem-
porary theories give importance to both patient and psychotherapist, as well as to
“the contextual model of psychotherapy focusing on common factors instead of
treatment techniques, and actual trends in psychodynamic therapy, which accentu-
ate critical moments of interpersonal experiences transforming the procedural
knowledge of patients on attachment patterns” (Schiepek et al. 2013).
6.2 Clinically Relevant Concepts from Traditional One-

Person Psychology: A Two-Person Relational
Perspective
While it would be beyond the scope of this book to comprehensively define all of
the terms relevant in working with children and adolescents from a traditional one-
person model, we have chosen to focus on the concepts that are most relevant and
6.3 Traditional Unconscious in Traditional One-Person Psychology and Two-Person 119
Table 6.1 Two-person relational psychotherapy

Relational Traditional
Implicit and nonconscious Unconscious
We-go Ego
Intersubjectivity and cocreation Neutrality
Implicit relational knowing Transference
Emotional availability and social referencing Countertransference
Regulatory schemas and Intersubjectivity Object relations
Enactments and self-disclosures Boundaries
New and corrective emotional experiences Insight
The two-person relational psychotherapist gives importance to the context of the patient’s reality,
as it allows to know the type of corrective emotional experiences needed by the patient, that will
be stored in implicit nondeclarative memory and nonconscious, utilized in the future with more
adaptive relational knowing
frequently used in the clinical work of a psychodynamic psychotherapist. Moreover,

the terms used in traditional one-person psychologies have been ingrained in our
implicit nondeclarative memory and are ubiquitous in the psychotherapeutic ver-
nacular. Thus, as we discuss two-person relational concepts herein, we do not intend
to portray Freud and the traditional one-person model as the straw man to be deval-
ued; rather, we hope to provide a broad perspective with regard to these competing
concepts from both approaches and provide the information needed, in a succinct
manner, for the reader to arrive at his or her own conclusion. Accordingly, we—as
relationalists—seek to provide the reader a chapter that allows him or her to under-
stand the differences in common terminology of psychodynamic practice and to
have the tools to discuss these terms and concepts, given that he or she will invari-
ably need to contend with skeptics and critics (Table 6.1).
6.3 Traditional Unconscious in Traditional One-Person

Psychology and Two-Person Relational Psychology
Unconscious in Traditional One-Person Psychology
Freud believed that the unconscious was a hypothetical region of the mind. Further,
he posited that the pressure from the instinctual drives resided in the unconscious,
as they were repressed and only evident when the drives became conscious if accept-
able to the superego or in the form of neurotic symptoms or maladaptive ego defense
mechanisms. In traditional psychoanalytic theory, these drives reflect a conflicted
unconscious, which is hidden behind defenses derived from the ego and superego.
In traditional psychoanalytic treatment, the primary goal is to make the “uncon-
scious” conscious, a process best captured by Freud’s now famous maxim of psy-
choanalytic work: “Where id is, there shall ego be” (Freud 1916–1917). In making
the “unconscious” conscious, Freud suggested that insight is achieved and, thus,
maladaptive defenses are relinquished in favor of more adaptive defenses (Delgado

et al. 2011), and clinical improvement ensues. Accordingly, traditional psychoana-
lytic treatment focuses on the replacement of maladaptive ego defenses with mature
ego defenses.
Unconscious in Two-Person Relational Psychology
In two-person relational psychology, the unconscious phenomena are dynamic and

nonconflicted and are commonly referred to as the nonconscious. Additionally, the
nonconscious processes consist of (1) meaning-making processes and (2) internal
regulatory and interpersonal schemas within nondeclarative memory systems in the
form of implicit relational memory:
An everyday example of the relational nonconscious

A young physician was walking from his office to his car when he received a
call on his smartphone from his 4-year-old daughter, who had just returned
home from the zoo. The father implicitly knew which tone of voice to use
when talking to his daughter, who was sharing her excitement about the trip
to the zoo she had taken with her mother. As his daughter exclaimed, “Daddy,
I saw two big elephants and one baby elephant!” the father, without explicitly
thinking about the tone of voice, cadence, etc., responded to his daughter in a
manner that allowed her to know that he shared her excitement and was curi-
ous about her trip—affective attunement. As the father was about to enter the
stairwell of the parking garage, he encountered a colleague who asked him
about the location of tomorrow’s staff meeting. The father covered the smart-
phone with his hand and, as he answered his colleague’s question, changed his
tone of voice accordingly. This shift in tone of voice, between both conversa-
tions, was unrelated to the traditional ways of thinking about the unconscious
(e.g., id, ego, or superego conflict models); rather, this shift in tone of voice
was a result of information stored in nondeclarative memory systems that was
nonconsciously accessed when needed to move along the interactions in pres-
ent moments (see Chap. 5).
From a two-person relational perspective, the physician’s tone of voice implic-

itly communicates to his daughter and to his colleague that he is affectively and
intersubjectively attuned to them at a nonconscious level. In a traditional one-
person model, the decision to shift speech pattern, tone of voice, and affect
reflects a function of the ego, either as a compromise of instinctual drives or as a
shift in internal object representations that are influenced by the superego. The
view of a nonconflicted, relational nonconscious thus creates contentious discus-
sion in that slips of the tongue (i.e., Freudian slips), dreams, and oedipal conflicts
have limited relevance in understanding the human mind by two-person rela-
tional psychology.
6.4 Psychic Determinism in Traditional One-Person Psychology and Two-Person 121
6.4 Psychic Determinism in Traditional One-Person

Psychic Determinism in Traditional One-Person Psychology
The unconscious and psychic determinism are concepts at the heart of Freud’s psy-
choanalytic theories. They are the precursors to Freud’s universal Oedipus complex.
Brenner (1974) describes psychic determinism as a concept that Freud adhered to
and assumes that nothing in everyday life happens by chance or in a random man-
ner, “Each psychic event is determined by the ones which preceded it. Events in our
mental lives that may seem to be random and unrelated to what went on before are
only apparently so. In fact, mental phenomena are no more capable of such a lack
of casual connection with what preceded them than our physical ones. Discontinuity
in this sense does not exist in mental life.” Freud’s concept of psychic determinism
in its narrow view placed in doubt matters of free will. As such, Freud believed that
if the analyst had unlimited access to an individual’s unconscious (e.g., free associa-
tions, parapraxes, and dreams), it would confirm that all psychic phenomena had
meaning and did not occur by accident.
Psychic determinism in a 15-year-old adolescent

John, a 15-year-old adolescent, appeared anxious in his weekly psychother-
apy appointment and shared with his psychotherapist that he forgot to place a
lock on his bike, which was in the front of the psychotherapist’s office. From
a psychic determinism standpoint, the psychotherapist might ask for associa-
tions of why this may have happened, believing that this “forgetting” repre-
sented unconscious conflict due to the fact that it happened within the context
of his psychotherapy appointment and may have been evidence of possible
transference manifestations. With the patient’s associations, the psychothera-
pist can then decipher the “meaning” of such act and may choose to explore
further or interpret it.
Thus, it seems that the concept of psychic determinism attributes individuals to

not being free to make decisions based on contextual circumstances and needs.
Psychic Determinism in Two-Person Relational Psychology
Psychic determinism and free associations, by virtue of the assumption that all psy-
chic phenomena have unconscious meaning, cannot exist in true two-person rela-
tional psychology. Hoffman (2006) states, “Free association is still one of the sacred
cows of the psychoanalytic tradition; it is a term one tampers with at peril of his or her
psychoanalytic identity. Can you claim to be a psychoanalyst if you do not ‘believe in’
free association?” The two-person relation model of psychodynamic psychotherapy
relies on here-and-now subjective experiences between patient and psychotherapist

that are shaped and unique to the dyad. It is through moments of meeting cocreated
by the dyad that change occurs, at the implicit level. Holland and Kensinger (2010)
conclude that when memories are reconstructed at the time of retrieval, they are prone
to memory biases and inconsistencies. The affective characteristics of the event can
influence how a memory is encoded, stored, and retrieved. They add that emotional
memories are never perfect representations of the past and are recalled through a dis-
torted lens. They eloquently state how positive here-and-now experiences can help
patients, “remembering our past experiences and behaviors as more positive than they
actually were may allow us to maintain a coherent, positive sense of self and to forge
positive social relationships. Similarly, the flexibility in the construction of events at
retrieval may enable us to direct our future behavior and to regulate our emotions.”
In returning to the example of the adolescent who forgot to lock his bike, a psy-
chotherapist utilizing a two-person relational model would see a variety of possibili-
ties as to why this occurred. First, the adolescent may have simply forgotten to lock
the bicycle due to other thoughts having taken priority. In this regard, he may have
been preoccupied with other thoughts, such as thinking about being on time for his
appointment, reflecting on his girlfriend’s basketball game, planning his homework
strategy for his evening assignments after the appointment, etc. In other words, the
reasons that underlie his “forgetting” are many and may have not been related to the
psychotherapist. Second, the adolescent having shared that he forgot to lock his bike
may be a result of his feeling safe, in the intersubjective sense, with his psychothera-
pist, with whom he is able to share his dilemma, hoping that the psychotherapist
recognizes his wanting to go out lock his bike and keep it safe.
In two-person relational psychology, one cannot infer that the adolescent “forget-
ting” to lock his bike represents a repressed unconscious mental process, derived
from a conflict that can only be discovered through an archaeological excavation in
which the psychotherapist seeks to uncover a hidden truth. Instead, the two-person
relational psychotherapist will attend to the patient’s tone of voice and affect and, in
parallel, will attune to his or her own experience as it is cocreated in intersubjectiv-
ity. These elements will direct the psychotherapist to determine the type of new
emotional experience that would be most helpful for the adolescent. To return to our
example, one might imagine a scenario in which the adolescent patient wanted to go
and lock the bike in order not to risk losing it, although he waited for his appoint-
ment to start in order to not offend his psychotherapist. In this scenario, in a noncon-
scious manner, the adolescent relates in what is familiar to him—internal working
models through implicit relational knowing—given that, for him, respecting adults
is more important than asserting himself. The psychotherapist notices intersubjec-
tively that he feels like telling the adolescent: “You don’t need to be so polite. Go
ahead and lock it; I can wait a few minutes.” With this experience, he is reminded
about the adolescent’s pattern of not asserting himself in most situations. This allows
the psychotherapist to feel that one possible intervention, which could serve as a new
and corrective emotional experience and cocreate more adaptive neuronal pathways,
was, to say, “I know how much you value your bike and I am glad that you told me
about not locking it. How about I wait here while you go lock it?” In a different
scenario, the psychotherapist intersubjectively notes that the adolescent is anxious
6.5 Drive Theory in Traditional One-Person Psychology and Two-Person Relational 123
knowing that his bike is not locked, and his anxiety prevents him from feeling com-
fortable in the appointment, a similar pattern his parents had noted—their son strug-
gled and was easily overwhelmed with anxiety when problem solving. In knowing
this, the psychotherapist may say: “You know, at your age, my bike was very impor-
tant to me. I see that your bike is very important to you, and I think we should not
have to worry about this. Let’s go and make sure it is locked.” We are aware that the
reader may think of many other possible scenarios that incorporate a two-person
relational model of intervention. In summary, the devil is in the intersubjectivity.
6.5 Drive Theory in Traditional One-Person Psychology

and Two-Person Relational Psychology
Drives in Traditional One-Person Psychology
Freud postulated that instincts or drives innately formed to eliminate any state of
tension from the body. Accordingly, Freud believed that bodily tensions were
aggressive and sexual in nature and were developmentally determined by the organ
of predominant interest to the infant for pleasure. For Freud, the origin of the drive
was a biological stimulus, although the drive itself was a psychic representation. In
this model, he proposed that, “from a biological point of view, an ‘instinct’ appears
to us as a concept on the frontier between the mental and the somatic, as the psychic
representation of the stimuli originating for within the organism and reaching the
mind” (Freud 1915). Freud stated about the infant: “From the very start, the infant
exploration of the external world is invested with libido. The drive towards taking
things into his mind, towards looking, touching, listening and exploring, satisfies
some of the wishes frustrated by the original objects.” Accordingly, intrapsychic
conflicts are considered a normal occurrence in the development of a child, which is
why Smirnoff (1971) and others consider child psychoanalysis as essential for
symptomatic children to reduce their anxiety through the dissolution the maladap-
tive ego defenses, which ultimately permits an outlet for the instinctual drives.
Drives in Two-Person Relational Psychology
Two-person relational psychology does not adhere to Freud’s drive theory. Rather,
two-person relational psychology proposes an innate relational matrix, the forerun-
ner for which was theorized by Bowlby. In this regard, Bowlby distanced himself
from the classical drive theory, as he believed that infants had innate prosocial
“wishes” to be with and to get along with others. This has been supported by a
wealth of infant developmental research (Emde and Hewitt 2001; Tronick and
Beeghly 2011), with strong evidence of complex prosocial processes occurring
throughout the life span: meaning making, social referencing, affective attunement,
internal working model schemas, mentalization, dynamic nonconscious, and
implicit relational knowing. We remind the reader of Tronick’s remarkable still-face
experiments in 1975 (Weinberg et al. 2008, Chap. 5) that capture the many efforts
an infant can resort to in reengaging with their caregiver. Additionally, a brief clip
of Tronick’s still-face experiment is available at www.YouTube.com.
6.6 Id in Traditional One-Person Psychology and Two-

Person Relational Psychology
Id in Traditional One-Person Psychology
Laplanche and Pontalis (1974) in the classic text The Language of Psycho-Analysis,
a dictionary of psychoanalytic concepts, define the id as “the prime reservoir of
psychical energy, [which] from the dynamic point of view, conflicts with the ego
and the super-ego—which, generally speaking, are diversifications of the id.” Thus,
in the simplest terms, the id is the agent of the bodily instinctual needs, desires, and
impulses, particularly of sexual and aggressive nature without respect to reality or
moral issues. The id embodies the instinctual sexual and aggressive drives and seeks
for immediate gratification (Freud 1920).
Id in Two-Person Relational Psychology
Two-person relational psychology does not adopt Freud’s structural theory and
therefore does not consider the id as a necessary concept, which presupposes the
need for an ego and superego. Instead, two-person relational psychology proposes
an innate strong process in which infants seek to engage with other humans for
comfort and survival and not for gratification of sexual or aggressive needs and
desires. That is, the attachment system is a “hardwired” motivational system in the
brain. The experience the infant has with his or her caregivers activates and encodes
meaning-making processes that will directly shape the organization of the motiva-
tional system in nondeclarative memory (Siegel 2001). As such, the concept of the
id is limiting, as it does not account for the active bidirectional mode of interaction
that shapes neuronal pathways, as occurs in two-person relational psychotherapy.
Additionally, genetically encoded information and neuronal activation can lead to
the activation of genes that shape the structure of the brain (Kandel 1999).
6.7 Ego in Traditional One-Person Psychology and Two-

Ego in Traditional One-Person Psychology
The ego, which has historically been viewed as the intrapsychic agency that negoti-
ates between the superego, the drives, and the id, is noted by Laplanche and Pontalis
(1974) to be “above all the expression of the defensive pole of the personality in
neurotic conflict; it brings a set of defensive mechanisms into play which are moti-
vated by the perception of an unpleasurable affect (signal of anxiety).” Further, “the
ego is an agency of adaptation which differentiates itself from the id on contact with
6.8 Superego in Traditional One-Person Psychology and Two-Person 125
external reality. It is also described as the product of identifications in the formation

of a cathected love-object by the id.” In short, the ego is the mediator of conflicts
between the id and the superego. In traditional one-person psychology, the psycho-
therapist helps the patient work through the pressures from the id: “Where id is,
there shall ego be” (Freud 1916–1917). Anna Freud focused on the ego’s uncon-
scious defensive mechanisms that originated during the child’s stages of psycho-
sexual development. She systematically classified these ego defenses, compiling a
comprehensive catalog in her classic work The Ego and the Mechanisms of Defense
(Freud 1937/1966), which later led to the school of ego psychology.
Ego in Two-Person Relational Psychology
As two-person relational psychology does not support Freud’s structural theory, the
ego, which presupposes the need for an id and superego, is not a useful construct.
Interestingly though, with regard to “ego functions,” the psychoanalyst Heinz
Hartman, who is often described as one of Freud’s favorite students, held that the
ego had a biological substrate that includes perception, memory, concentration,
motor coordination, and learning. He believed these innate ego capacities had
autonomy from the sexual and aggressive drives of the id and were not products of
frustration or conflict. Hartman coined the term “autonomous ego functions”
(Hartman 1958), and his ideas share much with recent concepts concerning implicit
memory systems and internal working relational schemas stored in nondeclarative
memory systems (Mancia 2006, also see Chaps. 5 and 7).
Further, two-person relational theory relies on the “we-go,” an intersubjective,
mutually adaptive process—as opposed to structure (i.e., the ego)—that exists at a
prereflective level and encompasses both “we” and “me” (Emde 2009; Iacoboni
2008, 2009; Iacoboni and Dapretto 2006). Freud’s ego as a concept fails to account
for the intersubjectivities of the person and those of the person they are interacting
with; these intersubjectivities ultimately subserve self-regulatory functions. The
psychoanalyst and developmental researcher Emde (2009) captured this failure of
the established Freudian school as follows: “We came to the realization that these
children had developed an executive sense of ‘we’ of the significant other being with
them, giving them an increased sense of power and control,” adding, “The self is a
social self.” Moreover, over the course of development, there are substantial gains
in the neurostructural foundations of social reciprocity and the development of “we-
ness.” It is through we-ness of the nondeclarative memory systems that internal
working models of attachment with self-regulatory functions are formed.
6.8 Superego in Traditional One-Person Psychology

Superego in Traditional One-Person Psychology
The superego, an intrapsychic agency that limits the drives of the id, has been referred
to as “the heir of the Oedipus complex in that it is constituted through the
internalisation of parental prohibitions and demands” (Laplanche and Pontalis 1974).

Further, the superego seeks to obey cultural and societal norms that have been incor-
porated into the person’s psyche. Returning to our example of the adolescent who had
forgotten to lock his bike, a psychotherapist who utilizes the traditional one-person
model notes that the adolescent experiences harsh superego pressures, feeling he has
done something wrong and believes that his psychotherapist will confirm this. In
turn, the psychotherapist would consider the adolescent having forgotten to lock his
bike as a transference manifestation with regard to the patient’s relationship with his
parents. From a Kleinian standpoint, superego formation occurs before the age of 2
and is a requisite component of the infant’s foray into the depressive position, wherein
“the child proceeds to develop a capacity of concern for others and guilt about one’s
actions and thoughts about others, with desire for reparation” (Winnicott 1965).
Further, Johnson and Szurek (1952) developed this concept of “superego lacu-
nae” (gaps in ego and superego functioning) when working with a 6-year-old boy
who chronically would run away. The authors understood the child’s running away
as a result of his father unconsciously encouraging him to run away, seeking vicari-
ous gratification from his son’s behavior. This led the boy to have a weakened super-
ego with lacunae or gaps in functioning. Johnson and Szurek concluded that serious
antisocial behavior, such as stealing, fire setting, and damage to property, in children
and adolescents, as the result of acting out unresolved intrapsychic conflicts through
parent-induced superego lacunae.
An everyday example thought to be due to pressures from superego lacunae is
when ostensibly bright children or adolescent do not complete school assignments.
This is considered a form of acting out of unconscious conflicts.
Superego in Two-Person Relational Psychology
Just as we have seen for the ego and for the id, the two-person relational psychol-
ogy does not adhere to Freud’s structural theory, and therefore the notion of a
superego does not live in this theory. Rather, in two-person relational psychology,
an implicit nonconscious social sense of morality develops as early as 9 months old
as infants interpret the different expectations and intents of others, which suggest
that infants (and adults) do not learn morality per se, but rather that morality is
innate (Bloom 2013). The early development of self was not only fundamentally
social but moral (Emde et al. 1991). This model developed from the work of the
developmental psychologist Kohlberg, who in turn based his explorations of moral-
ity on Piaget’s work. Kohlberg proposed a set of six developmental stages in moral
development, which served as the basis for ethical behavior (Kohlberg 1973); how-
ever, these stages were extended by Buchsbaum and Emde (1990), who found that
“children as young as 36 months represent a considerable amount of moral devel-
opment in narrative form. Children were able to articulate coherent stories about
rules, reciprocity, empathy, and internalized prohibitions. Most remarkable was
their ability to deal with alternative outcomes in order to resolve a moral dilemma.”
Much is yet to be known about moral development, particularly in regard to cultural
differences.
6.9 Psychosexual Stages in Traditional One-Person Psychology and Two-Person 127
6.9 Psychosexual Stages in Traditional One-Person

Psychosexual Stages in Traditional One-Person Psychology
Freud proposed that children progressed through several psychosexual developmen-

tal phases that were determined by the organ of predominant interest to the infant/
child for pleasure (e.g., oral, anal, and phallic). For Freud, unresolved conflicts in a
particular phase manifested themselves as a regression to the ego functions and
behaviors of the phase that they were fixated in. For example, it was believed that
conflicts in the oral phase can result in eating problems or alcoholism, whereas
unresolved conflicts in the anal phase can yield obsessional and anal-sadistic behav-
iors indicating pleasure in controlling and exercising power. As an aside, anal ero-
tism was thought to reflect sadistic forms of behavior by children with wishes to
destroy the object or to possess it. Finally, regarding conflicts in the phallic phase,
symptoms relate to masturbation, fantasies about pregnancy, and sadistic concep-
tion of parental intercourse. Importantly, Freud’s theories about psychosexual stages
were formulated based on his observations of very few European Caucasian
children.
Psychosexual Stages in Two-Person Relational Psychology
The notion that psychosexual stages occur in a linear manner and are punctuated by
the resolution of stage-specific conflicts is antithetical to the two-person relational
psychology. In the contemporary two-person relational model, development occurs
in a multilayered and continuous manner in which a person may be in different lay-
ers simultaneously. For example, in the two-person relational model, the develop-
ment of a meaning-making process occurs in parallel with the development of
affective attunement and social referencing, independent of zone-based interests
and fixations (e.g., oral, anal, phallic). In essence, in a two-person relational model,
“the search for a theoretical structure that neatly places psychological disorders and
character traits along a continuum of purported developmental levels does not do
justice to what we know about the complex ways in which development proceeds as
a continuing interplay between evolving personal characteristics and the environ-
ments encountered and, over time, created by the evolving personality” (Wachtel
2003). Importantly, Erikson was the first theorist to offer a model of development
that extended over the entire life span, proposing that psychosocial stages of devel-
opment are influenced by the social context and relate to an epigenetic principle:
“Anything that grows has a ground plan, and…out of this ground plan the parts
arise, each having its time of special ascendancy, until all parts have arisen to form
a functioning whole” (Erikson 1968). Developmental research has now begun to
reveal the complex processes involved in the scaffold building of physical and psy-
chological competencies over time, which are not derived from instinctual drives
but rather from a genetically influenced developmental blueprint. Recent cross-
cultural research suggests that it is difficult to delineate the transition from one
developmental phase to another. Thus, the description of development in phases

(i.e., preoedipal, oedipal, latency, and adolescence) is somewhat artificial. More
likely, children have a developmental blueprint that is influenced by genetic, family,
and environmental factors, which promotes development (Delgado et al. 2011).
For example, walking as a developmental milestone is typically attained between
the ages of 9 and 15 months in a securely attached environment, wherein the infant
has been provided ample opportunity for motor development as well as balance and
gross motor coordination. The child that grows in an unpredictable and chaotic
environment (e.g., an environment in which disorganized attachment styles pre-
dominate) may learn to walk at earlier ages for survival and, in doing so, will be able
to access food or use mobility to distance themselves from violent situations. As
such, both children will have different cognitive and environmental pressures that
implicitly determine which developmental path promotes survival, rather than this
being influenced by the resolution of stage-specific conflicts.
Clinically, the two-person relational psychodynamic psychotherapist will need
to be familiar with cognitive, psychological, and social milestones (see Appendix
A), as a knowledge (and application) of these milestones provides clues as to
whether developmental or psychological discontinuities may be due to neurodevel-
opmental (e.g., learning disorders) or environmental factors (e.g., deprivation).
Such an understanding will aid the psychotherapist in being realistic in his or her
expectations of the psychotherapeutic process. Additionally, it will be important for
the two-person relational psychotherapist to have an awareness of variations in
these milestones among non-Caucasian and minority populations, although we con-
cede that, at present, the academic understanding of the development of cognitive,
psychological, and social milestones in these populations is lacking.
Finally, it is clear that we are in era that recognizes that sexual development
comprises biological, psychological, and social aspects of experience that Freud did
not consider as important during his time. Herein, sexuality in children and adoles-
cents remains a complex subject, as it also pertains to children who live with les-
bian, gay, bisexual, and transgender parents. This complex process is described in
the AACAP Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation,
Gender Nonconformity, and Gender Discordance in Children and Adolescents
(Adelson et al. 2012): “Much of what has been learned scientifically about sexual
orientation and gender development in the last generation has occurred in parallel
with societal changes in attitudes toward sexual orientation and gender roles.” This
is in alignment with the two-person relational model’s view of development.
6.10 The Oedipus Complex in Traditional One-Person

Freud’s Oedipus Complex
In traditional one-person psychoanalytic theory, the Oedipus complex is the corner-

stone of understanding a person’s personality structures (e.g., id, ego, superego, and
ego ideal) and their psychopathology. This universal conflict in Freudian theory
6.10 The Oedipus Complex in Traditional One-Person Psychology and Two-Person 129
involves the child’s development of unconscious aggressive wishes toward the

same-sex parent in order to possess the opposite-sex parent. According to Freud, the
importance of the Oedipus complex came to him while viewing Sophocles’ play,
Oedipus Rex, in Vienna. In a letter to Fliess he wrote, “The Greek legend seizes on
a compulsion which everyone recognizes because he feels its existence within him-
self” (Freud 1897). He later added, “Every new arrival on this planet is faced with
the task of mastering the Oedipus complex” (Freud 1905). In psychoanalytic theory,
the Oedipus complex is at its peak between the ages of 3 and 5 years old, the phallic
stage.
Freud (1924) wrote of the Oedipus complex:
A little boy will exhibit special interest in his father; he would like to grow like him, and be
like him and take his place everywhere…. He takes his father as his ideal…. At the same
time as the identification with his father, or a little later, the boy has begun to develop a true
object-cathexis towards his mother according to the attachment type…. The little boy
notices that his father stands in the way with his mother. His identification with his father
then takes on a hostile coluoring and becomes identical with the wish to replace his father
in regard to his mother as well.
In traditional one-person child psychoanalytic literature, the understanding

and, at times, interpretation of oedipal conflicts were considered essential for the
child to achieve a healthy love object choice and to overcome castration fears typi-
cally seen in the form of ego inhibitions (e.g., poor performance at school, eating
difficulties, or self-defeating behaviors due to unacceptable wishes within the tri-
angular relationship to parents). This position has been attenuated although not
ignored.
In writing about the Oedipus complex, Freud believed that a successful resolu-
tion led to a healthy love object choice by repressing incestuous wishes. The con-
cept of object choice sets the stage for Klein’s object relations theory.
The Kleinian school of object relations proposes that most of the child’s conflicts
occur in the early stages of life, thus emphasizing early superego formation leading
to the preoedipal conflicts based on split objects—the breast and penis—during the
paranoid position. When the paranoid position is resolved, the child moved to the
depressive position. The oedipal conflict was thought as part of the depressive posi-
tion, in which the child accepts the loved object as a whole object that can be loved
and forgiven for the hated aspects.
Jung’s Electra Complex
Jung (1961) proposed the Electra complex, a negative Oedipus complex that affected
girls and that emerged between 3 and 5 years old (in parallel with Freud’s phallic
stage). Freud was reluctant to accept this concept, as he did not see the usefulness
and did not believe girls experienced the castration complex as intensely as boys
due to their preoedipal attachment to their mother. Freud believed that in girls, the
“Oedipal complex culminates in a desire, which is long retained, to receive a baby
from her father as a gift—to bear him a child” (Freud 1924).
The Oedipus and Electra Complexes in Two-Person Relational

Psychology
Both two-person relational psychology and current neuroscientific data refute the
Oedipus and Electra complexes. In fact, Kandel, an American neuropsychiatrist and
recipient of the 2000 Nobel Prize in Physiology or Medicine for his research on the
neurobiologic basis of memory consolidation, recognized the complexities in the
area of infantile sexuality and questioned the relevance of the oedipal conflict: “This
is a complex area, because genotypic gender, phenotypic gender, gender identifica-
tion, and sexual orientation are distinct from one another but interrelated. Indeed,
the recognition of this complexity can render standard terms such as male, female,
masculine, and feminine imprecise and in need of qualification. These are all early
findings, and their consistency over groups of people, both heterosexual and homo-
sexual, is still being questioned.” He further added, “The methods at hand for estab-
lishing whether there are reliable anatomical differences between people with
different sexual orientations…. [These] should greatly influence psychoanalytic
thinking about the dynamics of sexual orientation” (1999). Thus, in a two-person
relational model, what is considered to shape a child’s interaction with others
regardless of their gender is set in motion early in life through meaning-making
processes that provide the affective attunement and social reciprocity needed for
present moments of intersubjectivity with others unique to the dyad throughout
their life (Emde 1992).
The infant’s interaction with caregivers is singularly the most important task to
ensure survival and adaptation to the world. As such, developmental research
reveals that early interactions between child and caregiver are stored in nonde-
clarative memory systems and become part of declarative memory systems later.
Thus, infantile memories from early childhood are not accessible to verbal or sym-
bolic recall, but rather are encoded within the nondeclarative memory system
machinery that is unique to each child and is driven by their innate cognitive abili-
ties (or limitations). Therefore, it is well documented that securely attached infants
can learn to elicit soothing experiences from their caregivers (both females and
males), which are stored in implicit relational memory systems. For instance, the
child can implicitly know that teachers who, regardless of their gender, are encour-
aging and warm are trustworthy and those that are critical and intrusive are worth
maintaining distance—implicit relational knowing. In contrast, in a traditional
one-person model, the psychodynamic psychotherapist may consider, in knowing
that the child’s parents are critical and intrusive, that the child’s experience of a
critical teacher is a displacement or projection of parental conflicts, when in real-
ity, the teacher is critical like the child’s parents. As Emde (1992) aptly states,
“Freud’s portrayal of the child’s experience during the family oedipal drama is
oversimplified. We know today that fathers do not appear later on the stage to
interrupt an earlier affectionate relationship with mother when the child becomes
3 or 4.” He adds, “Research has shown that fathers, under normative conditions,
develop early and qualitatively separate affectionate relationships with both young
boys and girls.”
6.11 Latency in Traditional One-Person Psychology and Two-Person 131
6.11 Latency in Traditional One-Person Psychology and Two-

Latency in Traditional One-Person Psychology
In traditional one-person psychoanalytic theory, latency is the period that begins

with the dissolution of the Oedipus complex and extends to the onset of puberty,
typically between the ages of 6 and 12 years old. It is believed that during this
period, repression intensifies and brings with it amnesia of the early conflicts, as
well as the development of sublimation, moral values (including shame), and aspi-
rations for future activities. This phase was thought to be of relative stability. Anna
Freud argued that what fostered children in the latency period to shift their attention
from their parents to their peers was diminished drive pressures (e.g., the pleasure
principle) in favor or the reality principle. Surprisingly, during the last 50 years, in
The Psychoanalytic Study of the Child, many of the clinical cases reviewed are of
children in child psychoanalysis or psychotherapy who became symptomatic during
the latency period, suggesting that this phase is thought of as lacking stability. This
notion is consistent with Bornstein (1951), who believed that children, in the early
phase of latency, struggle with increased incestuous wishes and masturbatory fanta-
sies as a consequence of harsh superego pressures and rigid ego defenses (i.e., the
externalization of superego pressures due to incomplete mastery of the oedipal
phase). During the latency phase, ego functions acquire greater stability.
Latency in Two-Person Relational Psychology
Unlike in traditional one-person models wherein development occurs in a linear

fashion involving distinct phases with discrete beginnings and endings, current
research suggests that the maturation of physical and psychological competencies
occurs in parallel. This is to say that the interrelated processes of temperament,
cognition, cognitive flexibility, internal working models of attachment, and cul-
ture—which are unique to each individual—serve as a scaffold for biological devel-
opment (Delgado et al. 2011). Thus, the traditional one-person conceptualization of
latency as a psychosexual phase is artificial. Children have a unique genetic devel-
opmental blueprint that is strongly influenced by family and environmental factors,
which when interwoven can act synergistically (Delgado et al. 2011). As such, one
does not have to look far to appreciate these complexities in personality formation
of school age children. For example, consider the situation of two school age sib-
lings: In the case of the first child, good affective attunement and social referencing
were present early in life and laid the groundwork for interpersonal success as a
school age child. The second child, as a toddler, also had ample emotional avail-
ability, affective attunement and social referencing from his or her parents. Moreover,
this second child exhibited receptive language deficits and attention deficit hyperac-
tivity disorder (ADHD), as well as a difficult/feisty temperament, which collec-
tively resulted in difficulties engaging with peers due to his incapacity for social
reciprocity. These deficits in the second child resulted in episodes of verbal or phys-
ical aggression, which ultimately confirmed, at an implicit level, that he was differ-
ent. Thus, both children had secure attachment environments, and there was no
suggestion of indolent, unresolved intrapsychic conflict. However, one child strug-
gled in making sense of the world as a result of his deficits, and his “advancing”
chronologically to the next developmental stage (i.e., adolescence) is unlikely to
result in symptomatic improvement. Finally, it is worth noting that during the ele-
mentary school years, the developmental milestones are complex (see Appendix A).
Among the most salient developmental tasks are competition in games, enjoyment
of group activities, enjoyment of conversation with others, increased interest in the
opposite gender, and increased respect for parents. Returning to our example of the
two siblings, we might expect that the first child would readily play with peers,
compete with classmates, and might play baseball in the neighborhood, whereas the
second child would—as a result of his difficulty to read the intent of others—chron-
ically feel misunderstood and struggle to participate in similar activities. As such,
the concept of latency is limiting as it does not account for the multifactorial com-
plexities of development.
6.12 Adolescence in Traditional One-Person Psychology

Adolescence in Traditional One-Person Psychology
In traditional one-person psychology, adolescence follows latency. The study of

adolescent psychological development was based on patients with significant psy-
chopathology (Delgado et al. 2012). In his Three Essays on Sexuality (1905), Freud
stated that the beginning of adolescence is heralded by the reawakening of the
oedipal conflicts and asserted that the adolescent’s developmental tasks were
“painful psychical achievements” to find a nonincestuous sexual object. Freud’s
daughter, Anna Freud, was among the first to describe the adolescence period as a
state of disequilibrium, or “turmoil” (1958). Subsequently, Blos (1968) introduced
the notion of a second individuation process during adolescence based on Mahler’s
(1974) separation–individuation phase of the infant. Blos believed that the adoles-
cent’s break from the internalized objects made possible the quest for “extrafamil-
ial love and hate objects” (Blos 1967). Upon completing this process, the object
relations of the adolescent become stable, with clear boundaries, and the adoles-
cent becomes more “resistant to cathectic shifts” (Blos 1968). In parallel, Erik
Erikson asserted that adolescence was not “an affliction but a normative crisis, a
normal phase of increased conflict characterized by a seeming fluctuation in ego
strength, and yet also by a high growth potential” (Erikson 1956). Taken together,
the traditional psychodynamic understandings of adolescence posits four key intra-
psychic developmental tasks: (1) loosening of infantile ties, (2) de-idealization of
the parents and overcoming castration anxieties, and (3) character formation and
the second individuation, all of which are dependent on the preceding process
(Fig. 6.1).
6.12 Adolescence in Traditional One-Person Psychology and Two-Person 133
Puberty
ation
form
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C hara s se
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o n o mou n)
ut atio
the a vidu
c t i o n of tion indi
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Intro nd sepa ing
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Fig. 6.1 Key tasks of adolescent development in classical theory (Adapted from Delgado et al.
(2012))
The traditional one-person form of psychoanalysis and psychotherapy of adoles-

cents focused on helping the patient overcome the regressive pull of the parental
ties, which accordingly led to the self-defeating and maladaptive behaviors of the
adolescent. Barrett (2008) views the adolescent’s self-defeating behavior as a manic
defense: “The loneliness results from the adolescent’s need to transfer love from
primary objects to new adult relationships not yet available to him. The resultant
emptiness may be defended against by overuse of the Internet, alcohol, cigarettes,
drugs, and food. These defenses are manic in quality in that they suggest an orally
based regressive attempt to ‘take in’ and ‘expel out,’ preserving the felt ‘lost’ object
and converting the loneliness into elation.”
Importantly, however, these theories that are focused on ego functions fail to
account for the influence of family factors and have been aptly critiqued by the fam-
ily psychotherapist Murray Bowen, who notes that psychoanalytic theory lacks the
theoretical formulation for the individuation that occurs within the context of family
triangles (Bowen 1972). Finally, a significant limitation of the traditional one-per-
son psychodynamic model is that it does not provide a theoretical understanding of
gay and lesbian adolescents or the physically, mentally, and learning disabled, areas
where further research is necessary.
Adolescence in Two-Person Relational Psychology
The twentieth century saw substantial advances in understanding the biological,

psychological, and sociological aspects of adolescent development. In two-person
relational psychology, adolescence is a period in which the developmental com-

plexities are viewed as having been built on the lifelong maturation genetic blue-
print within the context of innate temperamental and cognitive abilities—nature—as
well as environmental factors, including the availability of affective and social ref-
erencing and implicit relational knowing, nurture. That is, adolescence is not con-
sidered a distinct phase of a linear process as in the traditional one-person model.
Accumulating data supports the notion that adolescent behavior cannot be reduced
to purely psychological or biological phenomena. Imaging studies of adolescent
brains show that during adolescence, the area of the brain responsible for organiza-
tion, planning, and strategizing is not fully developed, as the gray matter continues
to thicken, confirming aspects of fluidity in decision making and a number of other
cognitive capacities (Giedd 1999).
Offer and colleagues’ empirical research occurred with adolescents in the “real
world” (rather than in clinical populations) and suggests that the majority (80 %) of
adolescents managed the transition from childhood to adulthood quite well.
Specifically, these longitudinal studies of adolescence (Offer and Offer 1975) sug-
gest that most adolescents either progress “steadily” or with a sequence of develop-
mental spurts, which are punctuated by episodic conflict, whereas 20 % of
adolescents appeared to take a more tumultuous route through adolescence.
Contemporary psychodynamic understanding of the adolescent is strongly influ-
enced by attachment theory, developmental psychology, and intersubjectivity, the
implicit nondeclarative memories of the interactions between self and others. The
typical adolescent develops the ability to regulate the shifts of affective states and
judges how to convey, within reason, autonomous opinion without compromising
relationships—the use of an abstract self within the backdrop of early secure attach-
ment patterns (Delgado et al. 2012).
Further, even with the advances in developmental psychology, the understanding
of gay, lesbian, bisexual, and transgender adolescents is challenging and an area that
requires further research. Additionally, in regard to physically, mentally, and learn-
ing disabled adolescents, although challenging, their psychological needs must be
determined, and their treatment recommendations must be made after a careful
assessment of the four pillars in a contemporary diagnostic interview (Chap. 8).
This will lead to a better grasp of their cognitive strengths and weakness to tailor
treatment of these individuals with realistic expectations, regardless of their chrono-
logical developmental phase.
As a note, an area that is of interest to sociological adolescent research is the
impact that YouTube®, Facebook® instant messaging, text messaging, Instagram®,
and Twitter® will have on matters of intersubjectivity, which typically depends on
face-to-face interactions to discern intent of others through the tone of voice and
facial expressions. This has become an issue too complex for psychodynamic theo-
ries alone.
6.13 Defense Mechanisms in Traditional One-Person Psychology and Two-Person 135
6.13 Defense Mechanisms in Traditional One-Person

Defense Mechanisms in Traditional One-Person Psychology
The concept of defense mechanisms is part and parcel of the everyday lexicon of
child and adolescent psychiatry trainees, their supervisor, and experienced clini-
cians. It is the “go to” manner of understanding a patient’s and their family’s psy-
chological symptoms and behaviors. The concept is at the heart of the traditional
one-person model in understanding others, with broad statements of “that patient is
splitting,” “the patient is using reaction formation to deal with their anger about
being diagnosed with diabetes,” “I like the patient because she sublimates and is
able to get along with her parents,” etc. In essence, it involves understanding the
patient’s inner life through their ego defense mechanisms, while excluding the clini-
cian’s contribution to the patient’s discourse.
In traditional one-person psychology, the ego generates defense mechanisms to
psychologically mediate conflict among the id (drives) and the superego (urging
civility). Also, this theory contends that “the window into…[the] personality
[derives from an] understanding of the ego’s defense mechanisms that an individual
employs in coping with daily-life anxiety and threats to self-esteem from intrapsy-
chic conflicts” (Delgado and Strawn 2014).
While Sigmund Freud was the first to describe defense mechanisms, much of our
understanding of these processes comes from his daughter, Anna Freud. She com-
piled a comprehensive catalog of these defenses in The Ego and the Mechanisms of
Defense (Freud 1937/1966). Anna Freud further believed that defenses would be
best assessed through the understanding of the child’s play and that this was the
equivalent of free associations. She believed that the goal of a child’s psychoana-
lytic treatment was to improve their ego functions by interpreting their ego defenses,
and she provided reassurance and gave suggestions to the parents on how to interact
with their child (Freud 1937/1966). More recently, however, there have been subtle
changes in our understanding of defenses, with a distinction being made between
mature and immature levels and then being hierarchically categorized as mature,
neurotic, immature, or pathological, as conceptualized in George Valiant’s seminal
work, Ego Mechanisms of Defense: A Guide for Clinicians and Researchers (1992).
Delgado and Strawn (2014) further state, “Sometimes we might consciously
know which defense mechanisms we use in relation to others—as in humor to man-
age family conflict, or denying or overlooking a colleague’s negative comments—
but in most cases they occur unconsciously. Defense mechanisms usually are
adaptive and can have a salutary effect, allowing an individual to function normally.
Importantly, however, when used in a repetitive fashion, defense mechanisms can
become maladaptive and induce further anxiety.”
Defense Mechanisms in Two-Person Relational Psychology
Two-person relational psychology does not endorse the existence of instinctual

drives, which imply the need for the use of defense mechanisms against pressures
from the id and superego. Two-person relational psychology posits that a person is
not defending from intrapsychic pressures from the id or superego; rather, they
defend against experiences that are unfamiliar and subjectively provoke anxiety. An
example that occurred to one of the authors when supervising a child and adolescent
psychiatric trainee happened when the trainee stated: “The patient missed their psy-
chotherapy appointment. Last week I was on vacation, and I think she is mad at me
and is resisting coming because she is afraid at expressing her anger at me.”
Unfortunately, this is familiar to most of us; we all have had experiences of tradi-
tional one-person competency, when we firmly believed we clairvoyantly knew the
reasons for our patient’s actions. In this case, the author suggested viewing the
patient’s absence within the context of the patient having improved with healthier
adaptive patterns of interaction with others that had occurred through a two-person
relational approach, which provides new emotional experiences through moments
of meeting (see Chap. 5). Although the trainee was reluctant in tolerating the ubiq-
uitous uncertainty of a two-person relational model, she was able to consider several
scenarios for the patient’s missed appointments. The following supervisory hour,
the trainee was outwardly in a jovial mood. She stated: “Wow, it is so important to
think about context. The patient missed because she interviewed for a really good
job that morning, and they asked her to stay that afternoon to complete her paper-
work. She was so excited that she forgot to call and cancel, and when she noticed
she hadn’t called, she knew I would understand. She is so much better.” A note to
the reader: Context is not only about the realities noted in verbal form; it also
includes the intersubjective experiences with the patient, which will be different
with each dyad. In this example, the intersubjective experience of the previous ses-
sion set up the feelings experienced in the missed session: the patient felt the trainee
would understand, while the trainee initially worried that the patient was resisting,
but then was able to tolerate the uncertainty when taking into account her positive
intersubjective experience of the earlier session. We also will not ignore that the
reader may have noticed the comment by the patient “forgot to call,” which from a
traditional one-person model may also be considered as resistance, and—depending
on the psychotherapist’s school of thought—may be viewed as fear of sharing her
success; fear in not receiving the mirroring needed for such an achievement, as had
previously occurred with her parents; fear in destroying the relationship due to the
psychotherapist’s vacation; etc. In a two-person relational model, the patient’s for-
getting to call may genuinely be due to her excitement about employment, which is
reasonable to have been a step forward in her well-being.
Therefore, given that two-person relational psychology conceptualizes a patient’s
behavior as influenced by nonconscious relational schemas initially set in implicit
nondeclarative memory systems by interactions with the many people they had a
relationship with, it is natural for the trainee or newly minted psychotherapist to
have a certain degree of discomfort in their quest to understand the reasons for their
6.14 Object Relations Theory in Traditional One-Person Psychology and Two-Person 137
patient’s behaviors. As we have stated throughout this book, tolerating uncertainty

and relying on change to occur in here-and-now interaction at the implicit nonde-
clarative local level may be a new concept to the reader that we hope to instill.
Attachment and developmental researchers demonstrate that implicit schematic
patterns of relatedness (i.e., internal relational knowing) are sensitive to the dele-
tions and distortions that occur during interactions. For example, the child attending
kindergarten who displays oppositional behavior when the teacher encourages him
or her to participate during the story reading time may be avoiding participating in
something that is not familiar to him or her if he or she has never been exposed to
reading by caregivers. Thus, the child’s oppositional behavior occurs at an implicit
level, likely having seen a caregiver also refuse to participate in an activity they did
not master, perhaps also reading. In short, in a relational model, “all that happens in
interactive and affective life…replace[s] the idea of conflict between tripartite struc-
tures with this more dyadic view of complex patterns of conflict between the inten-
tional directions of the self and the intentional directions of important others that are
represented at the implicit level” (BCPSG 2002; 2005; 2007).
6.14 Object Relations Theory in Traditional One-Person

Object Relations Theory in Traditional One-Person Psychology
More than half a century ago, a natural transition from ego psychology to object
relations theory occurred. Melanie Klein (1882–1960), a student of Sigmund Freud,
was the first object relations theorist and postulated that object relations were at the
center of a person’s emotional life (Klein 1932). In the simplest terms, object rela-
tions refers to the capacity to have stable and rewarding relationships based on the
internalization (a process closely related to introjection) of the early childhood rep-
resentations of others in the form of “objects.” However, internalization of these
objects is not a mere imitation. Filtered by the child’s wishes and needs, individual-
ized significance is attributed to these “objects” (Delgado and Songer 2009).
Additionally, Klein proposes a paranoid position of the child when internalized
representations of caregivers are experienced as part objects that the mind splits into
“good” and “bad” objects (e.g., the loving, nurturing mother and the depriving
mother). In the early years, the child maintains the self-object split and, in doing so,
avoids the distress associated with recognizing that there are aggressive and depriv-
ing aspects of the self as well as of the other. Then, as development progresses, from
4 to 12 months old, the child learns to integrate and tolerate that a person has both
“good” and “bad” parts and enters a healthy phase that Klein describes as the
depressive position (Klein 1932). Having psychologically achieved the depressive
position, the child proceeds to develop a capacity of concern for others and guilt
about one’s actions and thoughts about others, with a desire for reparation (Winnicott
1965). For Klein, psychoanalysis in children alleviated the primitive anxieties from
the harsh internalized objects and inner persecutors (i.e., paranoid position), and
modified this through transference interpretations that removed a blockage from the
artery to the child achieving a depressive position. The object relations theorist and
psychoanalyst Otto Kernberg, MD (1928–), suggested that when the patient’s inter-
nal representation of others remains “split,” they primarily use low-level defense
mechanisms, including splitting, projection, and projective identification (Kernberg
1976). According to Kernberg, these patients are best understood as exhibiting a
borderline level of organization, with poor capacity for affect regulation, and are
prone to impulsive actions, including suicide (Kernberg 2000; see Defense
Mechanisms, this chapter).
Paulina Kernberg was the first to study the early signs of personality disorders in
children and adolescents from an object relations point of view. She wrote, “The
potential for psychological change comes through the activation of dissociated or
repressed internalized object relations and through the empathic and shared inter-
change with the analyst. This patient could discern more clearly what belonged to
the present from what belonged to the past and what was being distorted in both
present and past.” She goes on to state, “It is more relevant to the patient to under-
stand the determinants of her object relationships than to determine what is
intrapsychic or interpersonal” (Kernberg 1988).
Object Relations Theory in Two-Person Relational Psychology
An infant’s temperament, cognition, cognitive flexibility, and internal working

models of attachment that allow him or her to cocreate experiences of the self with
others do not originate from Freud’s instinctual drives or Klein’s objects; rather,
these relational processes are derived from complex nonconscious meaning-making
processes stored in implicit nondeclarative memory systems (Chap. 5). The infant
elicits and shapes experiences within the context of others and cocreates self-
regulatory schemas based on the opportunities for affective attunement and social
referencing in his or her environment. As eloquently described by Emde (2009),
“We are dealing with human relations, not objects—‘we-ness’ introduces an impor-
tant new domain that has not been encompassed. The mirror neurons research indi-
cates that our neurobiology commits us to others at a basic prereflective level, and
that there is a primary sense of ‘we’ as well as ‘us’” (Emde 2009; Iacoboni 2008,
2009; Iacoboni and Dapretto 2006). Importantly, two-person relational theory
emphasizes knowledge of a child’s or adolescent’s family and social systems and
posits that this is essential to contextualizing to the developmental processes,
accounting for cultural and social norms. Similarly, as with drive theory, object rela-
tions fails to attend to family and social systems in which the child lives and often
fails to integrate the importance of multiple caregiving figures in the form of par-
ents, aunts, uncles, and grandparents relating with the infant in early life, contribut-
ing to the infant’s developmental processes. Thus, object relations theory also limits
the importance of cultural and social norms in the development of the child and
adolescent. Finally, many object relations concepts (e.g., introjection, projection,
projective identification, and splitting) fail to account for the psychodynamic
6.15 Transitional Objects in Traditional One-Person Psychology and Two-Person 139
psychotherapist’s proclivities as a contribution to the cocreated moments of meeting

in the therapeutic relationship (i.e., the psychotherapist’s own internal relational
knowing when interacting with the patient, intersubjective experiences).
Stated differently, the study of a nonsymbolically based representational system
has become the central contribution from infant research (Beebe and Lachmann
2002; Tronick 1998). Thus, the older term, “internalized object relations,” connotes
the “taking in from the outside,” rather than the “taking in” of the here-and-now
implicit and nonconscious subjectivity that is inherent in two-person relational psy-
chology (Tronick 1989). The older term is also more identified with the literature on
pathological rather than adaptive relatedness and is more often used to refer to past
relationships and their activation in the transference rather than with more general
representational models that are constantly accessed and updated in day-to-day
encounters.
6.15 Transitional Objects in Traditional One-Person

Transitional Objects in Traditional One-Person Psychology
Coined by the pediatrician and psychoanalyst Donald Winnicott, the transitional

object (1953) refers to any material object, typically something soft (e.g., a blanket
or stuffed animal), that serves as the infant’s first intrapsychic “not-me” possession.
Winnicott believed that the infant’s reliance on the transitional objects was a normal
phenomenon that allowed the child to transition from the first oral relationship with
the mother’s breast to a true “object relationship” (Laplanche and Pontalis 1974).
Conceptually, Winnicott (1965, 1971) was clearly referring to both drive and object
relations theories as demonstrated in his comments:
I have introduced the terms “transitional objects” and “transitional phenomena” for desig-
nation of the intermediate area of experience, between the thumb and the teddy bear,
between the oral erotism and the true object-relationship, between primary creative activity
and projection of what has already been interjected, between primary unawareness of
indebtedness and the acknowledgement of indebtedness (“Say: ‘ta’”). By this definition an
infant’s babbling and the way in which an older child goes over a repertory of songs and
tunes while preparing for sleep come within the intermediate-area as transitional phenom-
ena, along with the use made of objects that are not part of the infant's body yet are not fully
recognized as belonging to external reality.
Winnicott noted that the transitional phenomena occur between the ages of 4 and
12 months, and he postulated that these phenomena served as a defense against the
feelings of depression and the separation anxiety that results from times when the
mother is absent. Further, he believed that the overuse of transitional phenomena
gave rise to psychopathology, if the projected object was of a persecutory nature, as
it would have a fetish quality and could ultimately lead to drug addiction, pathologi-
cal lying, and theft (Winnicott 1953). Not surprisingly, many Kleinian analysts
criticized Winnicott’s concept of the transitional object, as it was an inanimate

object that could not represent pathological manifestations of object introjections.
The concept of a transitional object has found a home in the general and psycho-
therapy lexicon, although not necessarily in the way that Winnicott had conceptual-
ized it. It is common to refer to “binkies,” stuffed animals, or “blankies,” as
transitional objects, although, in reality, these objects are likely a soothing object
rather than the transitional object in the Winnicottian sense: not-me possession, an
intrapsychic representation of mother’s breast.
The concept of medication used as a transitional object will be discussed in the
psychopharmacology section below.
Transitional Objects in Two-Person Relational Psychology
The concept of a transitional object and, for that matter, transitional phenomena in
two-person relational psychology holds broad and contextual meanings. The con-
cept of a transitional object represents a transitional “real” soothing object, rather
than a “not-me” object representation of Winnicott’s traditional one-person model.
A “real” soothing object may have a variety of meanings within the context of
implicit relational knowing. Put simply, soothing objects facilitate meaning-making
processes. For example, we are familiar with the image of a young child dragging
along their real soothing object, be it a stuffed animal or special blanket, and most
parents have had the unforgettable, frantic, and even desperate experience of return-
ing home, to a restaurant, or to a relative’s home when their child’s “binky,”
“blankie,” or teddy bear has been forgotten and the child demands for it to be found.
We empathize with the reader that is familiar with this scenario, and in reading this,
he or she may implicitly smile as they are reminded of their own experience. That
is, the reader has stored this experience in implicit nondeclarative memory that he
or she retrieves affectively when recalling the moments. In thinking about this topic,
the lead author is reminded of his friend and colleague Efrain Bleiberg, who fre-
quently shares the story of his son forgetting his teddy bear at his grandmother’s
house. Dr. Bleiberg was frantic with excitement upon learning that his friend would
be traveling near the boy’s grandmother’s home and could bring back the teddy bear
for his son. In fact, he pleaded on behalf of his son—and for his family’s sanity—to
bring back the teddy bear. When the teddy bear was returned, Dr. Bleiberg wel-
comed the news with joy and relief and continues to reminisce and laugh about the
experience, an example of an experience stored in implicit nondeclarative
memory.
We note that Dr. Bleiberg’s son’s teddy bear does not represent a transitional
object in the Winnicottian sense, where the object represents the absent mother. In
fact, on many occasions, a child who has forgotten his teddy bear may no longer be
interested in the soothing object upon its return. Thus, the meaning-making process
progresses developmentally, and the individual no longer seeks objects for soothing,
but rather seeks affective communication and social reciprocity from family and
friends. In short, the concept of transitional objects is ubiquitous, at least from a
6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional 141
conceptual standpoint, and has been widely used in day-to-day psychodynamic psy-
chotherapeutic work, although not necessarily in the way that Winnicott had set out
to describe. The transitional soothing real object phenomenon plays an adaptive role
for many individuals. For example, many young women, and some men, when leav-
ing for college take an identifiable, real transitional object from childhood. In doing
so, such an adolescent copes with the challenge of separation from his or her family,
which is influenced by the complexities of temperament, cognitive, and affective
flexibility and attachment patterns and not developmentally confined to the first
years of life as Winnicott had believed. Put differently, the real soothing object rep-
resents a regulatory schema and nonconscious memory of an earlier experience not
accessible through semantic memory. This action is not what Winnicott intended as
an introjection as a “not-me object relation” experience.
When a child grows up in an unpredictable and insecure environment, he or she
has limited exposure to the emotional availability that real objects represent or
may—developmentally—lack internal implicit nondeclarative abilities to store their
positive affective experiences. Sadly, for some, the precursors of familiar soothing
objects are made available by their family and may take the form of illegal sub-
stances or weapons. These children are prone to being teased, promoting further
dismissive and disorganized forms of attachment (Chaps. 5 and 8). Further, in a
traditional one-person model, the use of illegal substances or violence may be
understood as identification with the aggressor. For example, an adolescent girl who
was removed from her home at an early age due to neglect had lived in several foster
homes due to her oppositional and help-rejecting behavior stored in implicit nonde-
clarative memory. Several foster parents noted that she constantly sucked on her
thumb at home and at school: “She goes to sleep and wakes up with the thumb in
her mouth.” A traditional one-person psychology view may understand her behavior
as unconscious self-soothing experiences that can represent the intrapsychic repre-
sentation of a non-soothing, split-off, bad mother object. In a relational model, her
thumb sucking may represent a maladaptive meaning-making process and may con-
vey a physical indicator of possible psychological maltreatment or neurobiological
survival skills of the implicit memory. The foster parents have repeated what she
recognizes as being familiar at an implicit level—to be once again criticized and
rejected for her behaviors.
6.16 A Review of the Most Commonly Cited Defense

Mechanisms in Traditional One-Person Psychodynamic
Psychotherapy: A Two-Person Relational View
Introjection, Projection, and Projective Identification

in Traditional One-Person Psychology
Introjection and projection in traditional one-person psychology refer to the internal-

ization of psychological characteristics that a child attributes to caregiving and
parental figures, which are filtered by the child’s internal wishes and needs (Delgado
and Songer 2009). When these characteristics are psychologically unbearable to rec-
ognize as one’s own, they are projected onto another person. For example, introjec-
tion of positive early childhood experiences is evinced when psychologically healthy
children allow for a parent to reassure them in an empathic manner to overcome a
negative life event. As a corollary, when the child has been a victim of neglect or
abuse, he or she may unconsciously be loyal to the introjection of the bad object
representations (i.e., negative experiences) and, unable to psychologically access a
healthier internal experience to interpret the situations, are likely to recreate/repeat
early experiences in which they were criticized for “being bad.” In psychodynamic
psychotherapy, this individual is inclined to believe that the psychotherapist is a rep-
resentation of the critical parents—transference of introjections onto the psycho-
therapist—and is prone to misinterpretation of the psychotherapist’s good intentions,
which needs to be interpreted so the patient can accept and work through the harsh
superego functions and improve ego functions. Further, when an individual needs to
avoid recognizing that some negative attributes, desires, and emotions are their own,
he or she may unconsciously project them onto another person (Akhtar 2009). At
first glance, the process may be seen as akin to Freud’s transference; however, pro-
jection involves an individual transferring his or her own state of mind onto an object
(e.g., the psychotherapist), whereas with transference, the past parental experiences
are repeated with the psychotherapist who “stands in” for the parental object.
In the school of object relations, projective identification, a primitive phenome-
non, involves the patient psychologically forcing the disavowed bad self-object onto
a recipient who unconsciously returns the foreign bad self-object back to the patient
as if the recipient had owned it. As such, projective identification involves two com-
ponents: (1) projection as described above, in which the person blames the other by
projecting onto him or her the individual’s own conflicted unconscious object rep-
resentations of the self, as they cannot be tolerated as being their own, and (2) the
negative reactions by the “recipient” of the person’s projections, which “exerts
interpersonal pressure that nudges the other person to [unconsciously identify with
that which has been projected]” and unknowingly acts as the bad object (Gabbard
2010). Importantly, the ensuing behaviors on the part of the recipient are generally
not considered “in character,” but rather represent a reaction to the feelings that
belong to the person projecting (Delgado and Strawn 2014). These very reactions—
the inability to contain and tolerate the affective states evoked by the projections—
sadly confirm what the patient believed to be the case all along. In short, the
psychotherapist is caught up in identifying with a patient’s projections. Typically
the psychotherapist feels, “This isn’t like me.”
As with many traditional one-person psychodynamic or psychoanalytic theoreti-
cal concepts, projective identification and countertransference remain controversial.
In this regard, the difference between the two related concepts derives from the
theoretical school that spawned them. Moreover, some contemporary theorists and
practitioners consider these two mechanisms to be, for practical purposes, one and
the same (Renik 2004).
6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional 143
Introjection, Projection and Projective Identification

in Two-Person Relational Psychology
Both introjection/projection and projective identification originate from an uncon-

scious fantasy within a one-person model, and thus, in two-person relational psy-
chology—wherein an unconscious conflict-based fantasy does not exist—reference
to these phenomena is rare. Infant-based research suggests a bias of the infant
toward self-regulation and mastery, as well as a bias to create perceptual–experien-
tial coherence and organization of their happenings (Stern 1995). In this regard, the
infant’s brain is designed to make meaning of what goes together in reality.
Moreover, we now know that infants as young as 3 months of age experience dis-
tress when there is a discrepancy between reality and their mental representation of
the event. For example, when an image of their mother’s face is on a television
screen and her voice is desynchronized, the infants detect the discrepancy and
remain upset until the discrepancy is corrected—in other words, they remain upset
until a familiar and soothing experience is recreated (Dodd 1979; Trevarthen 1977).
In essence, the infant does not introject objects, but rather cocreates experiences
with the other person’s multiple representational “selves” or “schemas,” which
allow the two to share and co-experience the other’s internal working models of
attachment. This serves as the foundation for implicit relational knowing and facili-
tates the development of a coherent sense of self. Thus, in a two-person model,
children, and later adolescents, seek implicit relational partners, a “nonconscious”
search for that which is familiar and supports self-regulatory functions in the con-
text of their environment. In a traditional one-person model, this represents a repeti-
tion compulsion that results from pressures from the id on the superego in the
context of poor ego functioning.
In two-person relational psychology, when a psychotherapist has a reaction
that is not “in character” while interacting with a patient, this reaction is concep-
tualized as the psychotherapist being nudged by the patient’s nonverbal attributes
to nonconsciously retrieve a familiar relational schema that is triggered by the
patient’s particular attributes. For example, a psychotherapist may intersubjec-
tively notice that he or she had been playing checkers with an 8-year-old child in
a very competitive manner. Upon noticing this, the psychotherapist intersubjec-
tively recognizes that the child’s aggressive form of play and nonverbal dismis-
siveness had elicited the response the psychotherapist uses when interacting with
people who convey contempt. The psychotherapist can then proceed to use this
intersubjective information to help the child learn to reduce using his or her dis-
missive style and may say, “I am thinking of making this move, although maybe
this other move is better. Can you help me decide which is best?” The difference
in a two-person relational model is that the relational schema that was triggered
by the patient occurred at an implicit level and was not due to the reawakening of
the psychotherapist’s intrapsychic conflicts, as would in a traditional one-person
model.
6.17 Fantasy in Traditional One-Person Psychology

Fantasy in Traditional One-Person Psychology
The central concept of fantasy (or “phantasy,” per Melanie Klein) in traditional one-
person psychology represents an unconscious process that is defensive in nature and
protects against the pressures from the wishes of the id and the punishment from the
superego and internal object representations in the mind of an individual. In addi-
tion, fantasies—when they occur at the conscious level—may be conceptualized as
daydreams. In the traditional one-person model, fantasies and daydreams are akin to
free associations, revealing the unfiltered inner life of the child. In routine clinical
psychotherapeutic work, a traditional one-person psychotherapist might ask, “What
are your fantasies about?” to access the patient’s intrapsychic conflicts and to tailor
his or her interpretations. For example, a 16-year-old girl in weekly psychotherapy
shared her wish to live independently from her perceived controlling parents. Her
psychotherapist inquired as to her fantasies about what her parents or psychothera-
pist might say about her wish. In this model, her response guides her psychothera-
pist in interpreting the “fantasy” vis-à-vis transferential aspects, so as to provide
insight about her wish. If her fantasy is that her psychotherapist might think the idea
is unrealistic, her psychotherapist could interpret this as a projection of her own
ambivalence.
Fantasy begins in childhood and is revised throughout life, contributing to the
organization of experiences. With young children, in a traditional one-person model,
the concept of fantasy is essential, as it is considered a form of free association: play
is the royal road to a child’s unconscious conflicts (Bettelheim 1987). Common
fantasies of children include superheroes attacking “the bad guys,” or dolls wanting
to “marry and have babies with daddy,” typically which are proposed to represent
the child’s inner life with regard to unconscious wishes involving parental objects
that later become transferentially displaced onto the psychotherapist.
Fantasy in Two-Person Relational Psychology
In two-person relational psychology, fantasy represents the nonconflicted creative

and imaginative abilities of the child or adolescent. Imagination or fantasy is devel-
opmentally a cognitive meaning-making process; it is a form of interpersonal com-
munication through personal creativity. Therefore, the ability to create fantasies
representing a person’s imagination of other persons or things, which does not abide
by the norms of reality, originates during the meaning-making process in the infant
and continues throughout life, influenced by culture.
Confirmation of this creativity persisting into adult life is confirmed by popular
fantasy literature (e.g., works by Edgar Allan Poe, Lewis Carroll, Mary Shelley,
L. Frank Baum, J. K. Rowling) and popular movies (e.g., various films by Disney,
Steven Spielberg) whose popularity transcends many cultures. Moreover, fantasy
6.17 Fantasy in Traditional One-Person Psychology and Two-Person 145
role-playing games (e.g., Dungeons & Dragons, young children dressing as different
characters during Halloween) also represent the creativity of imagination and appeal
to broad audiences. In the example of the 16-year-old female who shared her wish to
live independently from her controlling parents, the two-person relational psycho-
therapist may explore what she imagines her life will be like if away from her par-
ents. Her response will guide the two-person relational psychotherapist to
intersubjectively develop a here-and-now new emotional experience. This new emo-
tional experience derives from realistic expectations (e.g., support her goal of mov-
ing out if she is experienced as being ready, caution her if she is experienced as being
impulsive and unprepared). Importantly, in this example and in two-person relational
psychotherapy, the psychotherapist does not base his or her guidance on transference
that would objectively distance him in the interaction. Rather, the guidance in a two-
person relational model derives from a “moving along” process, wherein both patient
and psychotherapist will experience an “Aha!” moment of meeting. If these moments
of meeting “feel right” intersubjectively, an implicit new and corrective experience
ensues. Additionally, the two-person relational psychotherapist—by being active and
present—recognizes when moments of interaction reflect mismatches of their expe-
riences and uses these moments to understand the patient from the inside out (Wachtel
2010). In our example, if the psychotherapist experiences the adolescent’s fantasy as
foolish, he may self-disclose and share: “I just think it sounds too difficult right now,
as you have so many things going on in your life. I think you should consider wait-
ing. How does that sound to you?” In this interaction, the psychotherapist does not
know how the adolescent patient will respond, although he expects that from his tone
of voice and facial expressions that patient may implicitly recognize that the psycho-
therapist is invested in her success (i.e., a moment of meeting has occurred).
When the young child fantasizes about superheroes “attacking the bad guys,” in
a two-person relational model, it is typically thought of as a representation of the
child’s use of imagination and not about his or her inner life or parental objects. If
the psychotherapist’s intersubjective experience of the child’s imaginative play
reveals that the play seems to represent fear of strong characters—seen in victims of
bullying or trauma—it would be reasonable for the psychotherapist to self-disclose
an alternate story to promote new and more adaptive neuronal relational pathways:
“I think we can tell [name of character] that you are also strong and smart. How
about if we teach the bad guys that we can ask for help from our parents or teachers
when we feel scared?” In this scenario, it will be important that the psychotherapist
use the characters that are known to the child to facilitate this type of play.
Additionally, if in the intersubjective field the child’s play represents elements of a
healthy and securely attached child, the psychotherapist may just observe the child
playing, as it represents a growth-promoting fantasy that the psychotherapist might
encourage. Regardless, the child will need to feel safe in the therapeutic setting in
order for either intervention to be employed.
We close with Einstein’s quote “Imagination is more important than knowledge.
For knowledge is limited to all we now know and understand, while imagination
embraces the entire world, and all there ever will be to know and understand” (Mills
1983).
6.18 Splitting in Traditional One-Person Psychology

Splitting in Traditional One-Person Psychology
Classified within the hierarchy of defense mechanisms as pathologic, “splitting” is

a difficult-to-define term secondary to some degree of conceptual heterogeneity. For
example, “splitting of the ego” is described by Sigmund Freud in his early work
(Freud 1938) as representing splitting of reality as in fetishism, whereas Kleinian
splitting represents a developmental stage for infants (Delgado and Strawn 2014) in
which the self is split as good or bad. Thus, splitting represents a metapsychological
concept in object relations theory. Herein, we have chosen to define splitting as the
inability to hold in mind that the person in a relationship is a whole entity with both
positive and negative attributes. When it becomes unconsciously intolerable for a
patient to accept that the person he or she experiences as depriving or abusive also
has positive characteristics, splitting occurs. In order to modulate his or her inability
to integrate and view himself and others as a whole objects with strengths and weak-
ness, the patient resorts to the use of primitive ego defense mechanisms and, like the
infant, “splits their self and other object representation into good and bad, self and
other objects” (Delgado and Songer 2009). This process prevents closeness, as the
relationship becomes distorted and no longer bound by reality (Delgado and Strawn
2014). Unfortunately, the term “splitting” in the colloquial sense is commonly mis-
used to describe situations in which individuals are pleasant with one person and
angry or belligerent toward another; this is actually a process of projection, rather
than splitting.
In Kleinian school, splitting arises from a child’s inability to successfully achieve
the depressive position and experience persons as whole; instead, the child remains
in the paranoid position and views others as either all good or all bad. If the child
feels their schoolteacher is supportive, he or she will be idealized and the child will
comply with her requests during class. When the relationship with the teacher is
threatened (e.g., she praises another child in class), the child will unconsciously
“split” her as an internal object and experience her as a cruel person who has
neglected him.
Splitting in Two-Person Relational Psychology
Not surprisingly, there is scant reference to the concept of “splitting” in the two-
person relational literature, and when found, the term generally refers to the split-
ting off or separating oneself in reality from unbearable affective states due to
relational trauma, not within the realm of intrapsychic object relations theory. Due
to the fact that splitting is a concept based on object relations theory, two-person
relational psychology does not view this as a valuable concept. Developmental
research demonstrates that the infant actively engages in meaning-making processes
that do not imitate the caregiver’s actions, but rather accurately interprets
6.19 Identification with the Aggressor in Traditional One-Person 147
intentionality and states of mind when in a secure environment (e.g., availability of

affectively attuned parents, etc.). Moreover, the infant or young child seeks to rees-
tablish what is familiar (Chap. 5) rather than “splitting” as an experience of a “good”
or “bad” object representation. Finally, two-person relational psychology allows for
uncertainty with regard to the motivation or intentionality of others.
In the above example, a psychotherapist utilizing a two-person relational model
might view the child’s inability to tolerate seeing the schoolteacher praise a class-
mate as due to the fact that the child had stored in implicit nondeclarative memory,
familiar relational schemas of adults neglecting him or her and giving attention to
other people. Conversely, when the child felt the schoolteacher was being support-
ive, the internal relational schemas of a kind caregiver were activated.
6.19 Identification with the Aggressor in Traditional One-

Person Psychology and Two-Person Relational
Psychology
Identification with the Aggressor in Traditional One-Person

Psychology
In 1933, Sándor Ferenczi formulated a phenomenon now known as “identification

with an aggressor” to explain the psychological (and intrapsychic) consequences of
sexual or physical abuse. Accordingly, a victim identifies with his or her abuser and
employs this reversal to “protect the self from hurt and disorganization” (Howell
2014). In the case of a child, anxiety is reduced, and distress and fears of the abuse
being repeated are attenuated as the individual becomes an aggressor, unconsciously
adopting the behavior of the abuser. This tendency of introjected representation of
the aggressor, which generates identification and affiliation with the perpetrator of
aggressor, appears to form the basis for “Stockholm syndrome.” This condition,
which may occur in nearly 10 % of victims (Fuselier 1999), serves the intrapsychic
function of allowing the victim’s feelings of helplessness to be replaced with an
illusion of control.
Identification with the Aggressor in Two-Person Relational

Psychology
The repetition of earlier traumatic emotional experiences, often seen in the lives of
survivors of relational, physical, or sexual trauma, occurs at the level of implicit
nondeclarative memory. Moreover, marked differences in how a person will react to
a traumatic event stem from differences in temperament, cognition, cognitive flexi-
bility, and internal working models of attachment. Analogously, a victim’s view of
his or herself and the world invariably shifts following abuse or trauma. In parallel,
implicit nondeclarative memory leads to implicit relational knowing which contrib-
utes to why people seek accomplices to that which is familiar. For example, children
who are raised in chaotic and abusive environments form disorganized patterns of
attachment, they unwittingly generally get involved with someone who mistreats or
abuses them as their original caregivers had. Moreover, these processes appear to be
influenced by differences in connectivity within emotional processing networks
(e.g., prefrontal–amygdala-based circuits, see Chap. 7) and occur in parallel with
neurostructural changes at the cellular level, including alterations in synaptic mor-
phology and dendritic spine density. Individuals with disorganized attachment pat-
terns often choose negative situations that are familiar over positive situations that
are unfamiliar; many survivors of childhood abuse or neglect equate love and affec-
tion with trauma. This phenomenon is central to the process of transgenerational
traumatization (Daud et al. 2005). Finally, resilience—which has a strong neurobio-
logic basis, described in Chap. 7—is an important factor, as not every person who
experiences trauma in childhood will “find” reexposure.
Two-person relational psychology acknowledges the genetic- and sex-based con-
tributions to developmental trajectories during childhood and adolescence, as in the
case when a child takes on the aggressor’s characteristics. As an example, one recent
study suggests that boys who experience trauma tend more often to identify with the
aggressor and later victimize others, whereas women who were victims of early
childhood trauma are prone to form maladaptive attachments with men that may
further traumatize them and their offspring (van der Kolk 1989). Thus, the moderat-
ing factors of this process that have received significant attention in developmental
research may inform the development of public health policy to prevent trauma in
children.
6.20 Treatment Goals in Traditional One-Person Psychology

Treatment Goals in Traditional One-Person Psychology
In a traditional one-person psychology model, insight is the ultimate goal of the

treatment—it aims to help the patient develop insight about his or her unconscious,
repressed conflicts and learn to make use of mature ego defense mechanisms.
Accordingly, the psychodynamic psychotherapist helps the patient to work through
the pressures from the unconscious drives or ego conflicts—“Where id is, there
shall ego be” (Freud 1916–1917) with regard to symptomatic improvement. It is not
only the drive model that adheres to this perception. In fact, adherents of object rela-
tions and self-psychology approaches also subscribe to what has been aptly termed
the “woolly mammoth model” (Wachtel 2003). This approach conceptualizes the
patient’s difficulties as originating intrapsychically through “early experiences, per-
ceptions, and inclinations [that] are…essentially frozen in time, preserved in their
original form like woolly mammoths buried in the arctic ice, prevented from chang-
ing and evolving over the course of development like other parts of the psyche that
are not similarly walled off and preserved” (Wachtel 2003).
6.20 Treatment Goals in Traditional One-Person Psychology and Two-Person 149
In child and adolescent psychodynamic psychotherapy, symptomatic improve-

ment occurs through the psychotherapist’s deft awareness of object relations, trans-
ference, conflicts, defense mechanisms, dreams, and countertransference
enactments. The psychotherapist intervenes in the form of insight-oriented com-
ments about the maladaptive ego defense mechanisms used or gives interpretations
of repetitive patterns of self-defeating behaviors when the child is ready and able to
understand these interventions. As such, the clinician must remain relatively neu-
tral, although they should not avoid empathic responses. Moreover, even in a tradi-
tional one-person model, when a clinician is working within children and
adolescents, parental work is essential.
The processes described above can be seen in an excerpt of a case presentation
from A Handbook of Child Psychoanalysis (Pearson 1968):
A 14-year-old female adolescent had allowed her boyfriend to take photographs of her in the
nude. He then showed these pictures to their mutual friends, which eventually came to the
attention of her parents. The adolescent stated to her parents and psychotherapist that she
believed that her boyfriend had done nothing wrong by showing the pictures to other peers.
In formulating this patient’s struggle, the psychotherapist notes: “careful study of the
patient found that this impulsive behavior was the result of an earlier over-severity of the
superego and resultant neurotic conflicts. The over-severe superego forced too much repres-
sion and the re-activated instincts overwhelmed the superego in an impulsive fashion.” In
this formulation, the adolescent seeks to gain insight about her impulsive and acting out
behaviors, which emerged as a result of harsh admonishments from her superego.
Thus, in this example, Pearson is very much embedded in a traditional one-

person model in understanding the origin and nature of the adolescent’s behavior,
and he omits any real personal contribution by the analyst to the interaction.
Treatment Goals in Two-Person Relational Psychology
In two-person relational psychology, the child or adolescent psychodynamic psy-

chotherapist seeks active engagement with the patient, so as to become an ally with
his or her intersubjective experiences during the session. The ensuing cocreated
experiences facilitate a construction of both internal working models of attachment
brought into the context of the therapeutic relationship, which ultimately provides a
new emotional experience. Attachment theory and developmental research involv-
ing infants support the existence of a bidirectional mode of human interactions
wherein cognitive and implicit memory systems shape an individual’s experience of
moments of intersubjectivity. It is through the mutual understanding of these
moments of intersubjectivity between patient and psychotherapist that allows for a
change from a maladaptive model of relating with others to a new adaptive model
cocreated in the here and now that allows for a new narrative in the nonconscious
implicit memory systems needed for successful clinical work. Put differently, the
goal of the two-person relational model is to help the child or adolescent learn to
enjoy play, allow for the loving of others, and obtain satisfaction from school.
In the example of the 14-year-old female adolescent that had allowed her boy-
friend to take nude photographs of her and believed that her boyfriend had done
nothing wrong in showing the pictures to other people, a two-person relational psy-
chotherapist might take a step back and review the information at hand. In thinking
of the contemporary diagnostic interview (CDI, see Chap. 8), the psychotherapist
could consider whether the impulsive behavior may be due in part to temperament
or cognitive weakness, which may have contributed to her low self-esteem and not
being able to see herself as a competent person. These events would also be assessed
within the context of the psychotherapist’s intersubjective experience with the
patient. In doing so, the psychotherapist will have a sense about her temperament,
cognition, internal working models of attachment, and whether her implicit rela-
tional patterns lead her to nonconsciously seek accomplices of impulsivity. This
gives the psychotherapist a blueprint on how to provide a new emotional experience
that, over time, can be stored in implicit memory.
Perlman and Frankel (2009) eloquently state: “Analysts and therapists commit-
ted to a relational approach engage the therapeutic situation with a few clinical
propositions in mind: (1) personality is formed through interpersonal interactions;
(2) the clinical situation is inherently intersubjective and shaped by mutual influ-
ence and must be conducted in a way that incorporates this fact; and, (3) the client
needs some kind of authentic personal engagement from the therapist. These
assumptions suggest a ‘model relational approach.’”
In two-person traditional child and adolescent psychodynamic psychotherapy,
the clinician will need to allow for the cocreation of implicit (nonconscious) or
well-thought-out enactments and timed self-disclosures that promote new and cor-
rective emotional experiences in the here-and-now moments of intersubjectivity.
Finally, the work with the child’s or adolescent’s parents intersubjectively is also
essential.
6.21 Neutrality in Traditional One-Person Psychology

Neutrality in Traditional One-Person Psychology
Freud asserted that for the patient’s conflicted past to be “transferred” in the context
of the treatment, a neutral analyst is critical. Moreover, the interpretations that
would ultimately break down maladaptive defenses and allow the patient to make
the unconscious become conscious and therefore gain insight could only be made in
a neutral space. This approach emphasizes the analyst’s neutrality, as a lack of this
neutrality could increase the patient’s regressive anxiety and contaminate the trans-
ference. As noted by Ellenberg (1970), “Freud rose up against the idea of the analyst
giving emotional gratification to the patient; the analysis should be conducted in an
atmosphere of abstinence.” In essence, gratifying a patient’s unconscious conflicted
wishes impaired the analysis of the transference. Moreover, Anna Freud, in
approaching neutrality from a structural standpoint, noted that neutrality should be
6.21 Neutrality in Traditional One-Person Psychology and Two-Person Relational 151
maintained with regard to all intrapsychic agencies, advising that the psychothera-
pist “take his stand at a point equidistant from the id, the ego, and the superego”
(Freud 1937/1966). Finally, Rubin argued that “evenly suspended attention” sup-
ports a neutral stance that renders the analyst capable of attending to a patient’s free
associations with openness: “the capacity to decode or translate what we hear on the
latent and metaphoric level” (Rubin 2009).
However, despite a long history of striving for neutrality, true neutrality is sel-
dom represented in the therapeutic frame. In fact, a survey of psychoanalysts
(N = 75) treated in a traditional psychoanalytic model reveals that areas that were
related to “the analyst’s qualities, such as genuineness and openness” were rated as
“most helpful” (Curtis et al. 2004). Further, the “areas in which the analysts noted
the most change in themselves were related to capacities for intimacy and a wider
range of emotions and behaviors. The areas of change are not the traditional ones
associated with symptom reduction, although serious symptoms were reported as
ameliorated. These results suggest that the most effective interventions are active
ones in a supportive relationship, suggesting that more than a good alliance is
needed.” Additionally, Lynn and Vaillant (1998) review of “Freud’s method” from
his clinical work of 43 cases and concluded that Freud frequently did not maintain
neutrality, often deviating from his recommendations for anonymity, 43 cases
(100 %); for neutrality, 37 cases (86 %); and for confidentiality, 23 cases (53 %). In
addition, there were significant extra-analytic relations between Freud and 31
(72 %) of these analysands (Lynn and Vaillant 1998). More recently, Greenson
(1967), described a patient who, during the psychoanalysis, noticed that Greenson
was more active in the sessions when the patient spoke about a particular political
party and was less active when the patient spoke about the opposite party. In spite of
Greenson’s belief that he had maintained neutrality, the patient revealed he had
concluded, through the analyst’s behavior, which party he favored. This example
not only illustrates the limitations of neutrality but also illustrates the patient’s inter-
subjective experiences that implicitly allowed him to know how his psychoanalyst
thought.
Traditional one-person child and adolescent psychoanalytic approaches have
attenuated the central importance of neutrality that is commonly emphasized in
work with adults. This relaxing of the neutrality edict facilitates the child feeling
safe and creates a transitional space, a bridge between subjective experience and
objective reality. In this regard, child psychoanalyst Pearson describes the therapeu-
tic alliance between the psychotherapist and child as unique: “The therapist may
need to compromise his neutrality to a greater and greater degree in order to estab-
lish and maintain a suitable working rapport with the child” (Pearson 1968). Once
the alliance is established, most of the work by the psychoanalyst or psychodynamic
psychotherapist focuses on transference manifestations and makes use of the inter-
pretation of defenses against conflicts. In the early child psychoanalytic movement,
the entry into adolescence or pubarche signified the capacity to develop a true trans-
ference neurosis, and therefore—at this point—it was important to not compromise
the neutrality in the form of countertransference. As such, Pearson (1968) cautioned
against countertransference manifestations, saying the “the nature of the treatment
in child analysis permits of the greater possibility that the analyst will assume and
gratify his wish to play one or another inappropriate parental role with the child:
omnipotent, demanding, giving, overprotective, sadistic, seductive, positive or neg-
ative oedipal.” In this, he stresses the importance in maintaining a neutral stance in
child and adolescent psychoanalysis and psychodynamic psychotherapy. Although
the relevance of neutrality in child and adolescent psychotherapy has recently been
decreased, it remains an important concept used in psychodynamic psychotherapy.
Neutrality in Two-Person Relational Psychology
In the two-person relational model, the role of the psychotherapist—particularly

those working with children and adolescents—is to be an active participant in the
psychotherapeutic process and to provide a mutual “empathic–introspective inquiry”
(Stolorow and Atwood 1997). Not all children and adolescents know how to develop
an introspective inquiry, and thus, the clinician demonstrates how to inquire about the
patient’s affective states. As discussed in the example of the adolescent who forgot to
lock his bike (earlier this chapter), the psychotherapist shares how he thinks about the
situation: “You know, at your age, my bike was very important to me. I see that your
bike is very important to you, and I think we should not have to worry about this.
Let’s go and make sure it is locked.” By this, the psychotherapist demonstrates and
educates the patient about the value in mutually sharing experiences and cocreates
new neuronal pathways as part of the new emotional experience. DeYoung (2003)
eloquently states the importance of mutuality, saying, “At the heart of relational ther-
apy there is the therapist’s commitment to be present, with caring and focus, in the
relationship.” Buirski and Haglund (2009) state it differently, “Intersubjective theory
focuses on the field created by the coming together of the subjective worlds of the
patient and therapist. Each patient–therapist dyad creates its own unique intersubjec-
tive field through the interplay of the patient’s and therapist’s distinctive individual
organizations of experience.” Moreover, regarding the concept of “evenly suspended
attention” (Brenner 2000), in relational psychology, this may limit the psychothera-
pist, as it directs the psychotherapist’s view of what is important to attend to at any
given time. Put simply, the child’s or adolescent’s view of reality is routinely influ-
enced by the psychotherapist’s attitude about the patient’s discourse. Finally, the
importance of neutrality in traditional one-person psychology has been questioned
by some as representing a form of suggestion—influencing a patient’s choice about
what to share during the session. For example, an adolescent may implicitly notice
that his or her psychotherapist demonstrates (also implicitly) interest in the adoles-
cent’s conflicts, parapraxes, and dreams but not in his achievements. As a conse-
quence, the adolescent may then consciously decide to share that what he or she
assumes is of interest to his or her psychotherapist so as to be liked, while inhibiting
the sharing of growth-promoting achievements made in between sessions.
The authors have found that in child and adolescent psychotherapy training
programs, when trainees are unclear as to how to proceed with a particular patient
6.22 Transference in Traditional One-Person Psychology and Two-Person 153
in the psychotherapy, regression to a neutral stance is common, and this is likely

motivated by a hope that the child or adolescent will take the lead in the session.
Having frequently observed this with our own supervisees, we agree with
Ferenczi, who believed that when a psychotherapist makes use of anonymity and
neutrality, in essence he or she is cocreating the original maladaptive internal
working model of implicit relational knowing, contributing to the child’s and ado-
lescent’s feeling of being alone when trying to discover how to ask and how to
allow help from another person. This is particularly important in providing cor-
rective emotional experiences for children exposed to adverse events, as neutral-
ity does not allow for the child or adolescent to feel they are in the presence of a
safe person or in a safe intersubjective field conducive to learning new adaptive
relational patterns.
6.22 Transference in Traditional One-Person Psychology

Transference in Traditional One-Person Psychology
For much of the twentieth century, Sigmund Freud’s process of transference, con-
sidered central to psychoanalysis and psychodynamic psychotherapy, was felt to be
a critical element for psychotherapeutic change to occur. In short, the phenomenon
involves the transferring of early, unresolved wishes and feelings toward parents or
caregivers onto the psychotherapist or another who has attributes that remind the
patient of these early unconscious experiences. By remembering and repeating with
the psychotherapist these unhealthy patterns, the patient’s conflicts are “worked
through” in the psychotherapeutic process (Freud 1914). Upon experiencing
improvement in the symptoms that brought him or her to treatment, the patient starts
making more mature life choices. Through the “interpretation” of transference man-
ifestations, the individual’s previously unconscious conflicts and maladaptive expe-
riences are brought to consciousness, resulting in the patient developing insight and
improving symptomatically (Delgado and Strawn 2014).
In Anna Freud’s The Psycho-Analytical Treatment of Children (1946), Freud
reviews the many forms of transference and the influence of the child’s age on trans-
ference manifestations. While she had doubts regarding whether children could
form a transference neuroses because they were still living with their parents (origi-
nal objects), and the analyst frequently would take a similar role as the original
parents, a caregiver, she still saw some working through of the transference as an
important aspect of treatment, particularly with regard to older children. Freud and
Klein agreed that child analysts and psychodynamic psychotherapists needed to pay
attention to the transference manifestations in the play and to interpret the maladap-
tive defenses used by the child. As discussed previously (see Neutrality, this chap-
ter), early child psychoanalysts believed that when children entered puberty or
adolescence, they were capable of a true transference neurosis.
Transference in Two-Person Relational Psychology
In two-person relational psychology, transference might be seen as a two-step, non-

conflicted process. First, infants, early in life, form internal working models or rela-
tional schemas when relating to others, and these schemas are stored in implicit
relational memory (e.g., nonconscious nondeclarative memory). Later in life, when
an individual is encountered whose attributes and personality match this schema—
in their here-and-now intersubjectivity—they nonconsciously remember the experi-
ence as familiar. For example, when a securely attached child sees their wonderful
grandmother for the first time, they may implicitly recognize the similarities of the
grandmother with the positive attributes of their mother or father, at least in terms of
stored relational schemas in nondeclarative memory.
Therefore, in two-person relational psychology, transference does not represent
a distortion of the patient’s perception of the psychotherapist. In essence, the equiv-
alent of transference in two-person relational psychology is the process in which
healthy internal working models or schemas of attachment are co-constructed
between patient and psychotherapist (see Enactments, this chapter), and stored in
implicit relational memory, and are nonconscious. The cocreated schemas of inter-
action can be used by the patient as a model when managing struggles of life outside
of the session. Wallin (2007) suggests that the traditional form of understanding
transference is potentially difficult for a patient, as it can evoke compliance, pseudo-
therapy, or rebelliousness against the psychotherapist. Winer (1994) captures this in
describing the inescapability of mutual influence between patient and psychothera-
pist and renders preposterous the notion that the psychotherapist could function as
the equivalent of a featureless mannequin the patient dresses in transference. Thus,
from a two-person relational viewpoint, we now appreciate that “the notion that
transference [with regard to a one-person model] can develop without contamina-
tion is an illusion” (Gill 1984).
6.23 Resistance in Traditional One-Person Psychology

Resistance in Traditional One-Person Psychology
In traditional one-person psychology, resistance is ubiquitous and inevitable in all

forms of treatments. A firewall against remembering neurotic conflicts of the past,
an ego defense against remembering the desires of the id, resistance is a central
tenet of treatment. Resistance is defined as “the patient’s unconscious opposition to
the unfolding and deepening of a psychoanalytic process” (Auchincloss and
Samberg 2012). Patients “resist” through mental processes, fantasies, memories,
character defenses, and behaviors. Resistance reflects the patient’s unconscious
anxiety about relinquishing familiar compromises and facing emotionally painful
self-awareness. While resistance is born and gestates in the unconscious, it persists
long after its conscious recognition. In psychoanalytic theory, resistance may also
6.23 Resistance in Traditional One-Person Psychology and Two-Person 155
exist in transference and at the level of the ego, id, or superego. In the child and
adolescent traditional model of psychodynamic psychotherapy, resistance is
observed when children refuse to enter the psychotherapy room, engage in repeti-
tion of certain types of play, or act out when the psychotherapist attempts to inter-
pret fantasies or behaviors. For adolescents, resistance may take the form of
forgetting appointments, using illicit substances, refusing to talk, etc.
Resistance in Two-Person Relational Psychology
In the two-person relational psychology, resistance is seen through a markedly dif-

ferent lens in terms of its phenomenology, origin, and function. Wallin (2007) deftly
captures the view of resistance in two-person relational psychology: “To consider
patients as opposing their own best interests, or opposing the therapist, risk giving
the therapeutic relationship an adversarial aura; further, it can cast patients as indi-
viduals concealing you the secrets and therapists as morally superior detectives or
confessors. Because neither context is likely to encourage patients to say what
hasn’t been said or nor what has previously had to remain unknown, the classical
conception of resistance may work as a barrier to exploration and integration.” It is
best to consider that patients may have implicit difficulty sharing what have been
intolerable affective states if they do not feel safe in the here-and-now intersubjec-
tive experience with their psychotherapist. In the two-person relational model, resis-
tance is not a concept that is useful, as it has a negative connotation and is commonly
thought of as a conflicted unconscious process. In the case of the adolescent who
during psychotherapy shares his dilemma about his bike not being locked, a rela-
tional psychotherapist will think of this not as resistance working in the session or
unconsciously avoiding the therapeutic process. Instead, the relational psychothera-
pist’s subjective experience is noticing the adolescent’s dilemma, being compliant
while risking his own bike, and is able to provide the affective attunement necessary
to develop a new way of affective communication—“your possessions are also
important to me”—a moment of meeting for the creation of new and healthier adap-
tive ways for the adolescent, rather than continuing to use relational schemas of
compliance to the imagined or real wishes of others.
Children who refuse to enter the psychotherapy room or engage in repetition of
certain forms of play are, in essence, not resisting but rather repeating internal
working models of attachment specific to the mutually cocreated relationship to
their psychotherapist. The child may approach material differently with a psycho-
therapist who has a different personality style or temperament. Moreover, if the
patient acts out with the psychotherapist, the origin of this may be multifactorial
(see Chap. 3), perhaps reflecting temperamental, cognitive (e.g., learning weak-
ness), developmental, attachment, or medical difficulties. Similarly, when an ado-
lescent forgets his psychotherapy appointments, uses drugs, or refuses to participate,
these behaviors warrant assessment within the context of a contemporary diagnostic
interview (Chap. 8) and attending to the intersubjective experiences cocreated. As
such, the two-person relational psychotherapist should consider whether the
behavior is specific to the psychotherapist, or if it results from one of the difficulties

previously listed.
6.24 Interpretations in Traditional One-Person Psychology

Interpretations in Traditional One-Person Psychology
Interpretation, a therapeutic action that “brings out the latent meaning in what the
subject says and does” (Laplanche and Pontalis 1974), is considered to be the sine
qua non of traditional one-person psychodynamic and psychoanalytic treatment.
That is, that which is to be interpreted is known by the analyst and not recognized
by the patient due to the defense mechanisms at work, repressing the unbearable
truth of their wishes and desires. In essence, interpretations are “at the heart of the
Freudian doctrine and technique. Psychoanalysis itself might be defined in terms of
it, as the bringing out of the latent meaning of given material” (Laplanche and
Pontalis 1974). Additionally, there has been little change in the role of interpretation
in psychoanalytic work over the past century. Anna Freud, like Melanie Klein,
believed that interpretations were central in psychoanalytic treatment of children
and adolescents. Klein advocated for deep interpretations early in the process and of
their primitive defenses to alleviate the child’s guilt for their destructive wishes and
fantasies. Moreover, “each time the analyst offers an interpretation that goes beyond
with the patient is consciously aware of, he or she invites the patient to see things,
if ever so slightly, from the analyst’s own theory-rooted perspective. To that extent,
interpretations are suggestions, and it is critical to the analysis to investigate whether
the patient believes he or she must adopt the analyst’s viewpoint in order to maintain
the therapeutic bond” (Orange et al. 1997).
In returning to the example of the adolescent who forgets to lock his bike upon
arrival to his psychotherapy appointment, several possible interpretations seem
reasonable from the vantage of traditional one-person psychology. If the psycho-
therapist believes that the event represents the repetition of a pattern in which the
patient wishes to be caught doing something wrong, he or she may choose to inter-
pret it accordingly. A different possibility may exist if the psychotherapist believes
that the event represents a pattern of self-doubt, in which case he or she may inter-
pret the wish for criticism by the patient unconsciously leaving his bike unlocked
and so on.
Interpretations in Two-Person Relational Psychology
The Boston Change Process Study Group has promulgated the clearest explanation
of interpretation in two-person relational psychoanalysis or psychotherapy: a need
for “something more” than an interpretation to bring about change. Referring to this
“something more,” Stern and colleagues (1998), in their seminal paper Non-
Interpretive Mechanisms in Psychoanalytic Therapy, note:
6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person 157
Using an approach based on recent studies of mother–infant interaction and non-linear

dynamic systems and their relation to theories of mind, the authors propose that the some-
thing more resides in interactional intersubjective process that give rise to what they will
call “implicit relational knowing.” This relational procedural domain is intrapsychically
distinct from the symbolic domain. In the analytic relationship it comprises intersubjective
moments occurring between patient and analyst that can create new organizations in, or
reorganize not only the relationship between the interactants, but more importantly the
patient’s implicit procedural knowledge, his ways of being with others. The distinct quali-
ties and consequences of these moments (now moments, “moments of meeting”) are mod-
eled and discussed in terms of a sequencing process that they call moving along.
Keeping with the vignette of the adolescent who forgets to lock his bike, upon
arrival to his psychotherapy appointment, several “something more than interpreta-
tions” are plausible. If the psychotherapist believes that the event represents repeti-
tion of a pattern in which the patient believes he is always careless and constantly
doing something wrong, the psychotherapist may choose to say, “That’s one way to
look at it. Can we consider that you made it here on time as representing something
you did right?” In a different scenario, the psychotherapist believes that the event
represents a pattern of self-doubt and may choose to say: “I wonder what got in the
way of you not going back and locking your bike, even if it led you to be a few
minutes late? I didn’t think of myself as being that rigid in terms of when you got
here.” In both scenarios, the first step is taken by the psychotherapist to cocreate a
here-and-now moment of meeting. This moment will need to be cocreated at an
implicit level within the intersubjective field. That is, the psychotherapist’s must
concentrate his attention on the nonverbal communication: intonation, rhythms and
tempi of speech, and musicality of the voice (Ferro 2002). The next step will depend
on how the patient responds to the something more than interpretation comments by
the psychotherapist. Wachtel (2011) states that for many patients, “interpretations
can be experienced as a message that their efforts to move beyond their longstand-
ing defensive way of communicating are not appreciated, that the struggle to be
more open and expressive has failed, even that the restrictions and inhibitions that
have limited their lives are simply too strong to overcome. Rather than promoting
the goals of the therapy, the comment induces discouragement or even self-
laceration.” In fact, we now recognize that psychotherapy no longer occurs “in an
era in which interpretation…as the exclusive therapeutic arrow in the analyst’s
quiver (Gabbard and Lester 2003). Havens (1986) adds, “In the current interpretive
climate of much psychotherapeutic work, patients sit waiting for the next insight
with their fists clenched. Small wonder, for it is rarely good news”.
6.25 Dreams and Parapraxes in Traditional One-Person

Dreams in Traditional One-Person Psychology
In early psychoanalytic writings, dreams are noted to occur during sleep when
superego functions are suspended, and this represents a period of time during which
ego defenses help the dreamer to remain asleep by making the dream incomprehen-
sible so as not to allow the conflicts into consciousness. Freud saw dreams as “the
royal road to the unconscious” (Freud 1900) and “the task of interpreting the dreams
is pretty well limited to psychoanalytic therapy, since it generally requires the appli-
cation of psychoanalytic technique,” referring to the use of free associations to deci-
pher the latent meanings of the dream content (Brenner 1974). In The Interpretation
of Dreams (1900), Freud instructs that the “two separate functions [of dreams] may
be distinguished in mental activity during the construction of a dream: the produc-
tion of the dream-thoughts, and their transformation into the [manifest] content of
the dream.” For Freud, dreams were composed of the manifest content (i.e., what we
recall upon awakening) and the latent content (i.e., the unconscious wishes dis-
guised in the dream). Thus, the psychoanalytic work of interpreting a dream utilized
the patient’s free associations to the dream, while the psychoanalyst deciphers four
elements: condensation, displacement, considerations of representability, and sec-
ondary revision.
Pearson (1968) deftly illustrates the use of the dream in traditional one-person
psychology in describing a dream by an adolescent:
Adolescent: “I saw one of the camp counselors and talked with him near my home. A friend
who lives next door got on his bike. The counselor was carrying a basketball, gym pants,
and sneakers. I saw two kids and mentioned their names. It wasn’t an unhappy dream.”
Analyst: Mark’s associations to the dream were: he knew that the counselor in the dream
was also a wrestler; the “two kids” reminded him of his peers (male and female) which he
made split up by creating conflict between them; and he did not find the girl attractive. The
analyst understands the dream as “the latent content of the dream appeared to be Mark’s
wish to split up his parents up and to wrestle (sexually) with his mother. It was therefore an
oedipal dream.” To note, Mark does not make reference in his associations to his parents or
mother after the dream, he did mention that he occasionally had wrestled with his sister.
The analyst’s work with the adolescent’s dream is in line with Freud’s prescrip-
tive dream work. Moreover, the adolescent’s associations guide the analyst, who
discovers the latent content of the dream, the patient’s wish to split up his parents,
and to wrestle (sexually) with his mother, giving the analyst the information needed
to conclude that this particular dream is oedipal in origin.
Parapraxes (Freudian Slips) in Traditional One-Person Psychology
In regard to slips of the tongue, or parapraxes, Freud held that they represented
repressed unacceptable instinctual desires that reach consciousness when they
bypass the patient’s ego and superego. For example, an 11-year-old child states that
he is frustrated with his demanding teacher who “always asks me to do more work.”
He later adds, “My mother doesn’t give me a break,” referring to his teacher. This is
considered to represent a parapraxis, “a compromise formation that serves the mul-
tiple functions of wish, defense, and adaptation” (Auchincloss and Samberg 2012).
Parapraxes are also thought to occur as slips of the pen or keyboard.
6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person 159
Dreams in Two-Person Relational Psychology
In two-person relational psychology, dreams are considered an amalgam of stored

information now known to activate the default mode network, including the precu-
neus, cuneus, medial prefrontal cortex, and occipital cortex (Dresler et al. 2012,
Chap. 7). In this section, we will briefly review selected work by dream researchers
to illustrate the complexities of understanding dreams and the relevance of this work
to the understanding of dreams in a two-person relational model.
In 1953, Eugene Aserinsky and Nathaniel Kleitman, considered the fathers of
modern sleep research, discovered the association of rapid eye movement (REM)
sleep and dreams. In this regard, Aserinsky and Kleitman noted that dream recall
remained intact when dreams occurred during REM (Aserinsky and Kleitman
1953). In a landmark 1977 study, John Allan Hobson and Robert McCarley pro-
posed “an activation-synthesis hypothesis of the dream process,” in which the acti-
vated prefrontal cortex synthesizes the dream by comparing the information
generated from specific brain circuits with the information that was stored in
memory (Hobson and McCarley 1977). Later, Hobson contextualized this under-
standing noting that our current understanding of dreams “is so different from
Freud’s as to make the use of a word like revision a euphemism. Because there is
essentially nothing left of the Freudian hypotheses, what is needed is not revision
but complete overhaul. Instead, what we see is a tenacious adherence to a faith in
the interpretability of dreams using vague and unscientific terms like metaphor and
hermeneutics” (Hobson 1999). In addition, Hobson and colleagues (2000) sug-
gested, “dreaming consciousness results from processes of arousal impinging upon
selectively facilitated, dysfacilitated or input/output-blockaded forebrain struc-
tures.” Specifically, fMRI studies reveal activation of the default mode network dur-
ing dreaming and further implicate the precuneus and cuneus, two structures that
subserve self-versus-other processing and structures that are activated during self-
referential processing during wakefulness.
Moreover, using dream symbolism—a tenet of traditional one-person psychol-
ogy—would be considered by some to be antithetical to two-person relational psy-
chology. Currently, and somewhat contradictory to traditional one-person
conflict-based models of latent dream content in children, we have made limited
progress in understanding the kaleidoscopic content of dreams in children. For
example, Resnick et al. (1994) note that “young children are able to give long,
detailed reports of their dreams that share many formal characteristics with adult
dream reports,” and a recent study by Honig and Nealis (2012) found that “girls
dreamed more frequently of family members. Boys reported more fighting and
chasing. Dream themes of boys, compared with girls, were twice as likely to include
monsters, wild animals, pets, and curiosity. Power themes were four times more
prevalent in boys’ dreams. Girls were twice as likely as boys to report joyful
dreams.”
Thus, one can appreciate that a purely interpretive approach to dreams might be
“unwise, for once we refuse to take the dream images for what they are, it is impos-
sible to determine in any objective manner which dream images should be regarded
as ‘symbols’ and what exactly they might symbolize” (Revonsuo 2000). Additionally,
in dream symbolism, an inherent danger will always persist in that “one can always
get rid of dream elements that do not fit in with one’s favorite theory by saying that
they actually stand for something else (most likely for something that the favorite
theory happens to be able to explain very neatly)” Revonsuo (2000).
Understanding dreams in children and adolescents represents a complex endeavor
in the two-person relational model. In this regard, the two-person relational psycho-
therapist working with children and adolescents attends to the patient’s experiences
and affects while the patient shares their dreams, although the psychotherapist must
also consider that what is being remembered does not represent a repressed intra-
psychic conflict, but rather the expression of a here-and-now conscious experience
unique to the patient–psychotherapist intersubjective dyad. This allows for under-
standing dreams in many different ways, and the two-person relational psychothera-
pist has the task of allowing his intersubjective experience in the here and now with
the patient to decide what elements of the dream may be relevant within the context
of their relationship and the patient’s history.
A brief return to the adolescent dream described earlier by Pearson (1968), but
this time through a two-person relational view:
Adolescent: “I saw one of the camp counselors and talked with him near my home. A friend
who lives next door got on his bike. The counselor was carrying a basketball, gym pants,
and sneakers. I saw two kids and mentioned their names. It wasn’t an unhappy dream.”
Relational Psychotherapist: Mark’s associations to the dream were: the counselor was
also a wrestler; the “two kids” reminded him of peers he had made split up by creating
conflict between them; and he did not find the girl attractive. A relational psychodynamic
psychotherapist is not concerned with having to uncover the hidden meanings needed to
understand the dream; rather, he attends to the shifts in affect as Mark shares the dream.
This allows cocreating, in the here and now, the intersubjective mutuality needed to know
what aspects of the dream are worth reviewing or ignoring. As previously noted, Mark does
not make reference in his associations to his parents or mother after the dream; he did men-
tion that he occasionally had wrestled with his sister.
The many possible avenues that could be taken by a two-person relational thera-
pist regarding Mark’s dream may include the following:
• The psychotherapist demonstrates interest in Mark elaborating on the positive

experiences (e.g., basketball, gym, friendships), as the psychotherapist notices
Mark’s excitement when he shares those elements in the dream. The psycho-
therapist, through his intersubjectivity, feels pride in Mark’s achievements.
• The psychotherapist experiences Mark as sharing the dream in a superficial or
trivial manner, as if believing that the psychotherapist may like dreams. The
psychotherapist does not feel—in the here-and-now moment—that it would
be helpful to explore the dream and chooses to explore with Mark that it seems
he is distant in the session.
• The psychotherapist experiences Mark as feeling safe in their relationship and
that in sharing the dream and associating to it, he seemed trying to flaunt appro-
priately his ability to reflect about the changes in his life. The psychotherapist
6.26 Countertransference in Traditional One-Person Psychology and Two-Person 161
chooses to demonstrate excitement to Mark’s comments in order to improve his

self-esteem and asks what other aspects of the dream he found of interest.
Internally, the psychotherapist believed that the new emotional experience was in
showing interest in Mark’s thoughts, as he had felt that throughout the psycho-
therapy process, the adolescent’s internal working models and implicit relational
knowing were that of not believing he was important to others.
• The psychotherapist experiences Mark as being anxious when sharing the dream,
although the psychotherapist intersubjectively felt the adolescent was reaching
out for help with the dream. The psychotherapist uses this opportunity to help
Mark feel safe and learn to explore his thoughts, and he proceeds to share that
understanding dreams has been controversial and that he, as a psychotherapist,
believes that what is most helpful is paying attention to how one feels when shar-
ing the dream, which many times has problem-solving ideas embedded.
In short, when the relational psychotherapist attends to his experience of the

shifts in the affect of a patient when sharing a dream, there are many avenues that
can be taken that are unique to the patient–psychotherapist dyad in the here-and-
now moments of intersubjective experiences.
Parapraxes (Freudian Slips) in Two-Person Relational Psychology
Like dreams, two-person relational psychology does not adhere to Freud’s under-
standing of parapraxes; rather, these “slips” are considered to represent linguistic
slips—that is, a problem with sequencing in grammar from inattention or insuffi-
cient knowledge (Möller et al. 2007). They represent neural response patterns that
have been primed by prior usage during anxiety-provoking events. Recent neuroim-
aging studies utilizing inhibition tasks suggest that the process of inhibiting auto-
matic responses (e.g., a combination of words that have previously gone together or
have been paired) activate the anterior cingulate cortex (Brown and Braver 2007), a
region that is responsible for the integration of both affect and cognition. This region
also represents a point of convergence for ventral (emotional) and dorsal (cognitive)
processing streams in the brain (Yamasaki et al. 2002).
6.26 Countertransference in Traditional One-Person

Countertransference in Traditional One-Person Psychology
Countertransference, the flip side of transference, occurs when the psychotherapist

unwittingly participates in the patient’s transference. In the traditional one-person
model, countertransference is generally seen as a negative process, as it may result
in the psychotherapist breaking his neutrality and anonymity, which can interfere in
the development of the transference by the patient onto the psychotherapist. In
countertransference, the psychotherapist’s unconscious reactions to the patient are

rooted in the psychotherapist’s own unresolved intrapsychic conflicts evoked by the
patient.
The concept of countertransference has direct relevance to the traditional model
in child and adolescent psychodynamic psychotherapy. Pearson (1968) captures the
complexities of this process deftly: “The varieties of countertransference in child
analysis are numerous and parallel those which may be encountered in adult analy-
ses. The nature of the treatment and child analysis permits of the greater possibility
that the analyst will assume and gratify his wish to play one or another inappropriate
parental role with the child: omnipotent, demanding, giving, overprotective, sadis-
tic, seductive, positive or negative oedipal. Or, in his work with the parents, he may
actively participate in the oedipal triangle, overidentify with the child’s attitudes
towards the parent at various levels of development, or remain oblivious to certain
aspects of the parental attitudes which are threatening to him.”
As with many psychodynamic or psychoanalytic theoretical concepts, projective
identification and countertransference remain controversial. Certainly, both pro-
cesses represent the reactions of the psychotherapist when he or she is the recipient
of a displaced conflict or projections from a patient, and they may share other psy-
chological facets as well. For many, the difference between the two related concepts
derives from the theoretical school in which they were indoctrinated. The classic
drive-theory doctrine countertransference in relation to the unconscious conflicts
with early objects, conflicts that are repeated when the patient transfers/displaces
past experiences onto the recipient. By contrast, in object relations, projective iden-
tification is a primitive phenomenon in which the patient psychologically forces the
disavowed bad self-object onto a recipient who unconsciously returns the foreign
bad self-object back to the patient as if the recipient had owned it. Interestingly,
however, some contemporary thinkers believe that these two mechanisms are, for
practical purposes, one and the same (Renik 2004).
Countertransference in Two-Person Relational Psychology
In a two-person relational model, the here-and-now active presence of the psycho-

therapist through implicit or explicit enactments and timed self-disclosures provides
a new emotional experience that leads to change at the implicit level, akin to a par-
ent providing an infant the affective attunement needed to mutually cocreate new
and adaptive experiences that are stored in nondeclarative relational memory (i.e.,
intersubjectivity). Further, in two-person relational psychodynamic psychotherapy,
this cocreated experience is an adaptive organizing principle in relation to others.
The active and self-disclosing interventions by the relational psychotherapist are
part and parcel of the relational and intersubjective approach. Relational interven-
tions are intended to be co-constructed by patient and psychotherapist, sharing
internal working models of attachment and implicit relational knowings from each.
Thus, in two-person relational psychology, the concept of countertransference—as
a construct—limits psychotherapists in that its use implies a unidirectional
6.27 Boundaries and Self-Disclosure in Traditional One-Person 163
influence (e.g., the psychotherapist reacting to the patient’s transference). As such,

Aron (1990) explains that “referring to the analyst’s total responsiveness with the
term countertransference is a serious mistake because it perpetuates defining the
analyst’s experience in terms of the subjectivity of the patient. Thinking of the ana-
lyst’s experience as “counter” or responsive to the patient’s transference encourages
the belief that the analyst’s experience is reactive rather than subjective.”
Interestingly, Gill and Hoffman (1982) report that a panel of blinded judges
reviewing audio recordings of psychoanalytic sessions noted that a patient’s percep-
tions of their analyst’s countertransference were often more accurate than their ana-
lyst’s self-assessments, supporting the relational tenet of intersubjectivity, wherein
the patient implicitly knows how the psychoanalyst feels about him or her. Thus, the
term “countertransference” “obscures the recognition that the analyst is often the
initiator of the interactional sequences” (Aron 1991). Hoffman (2009) adds, “We
cannot hide anymore. The cat is out of the bag,” and proposes that we admit that our
influence is inevitable and ubiquitous and that we should take full responsibility. He
shares that free associations and evenly hovering attention must be replaced by the
active analyst with the patient as real people actively talking and sharing mutual
subjectivities.
6.27 Boundaries and Self-Disclosure in Traditional

One-Person Psychology and Two-Person
Relational Psychology
Boundaries in Traditional One-Person Psychology
In Chap. 2, we reviewed how traditional one-person schools of psychoanalysis

and psychodynamic psychotherapy—including drive theory, ego psychology,
object relations, and self-psychology theories—overall maintain the need for ano-
nymity, neutrality, and abstinence (Freud 1915) in order to allow the patient’s
conflicted unconscious to surface in the form of transference. The adherence to
the role as an active observer—anonymity, neutrality, and abstinence—and not a
participant in the patient’s wishes for gratification, was thought to provide some
clarity about the crossing of boundaries, nonsexual and sexual, in the analytic and
psychotherapeutic encounter. Boundaries are considered to represent an “edge” or
limit of the appropriate behavior by the psychoanalytic psychotherapist in the
clinical setting (Gutheil and Gabbard 1993). Patients require an atmosphere of
empathy and predictability in their relationship to the psychotherapist in order to
feel safe, which allows for the sharing verbally and not in action their wishes and
desires. In contrast, the psychotherapist must recognize that the power differential
exists and must maintain professional boundaries, defined as actions that are made
in the best interest of the patient and not for gratification of the psychotherapist.
For an eloquent review of the complexities of this subject, we refer the reader to
Gabbard and Lester’s (2003) Boundaries and Boundary Violations in
Psychoanalysis.
In Psychodynamic Psychotherapy: A Clinical Manual (2013), Cabaniss and col-

leagues give importance on setting the frame before starting the psychotherapeutic
process, in order to avoid boundary crossings and/or boundary violations. They give
an example in which a psychotherapist extended a session by a few minutes to allow
a patient to compose after having discussed some distressing events. They believe
that the psychotherapist’s going over a few minutes is considered to be a boundary
crossing—a benign deviation from the frame that does not harm the patient and
allows for the advancing of the psychotherapy process (Guthiel and Gabbard 1993).
In current day, the psychotherapy of one’s own child—Sigmund Freud and Melanie
Klein analyzed their daughters—would be considered a boundary violation.
What defines a boundary crossing or violation is clearly more complex in the
treatment of children and adolescents and must be viewed within the context of
developmental issues. Holding an infant or helping a 6-year-old child remove their
coat is appropriate, while touching an adolescent is likely not, unless in specific
circumstances (e.g., disability). The “American Academy of Child & Adolescent
Psychiatry Code of Ethics” (2009) is designed to provide child and adolescent psy-
chiatrists an ethical framework of practice, with attention to boundary issues.
Self-Disclosure in Traditional One-Person Psychology
In the traditional one-person psychoanalytic and psychodynamic literature, self-

disclosure by the psychotherapist is seen as interfering with the treatment because it
gratifies the patient’s libidinal wishes, limiting the development of transference pro-
jections needed for insight to unfold. Self-disclosure has also been thought of as a
form of countertransference, an unconscious reaction elicited by the patient as a
result of the patient’s transference projections (see section on countertransference
above). In the traditional one-person model, attention to boundaries and self-
disclosures is crucial for the analyst to monitor in order to avoid gratifying the
patient’s wishes and contaminating the transference, prevent enactments from
occurring that will allow the patient to know the real person behind the neutral ana-
lyst, and engage in countertransference phenomena in the form of projective identi-
fications. Herein, in the traditional one-person model, self-disclosures are rare, and
when they occur, the content of the disclosure has been carefully scrutinized and
thought to be necessary to the process (e.g., if the psychotherapist is in training).
Boundaries in Two-Person Relational Psychology
Boundaries in the two-person relational model receive the most critiques from clini-
cians practicing from a one-person model. In this regard, gratifying a patient’s
wishes is viewed as a slippery slope, as it not only contaminates the transference, it
may also complicate countertransference phenomena. Common examples in two-
person relational psychotherapy of a psychotherapist gratifying a patient’s wishes,
so as to move along the psychotherapeutic process, include allowing a child in
6.27 Boundaries and Self-Disclosure in Traditional One-Person 165
treatment to borrow a toy, hugging a patient before the psychotherapist’s vacation,

sending birthday cards to a child or adolescent, and answering questions about the
psychotherapist’s personal life. Importantly, these moments occur when the psycho-
therapist intersubjectively experiences that gratifying the wish is in the best interest
of the patient, as it provides a new corrective experience that may have been lacking
and, thus, would not be considered to be crossing a boundary (a deviation from a
framework). Without a doubt, regardless to which psychotherapeutic theory one
adheres, enactments occur and represent a continuum, from subtle issues helpful to
patients to enactments with behaviors that are clearly harmful to the patient (e.g.,
exploitation, sexual involvement). Due to the complex nature of the psychothera-
peutic work with children and adolescents, we suggest the psychotherapist to have
regular consultation with a trusted colleague when they subjectively feel a dilemma
regarding their interactions with their patients.
Exactly what behavior from the psychotherapist defines a boundary crossing or
violation is clearly a complex matter in child and adolescent psychiatry, and it must
be viewed within the context of developmental issues. The “American Academy of
Child & Adolescent Psychiatry Code of Ethics” (2009) is designed to provide child
and adolescent psychiatrists an ethical framework of practice. Boundaries in two-
person relational psychology need to be flexible, intentional, and part of a well-
thought-out enactment. Similar to a boundary crossing, in two-person relational
psychology, the relaxing of a boundary occurs with forethought and intention and
aims to advance the psychotherapeutic process. In the above example of the adoles-
cent who forgot to lock his bike, the psychotherapist by going with the patient to
lock the bike is enacting a form of relationship that he hopes will create a new and
sustainable neuronal pathway stored nonconsciously in an implicit relational form.
This is to say that the adolescent learns to defer to social etiquette over the safety of
one’s own valuable property.
Self-Disclosure in Two-Person Relational Psychology
As discussed in Chap. 3, emphasis on active participation by the psychotherapist in

the psychotherapeutic process is essential but represents a major shift from a tradi-
tional one-person psychology to a two-person relational psychology. In this regard,
“self-disclosure has gone from being forbidden to being universally acknowledged
as therapeutic in the context of a good therapeutic alliance” (Maroda 2010).
Moreover, self-disclosure may be an inevitable aspect of a psychotherapeutic pro-
cess (Farber 2006) and occurs at both explicit and implicit levels. Regarding the
integrative nature of self-disclosure, Ziv-Beiman (2013) notes that self-disclosure
may “initiate a gamut of changes with respect to emotions, thoughts, motivation,
behavior and interpersonal relationships…. Self-disclosure is powerful because it is
integrative.” She further states, “Scholars of an intersubjective persuasion discuss
therapist self-disclosure in positive terms, principally in the context of disclosure of
countertransference. Relational scholars emphasize that exposure to subjective oth-
erness is essential for the foundation of the self and view therapist self-disclosure as
a form of intersubjective inquiry, which is part and parcel of every treatment. This
mutual inquiry enables the development of the patient as a subject with awareness
to the multiple self-states that emerge from the dialogue with the other within the
context of a range of intersubjective dyads, including the therapeutic dyad.”
In two-person relational psychodynamic literature, the psychotherapist’s self-
disclosure not only represents an enactment but also is the keystone of the therapeutic
alliance that advances the therapeutic goals in the form of new and corrective emo-
tional nonconscious experiences. As discussed earlier (see Countertransference, this
chapter), enactments are fraught with anxiety on the part of the novice psychothera-
pist or the traditional one-person psychotherapist attempting a foray into a relational
model of work. As Altman (2004) states, “relationalists believe that the analyst is
quite often not fully aware of the nature of his participation in the analytic interaction
until an enactment.” However, it should be emphasized that self-disclosure is not pro-
viding education or giving advice to a patient; rather, it is a moment when the patient’s
and psychotherapist’s intersubjectivities meet, and the psychotherapist believes a self-
disclosure benefits the process by facilitating anew emotional experience for the
patient to store in nondeclarative memory. Thus, not all self-disclosures or enactments
are conscious and will help the patient, and in fact some may lead to setbacks. There
is not a “one rule fits all” about when and what to self-disclose or enact, which is
important for supervisors to keep in mind (see Chap. 14). What guides the psycho-
therapist is the here-and-now intersubjective mutuality, which leads up to the enact-
ment of self-disclosure. Finally, the two-person relational psychotherapist “must
concentrate his attention on the modalities of his communication such as intonation,
rhythms and tempi of speech, in particular on the musicality of the voice” (Ferro
2002). In essence, the psychotherapist’s actions speak louder than his or her words.
It is worth noting that, despite the importance of self-disclosure as an enactment
being at the heart of the two-person relational psychology technique, the decision to
self-disclose may be complicated by many factors. Ziv-Beiman wonderfully illus-
trates this dilemma as she decides whether to self-disclose, and if so, what and how:
I am facing Naomi (age 34 years), one of my favorite patients, who is always hoping that her
“knight in shining armor” will arrive to rescue her “sleeping beauty.” Eight months into treatment,
we are stuck. I therefore take a calculated risk and, my heart beating, say to her, “most of my life
I believed that only slim people are eligible for membership in the society called ‘humanity.’
My life would begin, I thought, only when I lost sufficient weight to gain entrance into
this exclusive club. It took a lot of time—and pain—to realize that such waiting is useless.
Finally, I gave it up and accepted my size. This acceptance comes at a price, however.
Sometimes—fortunately not too often—I get rejected because of my weight. On the other
hand, I am much less dependent upon external approval. Now I spend much more time
expressing myself, feeling joy. I’m alive.”
In Ziv-Beiman’s masterful self-disclosing example, it is not about what is said,

but what is implicitly conveyed intersubjectively with her comments to the patient:
“I have been there, I also felt insecure and had a difficult experience but it did not
hold me back. I believe your feelings won’t hold you back either.” We recognize that
there will be other clinicians with different internal working models of attachment
and implicit relational schemas and they may choose a different way or a different
6.28 The Role of Parents and Family in Traditional One-Person 167
Table 6.2 Suggested practice guidelines in two-person relational psychotherapy

Psychotherapists should generally self-disclose infrequently.
The most appropriate topic for the psychotherapist to self-disclosure involves professional
background, whereas the least appropriate includes sexual and religious beliefs.
Psychotherapists should generally use self-disclosures to validate reality, normalize, strengthen
the alliance, or offer alternative ways to think or act.
Psychotherapists should generally avoid using self-disclosures for their own needs: removing
the focus from the patient, interfere with the flow of the session, burden or confuse the patient,
or blur the boundaries.
Psychotherapists self-disclose in response to similar patient self-disclosures.
Psychotherapists should observe carefully how patients respond to their self-disclosures, ask
patient for reactions, and use the information to conceptualize the patient and decide how to
intervene next.
It may be especially important for psychotherapists to self-disclose with patients who have
difficulty forming relationships in the therapeutic setting.
Adapted from Hill and Knox (2002)
time to self-disclose. This reflects the unique proclivities individual psychothera-

pists bring into the dyad that influence how they cocreate intersubjectively their
experiences. Further, Renik (1999) believes that it is best to play one’s cards face up
and states, “When an analyst is consistently willing to self-disclose, the patient is
more fully authorized as a collaborator in the clinical work. The patient’s active
participation may require the analyst to endure a measure of disconcerting expo-
sure.” We have found useful the guidelines regarding self-disclosure by Hill and
Knox (2002) in two-person relational psychotherapy (Table 6.2).
6.28 The Role of Parents and Family in Traditional One-

Person Psychology and Two-Person Relational
Psychology
The Role of Parents and Family in Traditional One-Person

Psychology
The role of a child’s or adolescent’s parents in a consultation process (and in the

course of treatment) is typically to provide the “objective” history of the child’s
problem, to provide medical history, to review developmental milestones, and to
consent to treatment. However, observing interactions between parents and their
children provides the consultant an overview of the family’s object relations and
dynamics. Upon completion of the initial diagnostic session or sessions, the pro-
vider delivers the recommendation for psychotherapy, and if agreed to, he or she
“sets the frame” for the process (see Chap. 9). Importantly, however, the role of
parents in child and adolescent psychoanalysis has been controversial for many
decades. The early controversies stemmed from Melanie Klein’s view that interpre-
tations were essential for the treatment of children and that there was little need to
include the parents. Moreover, Klein believed this would contaminate the process.
The Neo-Kleinians took a more encompassing approach in working with parents.
As such, Anna Freud believed that working in an educational context with the par-
ents during the child’s psychoanalysis was important in order to become a develop-
mental participant. Additionally, so as to avoid contamination of the transference
necessary to learn about the child’s inner world, Freud believed that a different
psychotherapist needed to be assigned to work with the parents. In this manner, the
child analyst could communicate actively with the parents’ psychotherapist to learn
about the realities of the child’s environment, without contaminating the process by
working with the parents directly. Yet there has historically been limited attention
paid to how to work with parents in traditional one-person psychology. For exam-
ple, in the 11 chapters of A Handbook of Child Psychoanalysis (Pearson 1968), only
3 of the 374 pages describe how to work with parents. The authoritative text sug-
gests scheduling regular appointments with the parents throughout the psychoanal-
ysis of their child and notes that there will be a “constant flow to the analyst of
detailed reports as to how matters are going for the child in his home, his relation-
ship with the parents and other significant persons, his emotional variations in their
precise settings, and the significant expressions of his thoughts and attitudes with
which the parents can supplement the analyst’s understanding of his young patient.
And, at the same time, the analyst will be eliciting from the parents a more complete
and detailed picture of the child’s entire life history, to be used as a background for
understanding and as point of departure when specific recommendations for modi-
fying the child’s program are made.”
For some, work with parents was undertaken with caution as it was thought that
the formation of the child’s inner conflicts were a consequence of the parent’s own
unresolved conflicts and anxieties, and thus, the work with the parents had the
potential to interfere with the psychotherapeutic process as a result of an uncon-
scious encouraging of maladaptive defense mechanisms (Delgado et al. 1993). This
notion parallels the central theme of Selma Fraiberg and colleagues’ (1975) classic
treatise, Ghosts in the Nursery, which describes the parents’ intergenerational trans-
mission of trauma with roots in their own history of conflicts that may unconsciously
be repeated through the rejection of their own child. In child and adolescent psycho-
analysis, when parents made efforts to be more involved in the child’s treatment, it
was commonly thought to be related to the parent’s jealousy of their child for having
a unique and positive relationship with the analyst.
More recently, in traditional one-person psychology, the importance of having
parents take an active role in the psychoanalysis or psychotherapy of their child or
adolescent has been appreciated. For example, Yanoff (2005), in reviewing Kerry
Kelly Novick and Jack Novick’s book Working with Parents Makes Therapy Work
(2005), writes, “[This] is a rare book. It is a book on a subject that is almost never
written about in psychoanalysis, even though its subject matter, working with par-
ents, is one of the most commonly encountered aspects of treating child patients.
The reasons for this void in the literature have always been difficult to explain.” In
traditional one-person psychology, the work with parents was partly educational
and allowed attention to the interactions between parents and their children, the
6.28 The Role of Parents and Family in Traditional One-Person 169
parents’ fantasies and transferences toward the analyst or psychotherapist, and the
countertransference reactions elicited by the parents. However, regarding these
countertransference reactions, Pearson (1968) noted, “The nature of the treatment in
child analysis permits of the greater possibility that the analyst will assume and
gratify his wish to play one or another inappropriate parental role with the child:
omnipotent, demanding, giving, overprotective, sadistic, seductive, positive or neg-
ative oedipal.”
The Role of Parents and Family in Two-Person Relational

Psychology
A major role of a psychotherapist is to alleviate his patient’s parental anxieties, so

as to prevent them from forestalling the psychotherapeutic process in the face of
uncertainty. To this end, it is critical to involve the child’s parents early in the psy-
chotherapeutic process and to make them active contributors. As previously noted,
the role of the parents during the psychotherapy process of a child or adolescent is
heavily influenced by the clinician’s theoretical stance. For the two-person rela-
tional psychotherapist, knowing about the child’s realities outside of the office is
emphasized, and this “knowing” demands help from the parents and occasionally
from other family members and peers. Altman and colleagues (2002) remind us that
“a relational approach to psychotherapy with children holds that there is no treat-
ment that is devoid of the therapist participation. In this approach, the interpersonal
nature of the work is one central theme rather than secondary or problematic. Taking
a position with the parents as part of the work, then, is no longer an interference
with the purity of the child’s therapy. Rather, it is an inevitable and useful part of the
work, to be handled as thoughtfully as possible.” Additionally, it is worth noting that
the psychotherapist has a tremendous influence on how other family members,
teachers, mental health workers, and at times pediatricians approach the patient
when knowing he or she is in psychotherapy. Thus, it is essential that the psycho-
therapist elicit their support in order to help strengthen the newly cocreated and
more adaptive neuronal pathways of the child. However, it is generally best to take
a supportive and educational approach when communicating with them.
As will be seen in the clinical cases presented in the following chapters, an active
role is taken by the relational psychotherapist in working with parents, and this role
proves invaluable in helping the patient. For example, in the case of the 17-year-old
adolescent female with relational problems (Chap. 13), the psychotherapist finds
himself intersubjectively experiencing paternal and caretaking feelings toward his
patient’s mother. This parallels the adolescent’s caretaking role of her mother, which
allows the psychotherapist to appreciate his patient’s mother’s limitations in provid-
ing the affective attunement that his patient desperately needs. In the case of the
infant with a feeding disorder (Chap. 10), the psychotherapist takes an active role in
providing the infant’s parents a corrective emotional experience by teaching the
importance in using motherese, with voice rhythmicity and an intonation that
matched their son’s physical movements.
We wish to emphasize that a two-person relational approach allows the psycho-

therapist to consider a wider range of possible implicit relational problems of
parents’ reactions to their child, if the child is part of a vulnerable population:
chronic medical illness, a learning disability, or a developmental disability.
Working with parents during the psychotherapy process allows the psychothera-
pist to intersubjectively attend to their experience of the problems and for provid-
ing the tools they need to implicitly feel as partners of the process, which goes a
long way. Amerongen and Mishna (2004) capture this dynamic, saying: “Drawing
from a body of knowledge about learning disabilities allows parents and therapists
to more accurately grasp the meaning of the behavior which then guides effective
management strategies. Informed empathy is a powerful tool in confronting the
challenges of problematic behavior in children with learning difficulties. By
employing informed empathy, vicious cycles of family interaction can be reme-
died and parents strengthened to provide more optimal developmental experiences
for their children.”
6.29 Everyday Life of the Patient in Traditional One-Person

Everyday Life of the Patient in Traditional One-Person Psychology
In a traditional one-person model of child and adolescent psychodynamic psycho-

therapy, the limits of active inquiries about the daily life of the patient are relaxed,
an attenuation of “boundaries.” Generally, traditional one-person psychotherapists
understand that the child’s descriptions of their daily life represent aspects of the
internal object representations of their parents. Thus, the everyday life of the child
or adolescent is deemed important to confirm the diagnostic formulation of the pre-
senting symptoms, but not essential. Further, the availability of this information, as
well as information gleaned from meetings with parents, inevitably influences what
the psychotherapist considers to be of importance if it confirms his or her theoretical
formulation of the patient’s problems. For example, at a recent treatment panel dis-
cussion, a psychiatric consultant from a two-person relational model was invited to
discuss the case of a 16-year-old intelligent adolescent boy with severe anxiety and
difficulties getting along with his peers. The presenting psychotherapist, trained in
a traditional one-person model, formulated that the adolescent’s anxieties and dif-
ficulties in getting along with peers resulted from oedipal conflicts and difficulties
with his second individuation process (Blos 1967) and that originated from living
with his father and having limited contact with his mother following his parents’
divorce. The presenting psychotherapist shared a vignette in which the patient’s
mother had left with his two younger sisters for New York for a weekend trip, while
the remainder of the family remained in the Midwest. The psychotherapist viewed
the trip as confirmation that the patient’s mother “had a rejecting attitude toward
him” because he was not taken on the trip, even though the patient had not given
importance to this event. The two-person relational psychotherapist who was
6.29 Everyday Life of the Patient in Traditional One-Person 171
discussing the case questioned the notion that the patient’s mother was rejecting as
she had sought treatment for her son, had been taking him regularly to his psycho-
therapy appointments, and had arranged for phone calls with her son while in
New York. The relational consultant, in essence, raised the issue that frequently
occurs in traditional one-person model: The information obtained is used to develop
a case formulation that provides little room for the consideration of what the patient
is sharing may be part and parcel of his everyday life (i.e., a mother taking her chil-
dren on a trip). It would be beyond the scope of this book to provide the result of the
consultation, but suffice it to say, it was agreed to reconsider the impression of the
adolescent’s mother as rejecting. We are reminded of the quote attributed to Freud,
“Sometimes a cigar is just a cigar.”
Everyday Life of the Patient in Two-Person Relational Psychology
In two-person relational psychology, the patient’s experience of his or her relation-

ships outside of the sessions provides a window into the reality of his or her family
and environment. It also allows one to assess the progress with regard to the use of
more adaptive patterns in the face of everyday life obstacles. In the case of the ado-
lescent described above, a relational psychotherapist might entertain several possi-
ble scenarios. First, the adolescent may have been jealous as he was not taken on the
trip. Second, he may have been happy that his mother took his sisters, with whom
he had a conflictual relationship, to New York, and thus away from him. Third, he
may have been relieved that all the females in the household were away. Fourth, he
may have enjoyed the trust that his mother placed in him in allowing him to stay by
himself. As we have discussed, the intersubjective experiences of the relational psy-
chotherapist with the patient ultimately provide the roadmap for how to understand
the event and how to proceed in order to provide a corrective emotional experience
for the development of more adaptive neuronal pathways and implicit nondeclara-
tive memory.
A two-person relational psychotherapist attends to the everyday life events of the
patient, as well as to the feelings experienced by the patient as he or she describes
the events, in the here and now between the patient and psychotherapist. Ultimately,
this contributes to a mutual cocreation of a new model in understanding the event
and thus moves the therapeutic process forward. For example, an adolescent male
who is seen in weekly psychotherapy shares with his psychotherapist his fright fol-
lowing his car having caught fire while visiting a friend. He adds, “I was so lucky
that I wasn’t in the car,” and uses his smartphone to show his psychotherapist a
photo of the car after the fire. Immediately, the psychotherapist realizes the serious-
ness of the event and is able to genuinely comment, “I am glad you are safe.” The
patient understands this a moment of meeting and says: “I know you care about me.
More than I can say about my mother. She got mad and thought that it was my fault,
until my grandpa told her it was not my fault; it was a faulty gas pump. I was scared,
I could have been killed.” Thus, in this vignette, we see the sine qua non of two-
person relational psychotherapy: “At the heart of relational therapy there is the
therapist’s commitment to be present, with caring and focus, in the relationship. The
commitment is particularly about being present while in session in the therapy
room” (DeYoung 2003).
6.30 Psychopharmacology in Traditional One-Person

Psychopharmacology in Traditional One-Person Psychology
In the traditional one-person psychology model, the use of medication was fraught
with doubt about its usefulness. The challenges to the psychoanalytic movement
from the use of pharmacological interventions became prominent in the 1960s. This
paralleled changes in the 1980 Diagnostic and Statistical Manual of Mental
Disorders 3rd Edition (DSM-III, American Psychiatric Association 1980), when the
influence of psychoanalytic theories began to lose ground. To this, articles that
attributed many symbolic meanings to the use of medication proliferated in the psy-
choanalytic literature of the day. For example, in writing from a traditional one-
person model, one psychoanalyst noted: “Unlike more generic or stereotypic
meanings, object representations attributed to medication may reflect the patient’s
specific dynamics and object relations. These representations are many and mutable,
and take on shifting and overlapping forms that evolve with the analytic process.
Medication may represent a third person within the framework of an analytic treat-
ment, expanding the analytic dyad into a triad and offering new transference para-
digms to explore” (Tutter 2006). She added, “Defensive displacement of transferential
qualities and attitudes, or split-off parts thereof, from the analyst onto medication
can serve as a powerful resistance to the awareness of the transference to the ana-
lyst.” Over time, the psychoanalysts and psychotherapists acknowledged that the use
of medication during psychoanalysis and psychodynamic psychotherapy could
enhance both modalities. Thus, by the turn of the twenty-first century, Gabbard and
Bartlett (1998) noted that the question was “no longer whether combining medica-
tion and psychoanalysis is beneficial; rather, a more compelling question is how the
combination is beneficial.”
Nevertheless, in child and adolescent psychoanalysis and psychodynamic psy-
chotherapy, the use of medications remains controversial. The benefits of the use of
medication with children and adolescents have been questioned, and currently there
continues to be significant debate about whether the treatment of attention deficit
hyperactivity disorder (ADHD), anxiety disorders, and depressive-spectrum disor-
ders with medications represents “best practice.” There is a negative perception from
some colleagues working within a traditional one-person model with regard to the
use of medication in children and adolescents. When a traditional one-person child
psychoanalyst understands that a 6-year-old girl’s difficulty sitting still and habit of
interrupting others in class represent a form of acting-out behavior due to internal
conflicts—and believes that helping the child understand the meaning of these
6.30 Psychopharmacology in Traditional One-Person Psychology and Two-Person 173
behaviors may lead to a decrease in symptoms—this understanding minimizes and

dismisses the significant evidence that she has ADHD (Kaplan and Delgado 2006).
Thus, in a traditional one-personal model, when, for example, the available clinical
and collateral evidence supports a diagnosis of ADHD, countertransference enact-
ments withholding the use of medication can be of significant detriment to the child’s
future. Additionally, in the traditional one-person model, a child’s resistance to tak-
ing medication may be considered a form of acting out of their internal conflicts.
Generally, in the traditional model, when a child does not comply with taking medi-
cation for the treatment of their medical conditions (e.g., insulin for diabetes, an
inhaled corticosteroid for asthma, chemotherapy for cancer), this resistance is attrib-
uted to internal conflicts that have been displaced onto the medication. A traditional
one-person child psychoanalyst or psychotherapist may choose to help the patient
understand the resistance as a matter of control, oedipal issues, fear of rejection, etc.,
and he or she may not recognize that the fear of taking the medication may be due to
certain realities (e.g., the parents cannot afford it, the child knows of a peer that
worsened taking the same medication, side effects not recognized by physicians).
Finally, it goes almost without saying that the use of medication in children and
adolescents can be a life-changing event. In the treatment of ADHD, the use of medi-
cation “is an important part of the therapist’s armamentarium, and often a necessary
one” (O’Brien 1992). We have colleagues of the traditional one-person schools who
openly state that medication limits what patients can learn in psychotherapy to
improve self-regulation. We suggest that the psychotherapist recognize his or her
biases about medication when working with a child, as they may be interfering with
best possible results.
Psychopharmacology in Two-Person Relational Psychology
In the two-person relational model, the clinician’s choice to recommend medication

is based on defined clinical criteria, paralleled with mutual intersubjectivity that
provides the clinician an understanding of what it is like for the patient to struggle
with their generalized anxiety, depressive symptoms, obsessions, tics, or attention
deficit hyperactivity disorder. Herein, with sensitivity, the psychotherapist can col-
laboratively help the patient review the pros and cons of starting medication.
When a two-person relational psychotherapist is reluctant to recommend medi-
cation, the child (or adolescent) or parents may implicitly recognize the reluctance
and may withhold sharing the symptoms, thereby preventing the opportunity for a
pharmacological intervention that may have provided marked improved function-
ing. This situation is not a form of countertransference or projective identification in
the traditional sense, but rather the psychotherapist’s nonconscious implicit work-
ing models of relating that cocreate a maladaptive emotional experience. It is hoped
that over time the psychotherapist will attend to his or her intersubjectivity and
recognize with humility that the patient may not be improving and, with the help of
collateral information, may reconsider recommending the use of medication.
6.31 Other Forms of Psychotherapy
Traditionally, psychoanalysts and psychotherapists of traditional one-person orien-

tation consider non-psychodynamic forms of therapies as not “real psychoanalysis
or psychodynamic psychotherapy,” in that they give short shrift to the understanding
of the inner life of the child or adolescent. In contrast, contemporary two-person
relational psychotherapists consider the use of other forms of psychotherapeutic
interventions as a necessary tool if one of those forms can recognize patient pro-
clivities and allow for the moving forward of the process. Other forms of psycho-
therapeutic interventions used when appropriate include: (1) family therapy, (2)
cognitive behavioral therapy (CBT), (3) dialectical behavioral therapy for adoles-
cents (DBT-A), (4) interpersonal psychotherapy for adolescents (IPT-A), (5)
trauma-focused cognitive behavioral therapy (TF-CBT), (6) group therapy, and (7)
mindfulness-based cognitive therapy (MBCT). If the two-person relational psycho-
therapist does not have formal training in such therapies, he or she may consider
referring the child to a colleague with expertise and work in tandem with them. As
an example, an adolescent girl who has been engaged in making superficial cuts to
her arms and is prone for further self-harm may benefit from DBT-A, and then,
when stable, a more formal two-person relational approach. A child with Tourette’s
syndrome may benefit from a combination of cognitive behavioral interventions—
including habit-reversal therapy—as well as active psychoeducational family ther-
apy and, after tic control has improved, a formal two-person relational approach to
improve matters of self-esteem, if needed. An elementary school age child with a
history of physical and sexual abuse may benefit from TF-CBT, followed by a for-
mal two-person relational approach.
6.32 The Use of the Couch in Traditional One-Person

Traditionally, psychoanalysts have followed Freud’s suggestion of using a couch in

psychoanalysis to allow patients to lie down and feel more relaxed when not looking
at the analyst and thus freer to talk. Since the patients did not see the analyst’s facial
expressions, they could focus on their fantasies, daydreams, and inner feelings.
Ross (1999) notes that in lying down, a person’s perspective changes and they focus
less on objects in the environment and more on images that arise from their own
minds. Not bound by an awareness of the analyst’s facial expressions and gestures,
the analytic patient is more readily able to imagine what the analyst is thinking or
feeling, too, which enriches the experience of analysis.
Emde (2009) raises the question that few have chosen to tackle: “Is the use of the
psychoanalytic couch necessary knowing the importance of the face-to-face implicit
meaning making which allows for the corrective emotional experience to occur at a
nonconscious procedural level?” The use of a couch in traditional one-person psy-
chology facilitates neutrality by treating the analyst as a blank screen, not interfer-
ing with the patient’s free associations. In contrast, the use of a couch in a two-person
6.33 Fairy Tales in Traditional One-Person Psychology 175
relational approach hinders the implicit reading of the facial expressions made by
both parties needed for meaning making. The goal of the treatment is the co-
construction of new emotional experiences based on the intersubjective and verbal
reciprocity. As Emde (2009) states, “My impression is that more and more work is
being done on occasions during analysis when there is sitting up and when there are
face-to-face encounters.” The couch may be used at times if a patient is in the pro-
cess of sharing traumatic events, and the patient will later need the face-to-face reci-
procity of the available and present psychotherapist to reestablish the atmosphere of
safety and cocreate new internal working models and schemas of implicit relational
healthier patterns. Finally, Emde (2009) conjectures: “Perhaps sitting up, face-to-
face interactions are especially important in early phases of traditional work when
one needs to encourage trust and a sense of security as well as a positive hopeful-
ness about adaptive change. Perhaps it is also especially important in the ending
phase of work when the analysand is experiencing and trying out new beginnings,
outside of the analytic relationship. Indeed, the role of taking up ‘practicing’ for new
modes of adaptation in real life as part of the final phases of analytic work, with
active encouragement of the analyst, is a topic deserving of more attention and is
considered an aspect of the developmental orientation for psychoanalysis” (Emde
2005).
In child and adolescent psychotherapy and psychoanalysis, the couch is gener-
ally not used. If it is used, it is an effort to allow the patient to feel comfortable, and
typically he or she lies in a manner that allows him or her to see the psychotherapist
face to face. Nevertheless, the authors wish to emphasize that in child and adoles-
cent psychotherapy, there is a need for the psychotherapist to be visible (face to
face) and to be present, demonstrated by his or her tone of voice—rhythmicity and
through intonation—so that the child or adolescent feels safe and learns to be with
others in healthier ways. The psychotherapist must ensure that this occurs and can-
not take for granted what the patient will or will not implicitly remember. As Emde
(2009) reminds us, much of the work with children and adolescents happens in the
face-to-face encounters of social reciprocity with affective attunement.
6.33 Fairy Tales in Traditional One-Person Psychology

If you want your children to be intelligent, read them fairy tales. If you want them to be
more intelligent, read them more fairy tales. ―Albert Einstein
The popularity of a traditional one-person psychology among the lay public is

evident in discussions of fairy tales, which are ubiquitous to the life of children.
Exposure to fairy tales occurs when parents read to their children, when children
read independently, and when children watch television. Moreover, fairy tales in the
traditional one-person model are in many ways considered akin to dreams and fan-
tasies in children. As such, in one-person psychology, a child’s interest in fairy tales
reflects the child’s inner life conflicts, whereas in the two-person relational
perspective, fairy tales represent the imaginative skills of an author who keeps the
child “hooked to the story,” much like a talented novelist keeps his adult reader
hooked. The appeal to the fairy tales is its novelty that implicitly encourages chil-
dren to develop their own imaginative skills in predicting (using nondeclarative
memory) what will happen next in the story.
Fairy Tales in Traditional One-Person Psychology
The importance of fairy tales in psychoanalytic thought dates back to Freud (1913),
who wrote: “It is not surprising to find that psycho-analysis confirms our recogni-
tion of the important place which folk fairy tales have acquired in the mental life of
our children. In a few people a recollection of their favourite fairy tales takes the
place of memories of their own childhood; they have made the fairy tales into screen
memories.”
The popular Grimm brothers’ fairy tales Hansel and Gretel and Little Red Riding
Hood have been staples of childhood for centuries and are represented in books,
puppet shows, cartoons, board games, video games, and feature films. In traditional
one-person psychoanalytic literature, we find that these two fairy tales have received
significant attention. In Fromm’s (1951) review of Little Red Riding Hood, he wrote:
“Most of the symbolism in the fairy tale can be understood without difficulty. The
‘little cap of red velvet’ is a symbol of menstruation. The little girl of whose adven-
tures we hear has become a mature woman and is now confronted with the problem
of sex. The warning ‘not to run off the path’ so as not ‘to fall and break the bottle’ is
clearly a warning against the dangers of sex and losing her virginity.” Additionally,
in 1976, Bettelheim published The Uses of Enchantment: The Meaning and
Importance of Fairy Tales, in which he proposed that fairy tales help children face
unconscious fears and conflicts, and he believed that through reading fairy tales, a
child would be able to unconsciously work through these conflicts. Bettelheim
believed that the main theme in Hansel and Gretel that appealed to children was
their symbolic separation from their mother. Bettelheim examined Little Red Riding
Hood’s journey through the forest and posited that this journey represented the task
of dealing with the transition from childhood and entering adulthood (i.e., losing her
virginity and reaching sexual maturity). In this treatise, he stated that Little Red
Riding Hood unconsciously views the wolf as a representation of her Electra com-
plex; the wolf is the unconscious father that has big arms, ears, eyes, and teeth.
Further, when the wolf (Little Red Riding Hood’s father) asks, “What are you car-
rying under your apron?” he suggests an unconscious projection of her desire for
her father to be aware of her sexuality. Additionally, Bettelheim believed that the
hunter represented Little Red Riding Hood’s unconscious wish for rescue from her
conflicted libidinal wishes toward her father, adding that when the hunter cuts open
the wolf's belly, it represents her wish to have her father’s child. Later, a paper by
the Finnish Psychiatry group (Psychiatria Fennica 1976) stated, “Fairy tales have a
moral function, strengthening the ego by introducing it to realistic possibilities.”
More recently, Jacobs (2011) reiterated the importance fairy tales have in traditional
6.33 Fairy Tales in Traditional One-Person Psychology 177
one-person psychoanalytic school of thought: “Fairy tales are understood as repre-

senting fundamental developmental conflicts, accounting for their enduring power
over time. The analytic encounter is seen as an analogue of the fairy tale.”
This is to say that traditional one-person school of thought often applies Freud’s
drive theory and Klein’s object relations theory to understand fairy tales, which are
believed to have an important role in the treatment of a patient’s unconscious con-
flicts represented by the story. Fairy tales from this view are also thought to repre-
sent children’s collective unconscious developmental struggles.
Fairy Tales in Two-Person Relational Psychology
We ask the reader to recall when, as a child, they were read the two popular fairy
tales by the Grimm brothers—Little Red Riding Hood and Hansel and Gretel—or
when the reader read them to their children. Of course, with new innovations in
technology, some may have viewed the fairy tale through an electronic device or
may have used such a device to play a video of the fairy tale to their child. It is our
hope that the moment the reader recalls these fairy tales, he or she will use noncon-
scious implicit memory to recognize the story and then, seconds later, will recall the
childhood experience, including who was present and in what context the story was
read to them or to their child (e.g., in bed, in a playroom, at the park, read by a loved
one). In doing so, the reader will have used an implicit relational knowing of the
experience. This process occurs at a nonconscious level and allows for the retrieval,
through sculpted neuronal pathways (chronic meanings), of the memories and expe-
riences in regard to when the fairy tales were heard.
Fairy tales are important to children who are fortunate enough to have caregivers
that provide a secure environment that encourages reading or watching children’s
stories in the presence of their emotionally available caregivers. Fairy tales promote
the use of imagination and creativity. Additionally, they embody the fears and anxi-
eties that are part of the developmental process that a child must master—with the
help of his or her caregivers—toward a successful resolution and improved under-
standing of morals. Not surprising, parents, when reading or storytelling these fairy
tales, make changes in their tone of voice to express reassurance to their child about
the story’s anxieties and fears. There is a verbal dance between child and parent, but
also a preverbal dance of meaning making (Tronick 1989).
Little Red Riding Hood begins, “Once upon a time, there was a dear little girl
who was loved by everyone who looked at her, but most of all by her grandmother.”
Hansel and Gretel begins: “Hard by a great forest dwelt a poor wood-cutter with his
wife and his two children. The boy was called Hansel and the girl Gretel.” Both fairy
tales begin by telling the reader that the children were loved and cared for.
Nevertheless, when the story begins to speak about issues of fear and abandonment,
it is immediately apparent that something about the story does not seem right. To
wit, in Little Red Riding Hood, we hear: “‘Oh! But, grandmother, what a terrible big
mouth you have!’ ‘All the better to eat you with!’” And in Hansel and Gretel, we
hear: “Early tomorrow morning we will take the children out into the forest…and
leave them alone. They will not find the way home again, and we shall be rid of
them.” Additionally, in the children’s version of the Grimm brothers’ tales, each tale
ends by assuring the children that the characters return back safely and are loved:
“Red Riding Hood thought to herself: ‘As long as I live, I will never leave the path
by myself to run into the wood, when my mother has forbidden me to do so,’” while
Hansel and Gretel “threw themselves round their father’s neck. The man had not
known one happy hour since he had left the children in the forest.”
It is worth noting that the Grimm brothers’ original tales were not thought not to
be suitable for children due to their not so happy endings. They later revised some
of their work in Children’s and Household Tales (Ashliman 1987), and later it
became known as The Complete Fairy Tales of the Brothers Grimm (Zipes 2003). In
fact, the original Little Red Riding Hood was written by French author Charles
Perrault in the seventeenth century and originally titled Little Red Cap, later revised
by the Grimm brothers to the form we are more familiar with today.
Viewing these fairy tales from a two-person relational perspective, they implicitly
reinforce traditional moral values in children—“Thou shall obey your parents, as they
have loved and cared for you.” The loving parent asks their child to obey when walk-
ing through dangerous areas and to beware of seemingly friendly strangers. This is
implicitly and explicitly understood between children and their parents. Thus, while
Sandor Lorand, a psychoanalyst and prominent disciple of Freud (1935), in a tradi-
tional one-person model believed that fairy tales could help a child find a solution to
the conflicts from the Oedipus complex, he also viewed fairy tales in what we now
consider a two-person relational model by taking into consideration matters of affec-
tive attunement. In this regard, Lorand noted: “The good or ill effect of fairy stories
rests largely on the circumstances under which they are related to the child. The story
must obviously be suited to the child’s age and condition. Care should be taken that
the tale is told in the proper physical and psychological setting. The time of day when
the storytelling takes place is, of course, important (for example, no ogre story before
bed time). Even such a minor detail as voice modulation should be given careful
consideration. Above all, the story teller should be certain that the tale is told for the
child, and not out of a sense of duty, or merely to relieve certain tensions of his own.”
We conclude by reminding the reader that fairy tales represent the essence of a
child’s rich imaginative and creative skills. The fairy-tale author who understands
children’s wish to master imagined and real-life worries will readily have the chil-
dren “hooked to the story.” The appeal to fairy tales is their novelty that implicitly
encourages children to develop their own imaginative skills in predicting what will
happen next in the story.
6.34 Summary
We have described the different terms of concepts in traditional one-person psychol-

ogy and our understanding of these concepts from a two-person relational model.
We hope that, at the end of this chapter, the reader may distinguish between mat-
ters of unconscious transference, resistance, and defenses through a two-person
References 179
relational lens. Finally, we suggest that the two-person relational psychotherapist

jettison the terms of traditional one-person model in favor of a new two-person
relational lexicon.
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The Neurodevelopmental
and Neurofunctional Basis 7
of Intersubjectivity
Anatomy is destiny.
—Sigmund Freud
Modern neuroscience has advanced significantly since Freud’s initial Project

for a Scientific Psychology (Freud 1895), in which he hoped to apply scientific
principles to the emerging discipline of psychoanalysis. As such, a sophisticated
quest to understand the human mind—over the last 125 years—has led to the
discovery of a radically different landscape than that which Freud had envisioned.
In this regard, multimodal scientific investigations have openly questioned the
validity of Freud’s concepts: “[Modern] science not only fails to support the cen-
tral tenets of Freudian dream theory but raises serious questions about other
strongly held psychodynamic assumptions including the nature of the uncon-
scious mind, infantile sexuality, the tripartite model of the mind, the concept of
ego defense, free association and the analysis of the transference as a way of
effecting adaptive change” (Hobson et al. 2000). Moreover, recent advances in
neuroimaging and neurodevelopmental research have profoundly advanced our
understanding of the key areas of “the relational brain,” the substrate for two-
person relational psychotherapy. Herein, we will briefly review the historical
developments of two-person relational psychotherapy, and in doing so, we will
detail the specific advances in developmental psychology. Additionally, we will
review the key theorists and researchers whose work and behavioral experiments
made possible the neurophysiologic investigations, which have, in turn, given rise
to our nascent understanding of the neurophysiology of attachment and
intersubjectivity.
Work in affective, social, and cognitive neuroscience and neuropsychology have
had a significant impact on psychodynamic psychotherapies. However, we distin-
guish between psychodynamic psychotherapies and psychoanalysis, because child
and adolescent psychoanalysis is by and large guided by a traditional one-person

DOI 10.1007/978-3-642-40520-4_7
186 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity
psychology (Chap. 2) and has been reluctant to incorporate neuroscience and devel-
opmental psychology into current theory and practice.
7.1 Developmental Psychology: A Foundation

for the Neurofunctional and Neurostructural
Understanding of Two-Person Relational
Psychotherapy
Developmental research, and in particular studies with infants, demonstrates that

what is stored or represented in the form of memory seems not to involve words or
images but rather experiences. Sander (1985) demonstrated that as early as 8 days
old, an infant can store a mental representation of the experience of a feeding
sequence that when disrupted (e.g., by a mother being asked to wear a ski mask dur-
ing feeding) generates distress in the infant that is strong enough to suspend his or
her feeding behaviors. Thus, memories of experiences are considered precursors to
early forms of implicit relational knowing, a representation of how to be with
another person that is not language based.
The implicit domain is richer, more complex, and larger in terms of knowing
about human behavior than explicit knowledge at all ages, not just in infancy. Thus,
implicit relational knowing is based in affect and action rather than in word and
symbol (i.e., preverbal) (Lyons-Ruth et al. 1998). This is to say, an infant knows
that feeding is a pleasurable experience when seeing and feeling attuned by his or
her emotionally available mother and disruptive when the feeding is not accompa-
nied by the mother’s affective attunement. This process is also nonconscious and
nonconflicted, meaning it does need to be repressed, as was traditionally believed
(Lyons-Ruth 1999). Moreover, this includes not only the desire and idea to act but
also the action, the object of the action, and the goal. In an experiment, a preverbal
infant observes a research assistant trying to drop an object into a bowl, but who
fails by dropping the object in front of and then behind the bowl. Although the
infant never sees the object dropped into the bowl, “with the invitation to imitate
what he saw, he immediately drops the object directly into the bowl and seems
contented with himself. The infant grasped the intention of the experimenter even
though he never saw it successfully realized. He gives priority to the intention he
has inferred over an action he has seen” (Meltzoff 1995; Meltzoff and Gopnik
1993). In another experiment, an infant watches an experimenter try to pull the
spheres off the ends of a dumbbell-like object but fail. Later when the infant is
given the object, he immediately pulls the spheres off and seems to feel good about
what he has done. The control condition consists of a robot that, like the experi-
menter, tries to pull the ball-like ends off but also fails. However, when infants are
given the dumbbell-like object after they watched the robot fail, they do not try to
pull the ends off. These infants have implicitly understood that robots do not have
intentions (Meltzoff 1995). Decety and Chaminade (2003) showed that an infant
who would imitate a mother putting a doll to bed would not imitate her putting a toy
car to bed.
7.2 Core Concepts of Development 187
7.2 Core Concepts of Development
The core concepts of development, as outlined by the National Research Council,

Institute of Medicine, in the book From Neurons to Neighborhoods (2000), provide
a clear and coherent road map of the developmental path of complex interactions
between the infant’s innate attributes (i.e., nature) and the influence of family and
the environment (i.e., nurture) in the context of social and cultural factors. Moreover,
the dynamic complexities of the relationship between “nature” and “nurture” sug-
gest that the concepts are best understood not as “nature versus nurture, but rather
nature through nurture” (Institute of Medicine 2000). Herein, we will review each
concept with regard to two-person relational psychotherapy in children and
adolescents.
Human development is shaped by a dynamic and continuous interaction

between biology and experience This concept is essential in understanding the
complex dynamic world from which our young patients come. Relational theory,
which encompasses two-person relational psychology, attends to the variability of
neurobiology (e.g., innate temperament, mirror and echo neuron systems, attach-
ment patterns, the family system, and the cultural aspects of both patient and psy-
chotherapist). It is the amalgam of these factors that ultimately influences the
interaction between the patient and psychotherapist and that allows for the cocre-
ation of a unique intersubjective experience. Moreover, two-person relational psy-
chotherapy can influence (through neuroplasticity-dependent mechanisms) the
acquisition of a better model of adaptation to the relational world, and this process
almost certainly has neurophysiologic foundations. This process in which experi-
ence facilitates neurostructural and neurofunctional changes has been eloquently
demonstrated in several recent preclinical studies, which collectively suggest that
the relationship between early stress and adversity, as well as poor-quality interper-
sonal experiences (e.g., being raised in an international orphanage), is associated
with deficits of functional connectivity between the amygdala and prefrontal cortex.
Additionally, in lower animals, early-life adversity is associated with changes in
neuronal architecture in regions that—in humans—likely subserve the encoding of
relational experiences (e.g., hippocampal neurons) (McLaughlin et al. 2007) and in
cortical areas responsible for the processing of interactions (e.g., cortical pyramidal
neurons) (Vyas et al. 2002). Additionally, there is evidence, again in lower animals,
that chronic, early adversity may drastically alter the morphology of the neurons
within the amygdala, including increased dendritic arborization and the lengthening
of dendrites (Fig. 7.1) (Vyas et al. 2006).
Culture influences every aspect of human development As we have reviewed

elsewhere (Delgado and Strawn 2014), culture—the constellation of languages,
social customs, traditions, beliefs, and values shared by a group of people linked by
family, race, ethnicity, region, or culture of origin—profoundly influence human
development. Additionally, an individual’s culture influences what is considered the
norm for loving and stable relationships. This norm will guide prenatal care, birth
Fig. 7.1 Chronic

environmental stress (blue)
results in increased
arborization, increased
dendritic spine density, and
elongation of dendrites in the
basolateral amygdala
compared to dendrites from
animals who have not
experienced environmental
adversity (red)
delivery systems accessed, feeding, sleeping, and parenting practices. Regarding

concepts that are germane to two-person relational psychotherapy (e.g., “meaning
making” and “implicit relational knowing”), it is clear that culture contributes to
the shaping and development of these processes, as well as to the underlying
neurofunctional and neurostructural bases of these processes.
Recent functional neuroimaging studies of Asians compared to Caucasian
Americans have demonstrated interesting findings in this regard. When individuals
from cultures that “habitually attend to the needs, perspectives, and internal
experiences of others compared to the self” viewed images of others in emotional
pain, increased activation of the anterior cingulate cortex and insula is observed in
the Asian subjects relative to the Caucasian American subjects. This suggests that
culturally bound “attunement to the subjective experience of others” may be

associated with neurofunctional differences across cultures (Cheon et al. 2013).
Additionally, the degree of dependency in cultures affects the processing of anger,
“an emotion that implies the disruption of harmony.” In this regard, during a task
of empathic processing, healthy Chinese individuals, who in this study are self-
described as more interdependent than German individuals, have increased activ-
ity in the dorsolateral prefrontal cortex, while the Germans exhibited increased
activation of the inferior and superior temporal gyrus (de Greck et al. 2012).
Moreover, the activation in the inferior and superior temporal gyrus correlated
with the degree of independence in the sample, suggesting that increased cultur-
ally related tolerance for anger is associated with activity in the inferior and supe-
rior temporal gyrus and insula (de Greck et al. 2012). Thus, while individual
differences in empathy and experience may direct these neurofunctional differ-
ences and the process is likely multidimensional with genetic and state-dependent
modulation, it is clear that culture is the ever-present factor that influences the
ways we communicate with patients, inhibits or enhances our understanding of
their illnesses, and provides the context that explains their reactions to the event
(Delgado and Strawn 2014).
The growth of self-regulation is a cornerstone of early childhood development

that cuts across all domains of behavior Children have the complex task of
implicitly and nonconsciously learning to manage emotions in the context of
interpersonal interactions, in addition to learning to regulate their internal physio-
logical states. This complex task is beautifully captured by Winnicott in his famous
aphorism, “There is no such thing as a baby,” meaning that without a mother, an
infant cannot exist, and we now recognize that infants have an intrinsic need for
interaction with their caregivers. Put differently, Emde (1987) notes that “infants’
emotions are, by their nature, relational.”
Thus, the child with a history of problems in self-regulation due to developmen-
tal or cognitive delays (e.g., autism, ADHD, learning disabilities) may benefit the
most from a more structured approach or a more behaviorally oriented approach
(e.g., parent–child interaction training [PCIT], behavior management) or, in the
case of ADHD, from pharmacotherapy. Nonetheless, we are not implying that
psychodynamic psychotherapy is not helpful to some children with self-regulation
problems; we are saying that a careful assessment of these aspects will allow for a
detailed identification of those that will not benefit from psychodynamic psycho-
therapy. Additionally, it is important to note that the capacity for self-regulation
may be significantly influenced by trauma (Schore 2002). In this regard, children
and adolescents with histories of maltreatment exhibit deficits in a myriad of
neuropsychological domains, including attention and abstract reasoning/executive
function, which likely subserve the capacity for self-regulation (Beers and DeBellis
2002). Moreover, there is also evidence to suggest that the neural circuitry of self-
regulation is altered in children and adolescents who have experienced significant
trauma. For example, Herringa and colleagues (2013) observed lower resting-state
functional connectivity between the hippocampus and subgenual cingulate and
reduced resting-state functional connectivity between the amygdala and cingulate

cortex in maltreated youth relative to healthy comparison subjects. Additionally, in
this sample, resting-state connectivity for these structures mediated the association
of maltreatment earlier in life and the presence of internalizing symptoms in adoles-
cence, suggesting that early maltreatment “may alter the regulatory capacity of the
brain’s fear circuit, leading to increased internalizing symptoms by late adoles-
cence” (Herringa et al. 2013).
Children are active participants in their own development, reflecting the

intrinsic human drive to explore and master one’s environment There is an
innate developmental motivation on the part of a child to master his or her environ-
ment and to learn “getting along” with others. Moreover, early positive experiences
with caregivers have a profound role in the developmental process in that it pro-
motes affect regulation and the neurophysiological changes entailed. Herein, a child
is an active participant in their development, seeking to elicit the affectively attuned
responses needed from their caregivers for a successful process.
Human relationships and the effects of relationships on relationships, are the

building blocks of healthy development Attachment theory (see Chaps. 3 and 8)
provides a longitudinal view of the way in which a child establishes early dyadic
relationships with his or her parents or caregivers. In turn, these relationships deter-
mine the quality of emotional relationships that the child will have with others
throughout his or her life span. As such, the internal working models of relationships
and the goodness of fit both serve as foundations for and ultimately facilitate inter-
personal relationships. It is recognized that developmental or behavioral distur-
bances in infants and toddlers may be a product of disturbances in the infant–caregiver
dyad (Bowlby 1999; Sameroff and Emde 1989). In this regard, this discordance
appears to have a neurofunctional basis. As such, a recent functional magnetic reso-
nance imaging (fMRI) study involving mother–infant dyads observed that mothers
who were more sensitive to their infants had increased activation of the right pre-
frontal cortex, including the right inferior frontal gyri, in response to their infants’
cry, compared to those mothers who were less sensitive to their infants (Musser et al.
2012). Additionally, in this study, mothers who exhibited more intrusive responses
to their infants had increased activation in the left anterior insula and temporal pole,
whereas mothers who had more harmonious interactions with their infant displayed
greater activation in the left hippocampal regions (Musser et al. 2012).
The broad range of individual differences among young children often makes
it difficult to distinguish normal variations and maturational delays from
transient disorders and persistent impairments Differences in cognitive and
affective ability affect one’s ability to achieve developmental competency or, in
other words, to participate in rewarding experiences with others. In this regard,
neuroimaging studies suggest structural and functional brain abnormalities associ-
ated with the presence of cognitive and linguistic communication disorders that
underlie these differences in cognitive and affective ability (Delgado et al. 2011;
Frodl and Skokauskasm 2012; Lai 2013; Webster et al. 2008). Specifically, regard-
ing learning disorders, 10 % of the general population may have learning weak-
nesses, and among this group, many have formal learning disabilities (Altarac and
Saroha 2007; Cooper et al. 2007). Considering these statistics, there is a selective
group of children and adolescents that have persistent impairments that make it dif-
ficult to assess maturational norms. Further, there is a group of children with physi-
cal disabilities, including individuals with visual impairments, hearing impairments,
speech disorders, etc., who may experience maturational delays. However, it is criti-
cal to recognize that within such a group, there will be significant variability in
apparent cognitive and affective ability, and it is of great importance to carefully
characterize any deficits in the context of these sensory limitations.
The development of children unfolds along individual pathways whose

trajectories are characterized by continuities and discontinuities as well as by
a series of significant transitions Development in children and adolescents occurs
as a series of transitions that are typically punctuated by physiological and physical
changes that parallel adaptive psychological advances (Emde and Harmon 1984). A
range of putative mechanisms likely mediate these developmental processes, as well
as heterotypic continuity and psychopathologic progression. These mechanisms
include gene x environment interactions, “‘kindling’ effects, environmental influ-
ences, coping mechanisms and cognitive processing of experiences” (Rutter et al.
2006). Moreover, when developmental transitions are due to or coincide with a seri-
ous illness or traumatic event, significant physiological and physical changes that
end in psychological discontinuities with maladaptive mechanisms may ensue.
An example frequently seen by mental health professionals that captures the
continuities and discontinuities of children is toilet training. This process can occur
along several possible pathways. For some, it may occur when developmentally
expected (between 24 and 36 months) and without major difficulties, while for oth-
ers, parental anxieties and wishes to have toilet training occur sooner or more
quickly may result in discontinuity with varying psychological sequelae. We clearly
have come a long way from early psychoanalytic thought in which problems with
toilet training were considered to be due to a fixation or regression of anal-level
intrapsychic conflicts.
Human development is shaped by the ongoing interplay among sources of

vulnerability and sources of resilience The way in which a child adapts to physi-
cal and emotional life challenges depends on the innate factors that activate specific
gene expression patterns, resulting in the production of protective and regulatory
factors. However, some children may be more vulnerable than others and may be
less affected by family or environmental adversity. The susceptibility to stressful or
traumatic events for a particular child continues to be difficult to determine, and it
will be critical for future work to explore these factors, particularly in “dandelion
children” (i.e., those youth who are psychologically resilient and able to survive
Major depressive disorder

Probability of developing
Number of stressful life events
Fig. 7.2 Serotonin transporter promoter polymorphism predicts likelihood of developing depres-
sion as a function of stressful life experiences. The red line represents individuals who contain two
short alleles (s/s), whereas the green line represents individuals who contain one short allele and
one lone allele (s/l) and the blue line represents those individuals who are homozygous for the long
allele (l/l) (Adapted from Caspi et al. (2003))
under adverse circumstances) (Boyce and Ellis 2005; Dick et al. 2011). Recently,
several studies of the genetic basis of resilience have focused on functional
polymorphisms in the serotonin transporter promoter region. Caspi and colleagues
first described this mechanism in a longitudinally followed cohort study in which
this particular functional polymorphism moderated the effect of adverse events on
the subsequent development of depression. In this regard, individuals who had one
or two copies of the short alleles exhibited increased depressive symptoms com-
pared to individuals who were homozygous for the long allele when they had expe-
rienced significant life adversity (Fig. 7.2), “thus providing evidence of a
gene-by-environment interaction, in which an individual’s response to environmen-
tal insults is moderated by his or her genetic makeup” (Caspi et al. 2003).
The timing of early experiences can matter but, more often than not, the
developing child remains vulnerable to risks and open to protective influences
throughout the early years of life and into adulthood The recognition of a chil-
dren’s neurodevelopmental plasticity in response to environmental changes reflects
“the capacity of the brain to reorganize its structure or function, generally in
response to a specific event or perturbation” (Institute of Medicine 2000), and “var-
ies inversely with maturation,” affirming the need for early interventions in order to
achieve the best outcomes. Accordingly, the two-person relational psychotherapist
facilitates brain neuroplasticity through here-and-now, intersubjectivity-based
experiences, which promote the development and strengthening of specific brain
circuits that are increasingly capable of processing mutual understandings when
relating to others.
7.3 The Neurobiology of Two-Person Relational Psychotherapy 193
The course of development can be altered in early childhood by effective

interventions that change the balance between risk and protection, thereby
shifting the odds in favor of more adaptive outcomes The most effective two-
person relational interventions occur early in the course of development and are
tailored to the physical and emotional needs of each child or adolescent and their
family. The interventions should be tailored to help the child or adolescent resume
their developmental tracjectory and should also facilitate the family unit’s return to
a homeostatic state, rather than relying on a theoretical formulation that may limit
the breadth of interventions needed.
7.3 The Neurobiology of Two-Person Relational

Psychotherapy
To understand the neurobiology of two-person relational psychotherapy and of the

developmental concepts described in this text, we must understand a number of key
concepts in neuroscience. In the sections that follow, we will explore the neuro-
physiology of these key concepts: (1) neuroplasticity, (2) the mirror neuron system,
(3) the default mode network, (4) social referencing and affective attunement, (5)
temperament, and (6) reflective functioning. For each of these processes, the rele-
vant brain structures and connectivity will be described.
Neurodevelopment: A Broad Overview
The development of the human nervous system is dependent on a myriad of genetic

and environmental factors. Additionally, there is significant remodeling of the ner-
vous system throughout development as an effect of experience, exposure to events,
learning, and through various epigenetic processes. Importantly however, while
neural connectivity changes throughout life, it is during infancy, the early school
age years, and then puberty that the greatest rate of change occurs. It is also during
these periods that there are significant regional changes in gray matter volumes
(Fig. 7.3). Many of these neurodevelopmental processes rely on neuroplasticity-
related phenomena. In short, neuroplasticity refers to the changing of neural net-
works through both “pruning” and also through the strengthening of synaptic
connections. Thus, as the brain processes sensory information, frequently used syn-
apses are strengthened while unused synapses weaken and eventually cease to exist.
Certainly, neuroplasticity has critical importance in two-person relational psycho-
therapy as summarized by Buirski and Haglund (2009): “Successful treatment leads
to the formation of new organizations of experience, new ways of understanding
oneself, and new expectancies based on these new understandings…. What happens
to the archaically formed ones? They neither disappear, are forgotten, nor are com-
pletely replaced by the newly formed ones. Rather, they persist in weakened form
within the organization of the personality.” They conclude by stating that when a
1.0
0.9
Age
0.8
0.7
0.6
Gray Matter
20 0.5
0.4
0.3
0.2
0.1
0.0
Fig. 7.3 Gray matter density significantly varies as a function of development, with latter matura-
tion occurring in the prefrontal cortex in late adolescence (Adapted from Gogtay et al. (2004))
person is under “duress, old maladaptive organizing principles can reemerge,

reviving past negative, self-defeating experiences.” In essence, two-person relational
psychodynamic psychotherapy aims to provide a corrective emotional experience
(Alexander et al. 1946).
7.4 Structures and Networks in Two-Person Relational

Psychotherapy
Anterior Cingulate Cortex
The cingulate cortex forms the superior boundary of the limbic system and over-
lies the corpus callosum from the rostrum to the splenium (Devinsky et al. 1995)
and is functionally and anatomically divided into several regions—anterior, mid,
and posterior—which have been further divided (Fig. 7.4). The anterior cingulate
cortex subserves the dual processing of cognitive and emotional information, as
well as the functional integration of these two streams (Allman et al. 2001;
Yamasaki et al. 2002). fMRI studies of this region in anxious youth have revealed
increased activation of this region during the viewing of fearful faces (McClure
et al. 2007), and activation in this region correlates with amygdala and
7.4 Structures and Networks in Two-Person Relational Psychotherapy 195
Fig. 7.4 The cingulate

cortex, shown in this cortical
reconstruction, forms the
superior boundary of the
limbic system and is
comprised of several distinct
subregions, including the
subgenual and pregenual
anterior cingulate (light
purple) as well as the dorsal
anterior cingulate (red)
Fig. 7.5 The ventromedial

prefrontal cortex (vMPFC,
yellow) is shown in this
cortical reconstruction
ventrolateral prefrontal cortex activation in anxious children and adolescents

(McClure et al. 2007). Importantly, the anterior cingulate cortex is functionally
connected with a concert of other structures that collectively orchestrate relational
processes (Fig. 7.5).
Medial Prefrontal Cortex
The medial prefrontal cortex (Fig. 7.5) is distinct in that, unlike the anterior cingu-
late or amygdala, it is large and comprised of multiple gyri, including the middle
frontal gyrus, inferior frontal gyrus, orbital gyri, etc. This structure is consistently
implicated in functional neuroimaging studies of social relatedness, social decision
making (Lin et al. 2012), empathy, and anticipation of social engagement. Moreover,
it has been suggested that the medial prefrontal cortex is “an action-outcome predic-
tor concerned with learning and predicting the likelihood of outcomes associated
with actions” (Alexander and Brown 2011). Additionally, this structure is connected
DLPFC
Hippocampus
Subgenual Dorsal
ACC ACC
Thalamus (MD)
Amygdala Ventral Striatum
Hypothalamus Sympathetic
Nervous
System VLPFC
Emotion Attention-
Cognition
Fig. 7.6 The neurocircuitry of relational processing. The neurocircuitry of relational processing
is highly connected with the prefrontal network. ACC anterior cingulate cortex, VLPFC ventrolat-
eral prefrontal cortex, DLPFC dorsolateral prefrontal cortex. Dotted lines represent inhibitory
relationships
with other regions within the prefrontal cortex, as well as the amygdala, hippocampus,
cingulate cortex, and some posterior regions, including the precuneus and cuneus
(Fig. 7.6). Given the interconnectivity with other structures, the medial prefrontal
cortex is a key structure within the default mode network (see below).
The Amygdala
The amygdala resides deep within the limbic system and is principally responsible
for generating central fear responses. This bilateral structure is composed of multi-
ple nuclei that are reciprocally connected to the hypothalamus, hippocampus, and
neocortex. The amygdala gives rise to two major efferent projections: stria termina-
lis and ventral amygdalofugal pathways. The stria terminalis innervates the nucleus
accumbens and the hypothalamus, whereas the ventral amygdalofugal pathway
innervates the medial thalamus and anterior cingulate cortex. In general, most but
not all functional neuroimaging studies have demonstrated increased amygdala
activity in adolescents with a myriad of psychiatric disorders and traits, including
anxiety (Strawn et al. 2014). It is noteworthy that this structure appears to not only
be functionally hyperactiviated in children and adolescents with anxiety disorders
but also those who are anxious in situations involving uncertainty and, in particular,
the intolerance of uncertainty, particularly with regard to relational phenomena.
7.4 Structures and Networks in Two-Person Relational Psychotherapy 197
Fig. 7.7 The precuneus

(light blue) and cuneus
(orange), shown in this
cortical reconstruction, are
contiguous structures which
are frequently implicated in
self-referential and self-
versus-other tasks
Fig. 7.8 Intrinsic

connectivity network data
from an adolescent utilizing
ICA components that were
best matched to templates,
respectively, using spatial
correlation (Image courtesy
of James Eliassen, PhD,
University of Cincinnati,
Center for Imaging Research)
The Default Mode Network
The default mode network consists of a number of connected structures, including

the medial temporal cortex, the medial prefrontal cortex, the posterior cingulate
cortex, the precuneus (Fig. 7.7), and the parietal cortex. It has recently been defined
based on resting-state connectivity observations from independent component
analysis (Beckmann et al. 2005; Schopf et al. 2010; van den Heuvel and Hulshoff
Pol 2010) (Fig. 7.8). This network is preferentially activated during “internal” tasks
(e.g., daydreaming, anticipation of the future, memory retrieval, and when
imagining another’s experience or perspective).
Of particular relevance to implicit relational knowing, the default mode network

may be responsible for generating spontaneous thoughts and linking experiences,
and it includes many of the same structures and regions that are implicated
in temperament, attachment, and mentalization (see below). Additionally, this
network—in particular the medial prefrontal cortex (Fig. 7.3)—subserves the
“social understanding” of others, and the functioning of this complex relational
process is subserved by a number of subregions within the medial prefrontal cortex.
In this regard, Li et al. (2014) have noted that these subregions of the medial pre-
frontal cortex participate in disparate processes as a function of their subsystem
role within the default mode network. First, the ventromedial prefrontal cortex con-
nects with other regions subserving emotional processing that are engaged during
social interactions. Second, the anterior medial prefrontal cortex, along with other
medial cortical structures, is highly connected to the cingulate cortex (both anteri-
orly and posteriorly), and this connection appears to subserve self- (with regard to
other) distinctions. Third, the dorsomedial prefrontal cortex, along with connec-
tions to structures within the temporoparietal junction, appears to be activated dur-
ing the reading and understanding of another’s mental state. In a recent review of
the medial prefrontal cortex within the context of the default mode network, Li and
colleagues (2014) note that “as behaviors become more complex, the related
regions in frontal cortex are located [anatomically] higher…. This reflects the
transfer of information processing from automatic to cognitive processes with the
increase of the complexity of social interaction.” Given our current understanding
of the default mode network, this system appears to be critical for both social
reciprocity and implicit relational knowing—central tenet of relational
psychotherapy.
The Mirror Neuron System and Its Functional Neurophysiology
Without question, of the recent discoveries of neuroscience, the concept that has
had the most impact in the field of psychodynamic and other forms of psycho-
therapy is the mirror neuron system. While knowledge of this system originates
from intracerebral recordings from lower primates, the system has been hypothe-
sized to exist in humans. The early primate studies suggest that neurons within the
inferior parietal lobule and inferior frontal cortex are activated when an animal
observes another individual perform a specific action and are similarly activated
when the individual is performing the same action. While the existence of this
system in humans is somewhat controversial and limited direct data are available
regarding humans, should such a system exist in humans, it would be of critical
importance in two-person relational psychotherapy. In this regard, Rizzolatti and
Craighero (2004) eloquently capture the potential importance of this system with
regard to understanding other people: “Mirror neurons present the neural basis of
a mechanism that creates a direct link between the sender of the message its
receiver. Thanks to this mechanism, actions done by other individuals become
messages that are understood by an observer without any cognitive mediation.”
7.5 Genetics and Two-Person Relational Psychotherapy 199
Thus, the mirror neuron system represents key neural elements needed for the
understanding of the intentions of others. Additionally, recent data from transcra-
nial magnetic stimulation studies “indicate that a motor resonance system may
exist in humans and that it possesses important properties not observed monkeys,”
and the dysfunction of the mirror neuron system in humans may be an underlying
core deficit in autism, perhaps shedding light about the social isolation common
in persons with autistic spectrum disorders. Moreover, studies of mirror neuron
systems suggest that one participates in the intentional states of the other at a
neuronal level by activating the motor neurons corresponding to the intentional
actions observed in the other but without having to imitate the other’s actions
(Decety and Chaminade 2003).
It is important to note, however, that mirror neurons do not simply code the
actions of others but also their intentions (Iacoboni et al. 2005). In this regard, recent
fMRI studies demonstrate that areas presumed to represent human mirror neuron
areas (e.g., the inferior frontal cortex and superior parietal cortex) respond differ-
ently to the observation of the same grasping actions, and these reactions seem to be
embedded with recognition of the different contexts of the intentions associated
with the grasping actions, such as drinking or cleaning (Iacoboni et al. 2005). Thus,
the mirror neuron system may not only code the action (e.g., grasping) but also code
the intention associated with it (e.g., grasping to drink).
A corollary system to the mirror neuron system, related to language processing,
has also been described in lower animals. This system, the echo neuron system, may
in fact represent a subgroup of mirror neurons (Lotto et al. 2009); Rizzolatti and
Craighero (2004) suggest that the system may be activated “when an individual
listens to verbal stimuli, [and] there is an activation of the speech-related motor
centers.” Further, Zatorre (2013) notes “recent evidence indicates that individual
differences in anatomical and functional properties of the neural architecture also
affect learning and performance in these domains.” If additional evidence supports
this theory, it will likely have significant implications regarding the importance of
the tone and rhythm of the psychotherapist’s verbal communications to the child
and adolescent in psychotherapy.
7.5 Genetics and Two-Person Relational Psychotherapy
In the early 1990s, an explosion of developmental research in infants shook the

foundation of traditional one-person psychological approaches, and their impact
continues to reverberate. These studies have called for increased attention to be put
on the very early developmental factors—during the critical phases—that serve as
the foundation for development of the infant brain. Along with this has been
increased attention to genetic influences. To date, genetic studies have focused on
associations of specific polymorphisms with structural and functional neuroimaging
findings and have also explored the relationship between specific genes and tem-
peramental traits, with the latter largely relying on genome-wide association studies
(GWAS).
Neurochemistry and Two-Person Relational Processes
While we primarily focus on the neurostructural and neurofunctional factors that

influence the two-person relational concepts in this chapter, it is important to
remember that the brain is inherently “wet,” and as such, it is bathed in a number of
neurochemicals that affect both relational processes and the neural substrates of
these processes. In this regard, recent attention has focused on the “social hormone,”
oxytocin, a peptide hormone that was discovered and synthesized more than a half
century ago (Du Vigneaud et al. 1953). Data from lower animals suggest that oxy-
tocin is involved in affiliative and bonding actions. Similarly, in humans, intranasal
administration of oxytocin increases interpersonal trust (Kosfeld et al. 2005) and
increases gazing at the eye region of human faces (Guastella et al. 2008). Thus, the
clinical potential for oxytocin to promote pair bonding, maternal behavior, social
attunement, and socialization in certain psychiatric syndromes, including autism,
depression, and posttraumatic stress disorder (PTSD), has received considerable
attention.
One recent study of oxytocin that is of is of direct relevance to two-person in
two-person relational psychotherapy involved an examination of the synchrony of
maternal and paternal brain responses to infant cues. In this study of parents of 4- to
6-month-old infants, coordination of both maternal and paternal functional brain
activation in social–cognitive networks that had been previously implicated in
empathy and social cognition was observed when participants viewed their children
playing in a video. Interestingly, maternal amygdala activation correlates with oxy-
tocin concentrations. Taken together, these findings suggest that “social-cognitive
networks that support intuitive understanding of infant signals and planning of ade-
quate caregiving may be gender specific [and that]…synchrony in the brain response
of two individuals within an attachment relationship…develops within the matrix
of biological attunement and brain-to-brain synchrony between attachment part-
ners” (Atzil et al. 2012).
Neurostructural and Neurofunctional Basis of Temperament
Recent investigations of temperament have revealed both anatomical and func-

tional differences in a variety of structures, although these investigations have
often utilized broader dimensions of temperament than the classic four dimensions
as described by Thomas and Chess (1982). Specifically, many of these investiga-
tions have focused on inhibited temperament, “a tendency to avoid novelty,” which
is a risk factor for anxiety disorders and may be associated with anxious attach-
ment. Inhibited temperament is associated with increased amygdala activity when
subjects view unfamiliar and unexpected faces (Blackford et al. 2011), and it is
also associated with attenuated activity within the dorsal anterior cingulate cortex,
which suggests that, functionally, “enhanced amygdala sensitivity coupled with
weak inhibitory control from the dorsal anterior cingulate may form a neural cir-
cuit mediating behaviors characteristic of inhibited temperament” (Clauss et al.
7.5 Genetics and Two-Person Relational Psychotherapy 201
2011). Additionally, Blackford and colleagues recently examined the functional

connectivity of this amygdala–anterior cingulate circuit in individuals with inhib-
ited temperament and observed that increased inhibition was associated with
decreased connectivity within the default mode and dorsal attention networks and
increased connectivity in salience and executive control networks (Blackford et al.
2014). This finding is of particular relevance to two-person relational psychother-
apy in that the default mode network is intimately involved in self-referential
thought processes. Additionally, and of direct relevance to relational psychother-
apy, behavioral inhibition is also associated with group x time effects with regard
to amygdala activation. As such, Blackford and colleagues recently demonstrated
in young adults who were classified as having behavioral inhibition that habitua-
tion of both the amygdala and hippocampus varied as a function of temperament:
Youth with uninhibited temperament demonstrated habituation in both the amyg-
dala and hippocampus, whereas youth with inhibited temperament failed to habitu-
ate in terms of amygdala and hippocampus during repeated presentations of faces
(Blackford et al. 2013).
Finally, the temperamental trait of behavioral inhibition observed in young chil-
dren (<5 years of age) not only subtends relational and neurofunctional aspects of
an individual, but it is also associated with persistent structural differences that
appear to persist throughout development (Hill et al. 2010). In this regard, Hill and
colleagues have observed significant relationships between orbitofrontal cortex vol-
ume and markers of behavioral inhibition that were observed when subjects were
5 years old or younger. Specifically, when the behaviorally inhibited children were
reported to have spent more time proximal to their mother and greater time staring
at other children, larger amygdala volumes were observed during the adolescent
period (Hill et al. 2010).
The Neurocircuitry of Implicit Relational Knowing
Examinations of the neurocircuitry of implicit relational knowing have focused pri-

marily on the medial prefrontal cortex, as well as the cingulate cortex, precuneus,
and cuneus. Interestingly, different aspects of relational knowing appear to be sub-
served by subregions of these structures. In this regard, neuroimaging studies have
identified “intention detection centers” that are activated in a subject when he or she
observes behaviors in another that lead the subject to infer an intention (Ruby and
Decety 2001). Specifically, in a fMRI task that involved a first-person perspective
versus a third-person perspective, the right inferior parietal, precuneus, posterior
cingulate, and prefrontal cortex were activated, suggesting that these regions sub-
serve the detection of “self-produced actions” compared to those of others (Ruby
and Decety 2001).
In addition, work related to implicit relational knowing has employed the use of
a social feedback task in which individuals received and—of particular impor-
tance—anticipated social feedback. During the period of time they were awaiting
the social feedback, there was increased activity in the ventral striatum, a structure
Fig. 7.9 Decreased average cortical convexity (i.e., primary curvature) in the medial prefrontal
cortex in anxious adolescents, in whom anxious attachment patterns predominate (p < 0.05, Monte
Carlo corrected with 10,000 iterations)
that is generally implicated within the brain’s “reward circuitry” and also in the
dorsomedial prefrontal cortex. Moreover, individuals who tended to experience
rejection (i.e., had high scores on a rejection sensitivity) had greater responses in
both the striatum and the dorsomedial prefrontal cortex when they were expecting
positive responses (Powers et al. 2013). Needless to say, this has almost direct
relevance to clinical relational work.
Finally, at the extremes of social cognition (e.g., autism and DSM-5 anxiety
disorders), there have been interesting developments with regard to neurostructural
findings. A recent postmortem study (Stoner et al. 2014) suggests that differences in
cortical maturation between weeks 19 and 27 underlie social deficits observed in the
most severely relationally impairing disorders—the autism spectrum disorders.
Thus, it is quite likely that milder alterations in cortical maturation and migration, if
present, could result in more subtle alterations in relational capacity and attachment.
In this regard, we observed that in anxious adolescents—in whom anxious attach-
ment patterns predominate—cortical thickness in regions that have been linked with
anxious attachment and self-versus-other processing (e.g., medial prefrontal cortex)
exhibits increased cortical thickness and decreased primary cortical curvature
(Fig. 7.9) (Strawn et al. 2014).
Neuroscience of Reflective Functioning
The functional neuroimaging of mentalization has focused on a series of medial

structures, which are often implicated in “theory of mind” fMRI tasks as well.
Mitchell and colleagues (2006), using fMRI, observed that when individuals men-
talize about someone who is “similar” to themselves, ventral regions of the medial
prefrontal cortex are activated, and these activations are linked with self-referential
thoughts. By contrast, when individuals mentalize about someone who is dissimilar
from themselves, the dorsal regions of the medial prefrontal cortex are activated
(Mitchell et al. 2006). Interestingly, these findings suggest that the ventromedial
References 203
Fig. 7.10 The neurocircuitry

of relational processing
shown is in this cortical
reconstruction, including the
medial prefrontal cortex
(light blue), pre- and
subgenual anterior cingulate
cortex (periwinkle blue),
dorsal anterior cingulate
(red), and the precuneus and
cuneus (green and yellow,
respectively) (Adapted from
Strawn et al. (2014b))
prefrontal cortex (Fig. 7.5) preferentially subserves “using knowledge about oneself
to mentalize about others.”
The neurobiology of two-person relational psychotherapy is ultimately sub-
tended by a number of structures, including the amygdala, medial prefrontal cortex,
anterior cingulate cortex, precuneus, cuneus, and hippocampus. These structures,
which at least cortically are located in the midline (Fig. 7.10), coordinate with the
limbic networks and default mode networks to subserve social referencing, affective
attunement, and reflective functioning—the foundation processes of two-person
relational psychotherapy.
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Putting It All Together: The Four
Pillars of the Contemporary 8
Diagnostic Interview
Such is the wonder of the human condition; the emergence of

new ways of being together and new meaning in relation to the
world and to one’s self.
—Ed Tronick and Marjorie Beeghly
The modern child and adolescent psychiatrist is well trained, familiar, and
comfortable with the use of the structured DSM-5 (Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition, APA 2013) interview style. In some
contexts, an even more structured interview may be desired, and several well-
validated tools are available to achieve this, including the Mini International
Neuropsychiatric Interview for Children and Adolescents (MINI-KID) and the
Schedule for Affective Disorders and Schizophrenia for School Aged Children:
Present and Lifetime Version (K-SADS-PL), which have both been demonstrated to
have high levels of interrater and test–retest reliability (Sheehan et al. 2010;
Kaufman et al. 1997). Thus, our assertion is not that these methods are invalid or
unreliable; rather, they are somewhat limited when seen within the context of a
contemporary two-person relational psychology model in understanding human
behavior and psychopathology.
In our experience, the well-worn biopsychosocial model of diagnostic formulation
is an uneasy trinity of disparate disciplines (Engel 1980). As commonly practiced,
each of these domains is derived from a different historical origin and maintains its
own set of beliefs. Given these inherent differences, the limited capacity for true
integration becomes apparent. However, by substituting the traditional one-person
model with the contemporary two-person relational approach, we have fundamen-
tally transformed the biopsychosocial model by bringing harmony within its ranks.
Considering that two-person relational psychology was developed over the last cen-
tury hand in hand with advancements in the fields of genetics, attachment theory,
developmental research, neuroscience, and social and cognitive sciences, it is

DOI 10.1007/978-3-642-40520-4_8
208 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview
natural that the standard diagnostic interview needed to be revised into a more
flexible and comprehensive approach.
We have structured this chapter with the goal of helping the child and adolescent
psychiatrist in training, the newly minted, or the experienced clinician learn how to
use the two-person relational contemporary diagnostic interview model. This inter-
view model provides an integrated developmental approach (biopsychosocial) in
understanding children or adolescents, which can help develop realistic and practi-
cal treatment recommendations. The integrated interview is intended to be helpful
in any setting and not limited to the evaluation of a child’s or adolescent’s readiness
for psychotherapy.
8.1 Contrast of the Contemporary Diagnostic Interview

(CDI) to a Traditional Diagnostic Interview
The goal of any diagnostic interview is to help the child and adolescent psychiatrist
or trainee tailor the treatment approaches that best suit the patient and ideally take a
biological, psychological, and social integrated approach (McConville and Delgado
2006).
The child and adolescent psychiatrist traditionally asks the child, adolescent,
and/or their parents to share the history of their present illness, with a timeline that
establishes when they first noticed the symptoms, the frequency of symptoms, and
variations in the intensity of symptoms over time, along with precipitating and per-
petuating factors. Over the course of a traditional psychiatric evaluation, the child
and adolescent psychiatrist or clinician may quickly become focused on elucidating
risk factors, identifying predictors of treatment response, and determining which
“symptoms” meet threshold criteria for a disorder. Thus, with the standard use of
the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5,
APA 2013), the diagnosis is based on a collection of signs and symptoms that have
been well defined. The child and adolescent psychiatrist or clinician is charged with
incorporating the information obtained from the patient, his or her family, and also
other multiple sources (e.g., prior medical or psychiatric treatment records) into the
formulation of effective recommendations, whether psychotherapeutic or
psychopharmacological.
It is agreed that an integrated biological, psychological, and social interview
is valuable when assessing patients and developing well-thought-out treatment
plans (Delgado and Strawn 2014). However, it is generally agreed that child and
adolescent psychiatrists in training learn to switch interview and diagnostic
approaches rather than integrate them, as Cardoso Zoppe et al. (2009) state,
“There is still tension between biological and psychosocial tendencies.” They
further highlight that current teaching methods for trainees routinely lack
integration and are heavily influenced by the setting in which the patient is seen
(e.g., academic, local hospital, community mental health center) and their super-
visors’ school of thought (e.g., traditional one-person, psychopharmacologist,
behaviorist).
8.1 Contrast of the Contemporary Diagnostic Interview (CDI) 209
A 12-year-old male with poorly controlled bipolar disorder

A 12-year-old male with poorly controlled bipolar disorder has been
increasingly agitated at home and at school. In supervision, it is suggested that
the child and adolescent psychiatrist trainee consider increasing the dose of the
patient’s mood stabilizer. A few months later, in the same setting but with a
two-person relationally informed supervisor, the trainee shares that the child
has continued to respond poorly to the medication changes. Though a combi-
nation of two mood-stabilizing agents intended to treat a rapid-cycling bipolar
disorder was considered, the supervisor considers an alternative diagnostic for-
mulation. The possibility within the integrative model is that the child may
have cognitive weaknesses, which could explain his poor abilities for behav-
ioral self-regulation when asked to complete complex tasks (e.g., schoolwork,
homework, and chores); medications had been of limited value in these con-
texts. The supervisor asks if the trainee had inquired about whether the trou-
bling behaviors were also reported when the child was involved in simple
tasks, such as games with family and peers, or when engaged in sports. In fact,
there were differences, although the trainee had thought they were due to the
ebb and flow of a mood disorder and not suggestive of temperamental and
cognitive problems. Furthermore, the trainee shares that the patient had a psy-
chotherapist who described the child as difficult with a poor moral compass
and who asked the trainee to consider changing medications as the current “are
not working.” In short, the trainee and psychotherapist had not taken an inte-
grated developmental approach in their diagnostic formulation of the child.
From a biopsychosocial perspective, we propose that when an integrated devel-

opmental approach is used in developing a comprehensive diagnostic formulation,
as in the case of the 12-year-old boy described above, it facilitates the complex deci-
sion making needed to outline the sequencing of the interventions to ensure success-
ful outcomes. One might describe this approach as a grasp of the interplay between
the forces of nature and nurture (Table 8.1).
Table 8.1 The biopsychosocial model

Biological The biological information should include:
a history of present illness, past personal and family’s medical and psychiatric
history as well as the patient’s innate temperament style, developmental milestones,
and cognitive function.
Psychological The psychological data, when seen through a contemporary two-person relational
model of inquiry, includes:
psychological developmental milestones, internal working models of attachment,
cognitive flexibility, and implicit relational patterns observed during the back and
forth of the co-created subjective experiences between patient and the clinician.
Social The social component of the integrated approach assesses: observed attachment
patterns between patient and family, within the context of social norms influenced by
their cultural beliefs, values and rituals.
We are aware that the skeptic child and adolescent psychiatrist trainee would ask
whether a biopsychosocial developmental interview is useful or practical. Further,
some feel that the child and adolescent psychiatrist should practice at the top of their
license: the evaluation of a psychiatric DSM-5 diagnosis with pharmacological rec-
ommendations and a referral to an allied professional for psychosocial interventions
if considered appropriate (Drell 2007). The authors are frequently asked, “Isn’t a
detailed biopsychosocial evaluation needed only if we are going to recommend
individual or family therapy?” This could not be farther from the truth, when con-
sidering that an integrated approach provides the critical information needed in
designing treatment recommendations and gives insight about whether the patient
and family is likely to comply.
In using a traditional DSM-5 type of interview, generally the child and adolescent
psychiatrist’s diagnostic formulation is based on the assumption that the responses
by the patient and parents or caregivers are factual and accurate, unless due to
psychotic processes or developmental disabilities. Delgado and Strawn (2014) aptly
capture the limitations of the DSM-5-style interview in child and adolescent
psychiatry, namely, that it ignores the patient’s temperament, internal working
models of attachment, learning abilities or weaknesses, and cognitive flexibilities
within the backdrop of the family and of the social and cultural environment in
which they have lived. Herein, the careful assessment of the patient’s innate and
relational factors allows the child and adolescent psychiatrist or clinician to obtain
in a succinct manner critical information as to whether the responses provided are
actually factual and accurate and then use this information to tailor an effective
treatment regimen (Delgado and Strawn 2014).
Although attending to temperament, internal working models of attachment,
learning abilities or weaknesses, and cognitive flexibilities may initially seem like a
A 12-year-old male with poorly controlled bipolar disorder (continued)

As we continue the case of the 12-year-old child with bipolar disorder, the
agitation and behavioral problems were seemingly due to temperamental dif-
ficulties, insecure attachment style, and learning disabilities that contributed
to poor cognitive flexibility and suggest why medications were changed often
and with limited results. In knowing this, the trainee can begin to sequence the
interventions: This is done by requesting formal cognitive testing, beginning
wraparound in-home services, developing visual behavioral strategies at
school, and educating the family and teachers about having realistic expecta-
tions for the child.
daunting task for the child and adolescent psychiatrist or clinician, it avoids poly-
pharmacy and reduces the likelihood of serious side effects. We are not minimizing
the lifesaving experiences some children and adolescents can have with the appro-
priate use of medication; rather, we are cautioning about the tension between
8.2 Overview of the Contemporary Diagnostic Interview (CDI) 211
biological and psychosocial interventions that can be limiting to a child’s future

(Kaplan and Delgado 2006).
8.2 Overview of the Contemporary

Diagnostic Interview (CDI)
Although we have identified some of the weaknesses of the traditional DSM-5 struc-
tured interview model, our primary goal is to add and enhance the techniques avail-
able to the child and adolescent psychiatrist or clinician’s toolbox to improve the
diagnostic reliability needed. However, we would not expect many of the “tools” to
initially fit neatly into current clinical practice. The contemporary diagnostic inter-
view (CDI) is aimed at observing and interacting with patients and their parents or
caregivers, and it is designed to capture a different spectrum of information that is
inaccessible by the standard DSM-5-style interview. As with the adoption of any
new useful and practical technique, the initial challenge will be overcome through
careful study and frequent practice.
We have found that the CDI increases reliability, consistency, and accuracy in the
description of the signs and symptoms endorsed by children and their parents or
caregivers, allowing for the development of a comprehensive diagnostic formula-
tion, as well as a two-person relational psychodynamic formulation. Herein, we will
outline a “how to” guide to complete a detailed CDI for the reader to consider using
in his or her day-to-day clinical work.
In certain medical situations such as a stroke or a dangerous arrhythmia, we
would argue that all the evidence needed for an accurate diagnosis and assessment
are plainly visible. However, we would argue that neuroscience has demonstrated
that human behavior does not readily play by the same rules of the observable to the
plain eye. Human behavior is exquisitely contextual and is influenced by numerous
factors, including both internal and external cues. Thus, a traditional unilateral
approach may, despite the best intentions of the clinician, result in obscuring the
true nature of the psychological difficulties and thus prevent optimal treatment. In
contrast, we suggest that engaging in the complex process of understanding our
patients and their parents or associated caregivers requires the active participation
by the child and adolescent psychiatrist or clinician to create an atmosphere of
safety, curiosity, and exploratory inquiry of all participants’ subjective experiences,
which will result in a more accurate representation of the patient’s lifestyle and
concerns at hand.
To illustrate this point, we consider our colleagues in pediatric cardiology. The
astute reader may claim that any form of a psychiatric diagnostic interview is not
different than a pediatric cardiology evaluation, as they are both based on a collec-
tion of signs and symptoms that have been well defined. In fact, child and adoles-
cent psychiatrists, like pediatric cardiologists, have begun to use neurological
diagnostic tests, computerized testing, and laboratory tests with increasing fre-
quency. We propose that the difference lies in the moment in which the pediatric
cardiologist intently listens to the quiet perturbations of the heart with his
stethoscope on the chest of the young patient. In these few seconds, the pediatric
cardiologist integrates his or her own subjective sense of what the young patient
needs to feel safe as the pediatric cardiologist reaches for the patient’s chest
with exquisite sensitivity to the patient’s unique physiology, quietly responding
to what he or she hears and rapidly adjusting his or her attention and exam based
on this moment of cocreation. The pediatric cardiologist’s future actions are
tempered by the observable and the implicit feedback provided by the young
patient in the here-and-now moments during the examination. Here, we must
stress that this is not a “mystical” moment but rather one informed through the
unique clinical intuition about working with children that was acquired during
the cardiologist’s early childhood experiences as implicit relational patterns
stored in his or her implicit nondeclarative memory systems and also through
his or her subsequent rigorous training grounded in an in-depth understanding
of anatomy and physiology. Herein, in a recent study, pediatric cardiologists
could identify a pathologic heart condition using only their physical exam
nearly 92 % of the time (Mackie et al. 2009) even when they did not have access
to an electrocardiogram (routinely performed at most visits). Thus, there is both
an explicit and implicit comparison between the pediatric cardiologist’s and the
child and adolescent psychiatrist’s exam. The moments during the time a stetho-
scope is on the chest, the awareness and interpretation of these “moments of
meeting” (Chap. 5) shared by both parties are critical to any subsequent deci-
sion making. The child’s experience in the situation will influence their heart
rate and their willingness to cooperate. Scientific advancements have broadened
our understanding of the importance of nonverbal communication and implicit
nondeclarative memory when people interact with each other. For the pediatric
cardiologist, the lines are blurred between a verbal history and the telltale physi-
cal signs; both stories are provided by the young patient yet neither is sufficient.
We hope to demonstrate through the findings of modern developmental research
and neurosciences that the tried-and-true semistructured verbal interview is
only a narrow slice of the raw spectrum of data available to the child and ado-
lescent psychiatrist.
The Contemporary Diagnostic Interview

• The clinician provides an atmosphere of safety
• Approaching the patient and parents or caregivers with vitality
• The alliance: goodness of fit for mutual curiosity
• The clinician has an open frame of mind
The Four Pillars of the Contemporary Diagnostic Interview

• Temperament
• Cognition
• Internal working models of attachment (IWMA)
8.3 The Contemporary Diagnostic Interview 213
Putting It All Together: Diagnostic Formulation and Treatment Plan

• Two-person relational psychodynamic psychotherapy
• Cognitive and behavioral therapies
• Criteria for formal cognitive testing
• Criteria for pharmacological intervention
8.3 The Contemporary Diagnostic Interview
The goal of a contemporary diagnostic interview is to facilitate the expression of the

patient’s and his or her parent’s temperament, cognition, cognitive flexibility, and the
patterns of relating with each other and with others. The child and adolescent psychia-
trist’s or clinician’s initial approach is best received when all parties are included in
the interview. This allows for an initial in vivo subjective experience of how the patient
and family have “danced together.” This is heightened by the fact that a request for a
psychiatric evaluation of a family member places the system in a stressful situation.
The advancements in developmental research and neuroscience inform us that
many more people are implicitly present during the encounter than what appears. In
addition to the personality attributes of the child and/or adolescent and his or her fam-
ily, the child and adolescent psychiatrist also brings, through his personality, his or her
own set of early childhood implicit relational experiences. Thus, given our understand-
ing of internal working models of attachment, the interview room is actually crammed
by nonconscious neurological imprints of past and present from each individual.
We will now describe how the child and adolescent psychiatry trainees and expe-
rienced clinicians alike can effectively perform a contemporary diagnostic inter-
view (CDI). Thus, to effectively perform a CDI, the child and adolescent psychiatrist
or clinician will need to do the following simultaneously: (1) provide an atmosphere
of safety in which the patient and his or her parents realize that they are more than
a set of signs and symptoms to be fixed; (2) approach the patient and parents and/or
caregivers with vitality; (3) provide a genuine emotional alliance that allows for
mutual curiosity about each other’s subjectivities, including temperament, cogni-
tion, cognitive flexibility, and internal working models of attachment (IWMA) from
childhood experiences; and (4) begin the interview with an open frame of mind that
allows for the psychiatrist or clinician to respond intersubjectively and in a mean-
ingful way to the patient’s and his or her family’s subjectivities. As Buirski and
Haglund say, “There is no subjectivity without intersubjectivity” (2009).
The Clinician Provides an Atmosphere of Safety
Patients and families approach mental health appointments with a great deal of trep-
idation and anxiety. Without an effort to create an atmosphere of safety to reduce
their implicit anxiety, the information obtained will be filtered through their lens of
caution and thus will be partially true but not complete. We can implicitly help
patients and families feel safe if they subjectively experience that the psychiatrist or
clinician is considering them as a system that has lived together for many years
rather than as persons with symptoms. With practice, the clinician can initiate a
conversation with friendly and jovial joining comments about external attributes of
the patient and parents or caregivers to create an experience for them in which they
feel important as persons and not simply entities with signs and symptoms.
Approaching the Patient and Parents or Caregivers with Vitality
In our experience, approaching the patient and their parents or caregivers with vital-
ity as part of a CDI provides the child and adolescent psychiatrist or clinician the
opportunity to engage with an openness and willingness to be known as a person
that is interested in who the patient and their parents or caregivers are as both people
and members of a larger unit. There is one teaching metaphor that resonates across
demographics and captures the core principles of the CDI vitality: approaching the
patient and parents or caregivers as a young family member. We propose that the
contemporary approach to a patient and their parents or caregivers should be similar
to that of approaching a young family member (e.g., cousin, niece, or nephew).
When adult family members meet a young family member, and it occurs as a
welcoming and desirable moment (albeit with some anxiety), secure internal work-
ing models of attachment implicitly create a space of vitality that allows the young
child and parents to “figure out” how to successfully and emotionally attune to each
other. The adult family member’s active sense of curiosity allows the young child,
in the nonverbal realm, to search for social reciprocity and affective attunement with
the adults, which then become coded and stored in nondeclarative memory (Chap. 5).
The loving family members first learn to be like them (the young child) by synchro-
nizing their gaze and with rhythmicity matching the voice and body movements of
the young child. This facilitates the process of the young child recognizing the adult
family member as like me (the young child). Both sides can then begin to store each
other’s state of mind in nondeclarative memory (Meltzoff 2007, see Attending to the
external attributes of the patient, this chapter).
In using this as a metaphor for interacting with our patients, we encourage the
child and adolescent psychiatrist or clinician to set the open frame of mind neces-
sary to help create an atmosphere of curiosity, which facilitates the “figuring out”
process of the patient’s and their parents’ or caregivers’ capacity for curiosity of
others’ mental states. In doing so, the child and adolescent psychiatrist or clinician
will be in a position to know if the verbal discourse matches their nonverbal com-
munication, giving reliability to accuracy of the information disclosed.
The Alliance: Goodness of Fit for Mutual Curiosity
Studies on temperament recognize the importance in having a goodness of fit

between a child and his or her parents or caregivers for the child to develop self-
regulatory abilities and adaptive models of interactions with others effectively
(Huizink 2008). We propose that the concept of goodness of fit between patient (and
their parents or caregivers) and the child and adolescent psychiatrist or clinician is
equally important in a CDI. Exploring the patient’s and their parents’ or caregivers’
ability to be curious by being curious about them is essential. For example, a jovial
child and adolescent psychiatrist with an easy/flexible temperament will facilitate a
patient with generalized anxiety disorder to share details about their anxiety. This is
because the patient implicitly is reassured by the child psychiatrist’s manner that
they will be understood. Further, the jovial child and adolescent psychiatrist may
need to make a concerted effort in slowing their tempo—voice and rhythm of verbal
inquiry—when interviewing a child and family with a slow-to-warm-up tempera-
ment, as his jovial attitude may inhibit the patient if it is perceived as pressure to
talk. In contrast, we have seen occasions when child and adolescent psychiatrists
approach patients and their family in an overly professional and serious manner,
which does not allow for an atmosphere of safety and, in essence, limits the reli-
ability of the information shared by the patient and family.
The Clinician Has an Open Frame of Mind
In child and adolescent psychiatry textbooks, setting the frame of mind by the clini-
cian when interviewing the patient and parents is superficially described as the need
to be empathic in order to establish rapport. We have found extant literature about
the importance in setting the frame of mind in the child and adolescent psychiatrist
or clinician during an integrated developmental biological, psychological, and
social contemporary diagnostic interview process. We submit that the frame of
mind of the child and adolescent psychiatrist when preparing for a CDI is crucial for
gathering information. Setting the frame of mind is essential for creating an atmo-
sphere of safety for the patient and their parents or caregivers in order to increase
reliability, consistency, and accuracy in the description of the signs and symptoms
they endorse. We cannot emphasize enough that during a CDI, the child and adoles-
cent psychiatrist’s or clinician’s personal attributes and beliefs will undoubtedly
influence what and how the patient chooses to share in regard to the problems and
symptoms they endorse. The patients (and their parents or caregivers) will be non-
consciously and implicitly (see Chap. 3) looking for nonverbal cues and behaviors
by the clinician to learn about his or her frame of mind and authenticity when in the
room. The child and adolescent psychiatrist or clinician brings his or her own tem-
perament, cognitive flexibilities, internal working models of attachment, and
implicit relational knowing models formed in early childhood to the interaction (see
Chap. 5), which will contextually influence what the patient and his family feel
comfortable disclosing.
The reader may ask how the child and adolescent psychiatrist or clinician sets his
or her frame of mind to allow for bidirectional subjectivities to develop with the
patient and parents or caregivers that are conducive for the necessary relational
closeness. We define an open frame of mind as when the psychiatrist or clinician
meets the patient and their family without preconceived opinions about how patients
of certain ages should think and behave. The suspension of analytic thought allows
for bidirectional subjectivities to develop. Therefore, the clinician’s assumptions

and beliefs regarding what is generally considered normal developmentally will
need to be constrained as best as possible during the initial phase of the interview.
The clinician has an open frame of mind

A 16-year-old African-American adolescent female patient had a close rela-
tionship with both of her parents, in spite of their divorce two years prior.
What led to the evaluation was that when her father began to date another
woman, the patient began to feel unhappy and unmotivated about completing
her schoolwork. She felt that her father’s girlfriend was critical of the close-
ness she had with her father, “and my father would just let her criticize me.”
The child and adolescent psychiatrist intersubjectively experienced the patient
as being genuine and realistic about her current dilemma and stated in a jovial,
slightly humorous and somewhat sarcastic manner: “It sounds to me like your
father avoids getting in the middle, although he is the one who created the
dilemma. This leaves you and his girlfriend needing to figure it out. That
seems quite unfair. I think we need to ask your father to openly share that both
of you are important to him.” The patient, with excitement and appreciating
the sarcasm, responded: “Wow, that’s it. Kind of funny the way you said it. I
was letting his girlfriend win when I began to act like a stubborn kid, proving
I was immature. My dad set us up, he needs to know I can share him if he tells
his girlfriend how much I mean to him.”
The example shows that the clinician’s open frame of mind and authenticity helped
the patient reflect on the reasons for her anger and self-defeating behavior. The inter-
action was facilitated by the personal attributes of the clinician, who had experience
in working with adolescents from divorced families. He openly shared his view of the
dilemma and, in doing so, cocreated more adaptive ways for the patient to manage her
dilemma. The interaction may have had a very different outcome if the clinician had
preconceived opinions about the tumultuous conflicts adolescents have with their par-
ents after the parents’ divorce. It may have led the clinician to nonconsciously assume
that the patient was somewhat unrealistic, difficult, and demanding, which would
have prevented allowing the intersubjective experiences between patient and clinician
to guide the process. The clinician’s closed frame of mind may have led him or her to
suggest less adaptive solutions to the dilemma based on generalizations about the
adolescent’s problem, encourage the patient to limit her wish for closeness with her
father, ask the patient to address her father’s girlfriend directly, or hypothesize that the
patient’s unhappiness would be best managed with medication, to name a few.
Additionally, if the patient struggled with a nonverbal learning disorder or other cog-
nitive limitations, the description of her conflicts with her father may not have been
accurate and the clinician would have intersubjectively experienced the patient as
superficial and unable to view matters from her father’s vantage.
Herein, the child or adolescent psychiatrist or clinician, by having an open frame

of mind during the CDI interview process and regardless of the age of the child or
adolescent, can accept that there is no true objectivity without taking into account
the intersubjectivity cocreated by all involved.
The clinician’s initial preconceived notion and the importance of culture

A 14-year-old Asian-American adolescent male, who had a close relationship
with his parents, began to display oppositional behavior and refused to partici-
pate in family activities related to his parent’s Asian culture. He also declined to
continue with violin classes, which were important to his parents, who hoped it
would lead to a scholarship in music for college. His parents were reluctant to
seek psychiatric help, feeling it was a personal family matter. They finally were
forced to seek help for their son when he voiced having suicidal ideation to a
school counselor. The child and adolescent psychiatrist typically used a jovial
and humorous approach. He recognized that culturally his approach could be
experienced as disrespectful—unlike in his own culture—and set his frame of
mind to approach the family in a tempered manner to allow for the intersubjec-
tive experience to guide his approach. In meeting the patient and parents, he felt
intersubjectively that the family was not interested in his opinions; they believed
their son’s problems were foolish and requested the clinician to reiterate to their
son that he had to obey them as they had given him everything he needed to
pursue a college education. The patient stated in a sarcastic manner, “I am not
their cultural experiment. They do not understand me.” The clinician intersubjec-
tively initially noticed feeling like the parents; the adolescent was being abrasive
and unrealistic, a common view where it is thought that firm limit setting by
parents is needed. The clinician intersubjectively noticed a wish to step in for the
parents asking the patient to appreciate their efforts to educate him. In doing so,
the clinician recognized that his feelings stemmed from an implicit relational
pattern familiar in his family: “children should be seen and not heard.” With this
in mind, he recognized that he did not have an open mind, as he had precon-
ceived notions about what the family needed, which did not allow his intersub-
jective experiences to guide him. With this realization, he opened the
intersubjective field and was able to take the vantage point of the cultural dilem-
mas in both parties (the parents, Asian, and the patient, Asian-American). He
proceeded to say, “This must be difficult for all of you. As parents, you are cor-
rect in wanting to remain culturally loyal to your values and beliefs, and your son
is also correct on wanting to fit in his peers’ social and cultural environment.”
This allowed the parents to consider the possibility that their son’s oppositional
behavior was due to the fact that he was struggling with integrating the social and
cultural discrepancies in his life and was hoping for his parents’ understanding.
This example captures the potential difficulties that can be created when the
clinician has a preconceived opinion of the nature of the patient and family’s
situation. In this case, he had a preconceived notion that because the family was
Asian, their beliefs and values needed to be respected and adhered to. Fortunately,
in allowing the intersubjectivity cocreated with the adolescent to guide the pro-
cess, he recognized that his preconceptions were limiting his ability to help the
adolescent.
8.4 The Four Pillars of the Contemporary Diagnostic

Interview
Mental illness does not exist in a vacuum; it is a set of signs and symptoms that
affects a person within the context of their personality and their environment. The
treatment must be of the person and not only of their illness. The four pillars of a
CDI are essential for understanding a patient from the inside out. The authors define
the four pillars of a CDI as those that define a person’s unique personality within the
context of others. The four pillars are the synergy of innate and environmental pro-
cesses that become the blueprint of how a child learns to develop and maintain self-
regulatory abilities and unique implicit relational patterns to successfully interact
with others.
The first three pillars—temperament, cognition, and cognitive flexibility—form
the foundation of the fourth pillar, internal working models of attachment (IWMA).
By understanding the contribution from each of the pillars, the clinician will have a
true biopsychosocial understanding of the patient and their parents or caregivers, as
well as their needs.
Although many psychodynamic and attachment-theory-based texts pay limited
attention to temperament and cognitive functioning in forming personality, contem-
porary developmental research has demonstrated that an individual’s genetic
makeup is a determining factor in the formation of a personality, which some con-
sider the basis of the psychodynamic self (Mancia 2006).
We now will review each of the four pillars obtained during a CDI. The pillars
are outlined in the order in which they emerge in the psychological development of
a person. We note that when using a CDI, the four pillars are simultaneously
elucidated.
8.5 Temperament
Temperament refers to the “stable moods and behavior profiles observed in infancy
and early childhood” and came to the forefront in developmental psychology and
child psychiatry in the 1960s and 1970s (Chess et al. 1960). Thomas and Chess
(1999) are recognized for their landmark scientific contribution to the study of tem-
perament. Their seminal work has achieved general consensus in that its expression
has been consistent across situations and over time. In their study, Thomas and
Chess longitudinally evaluated 141 children over 22 years, from early childhood
until early adulthood (1982, 1986). Over the course of the evaluation, nine tempera-
ment traits became apparent.
8.5 Temperament 219
Temperament Traits Derived from Thomas et al. (1970)
• Activity level
• Rhythmicity or regularity
• Approach or withdrawal responses
• Adaptability to change
• Sensory threshold
• Intensity of reactions
• Mood
• Distractibility
• Persistence when faced with obstacles
The work of Thomas and Chess confirmed what the British psychoanalyst and
father of attachment theory, John Bowlby, MD (1907–1990), had hypothesized: A
child’s temperament influences how the child is experienced by their parents and sig-
nificantly shapes how the parents interact with the child (Bowlby 1999). This way of
thinking, where an active and bidirectional relationship exists between the child and
caregiver, represented a significant point of divergence from the previously accepted
understanding of the infant as a passive recipient and product of his or her environment
(Mahler 1974). In essence, the child was seen as a full contributor to the “goodness of
fit” (Thomas and Chess 1999) between the child and the parents or caregivers. The
issue of goodness of fit between patient, parents, and clinicians is often overlooked in
spite of it being one of the most significant factors that lead to successful evaluation
processes (see section “The clinician has an open frame of mind” this chapter).
Thomas et al. (1970) found that “some children with severe psychological prob-
lems had a family upbringing that did not differ essentially from the environment of
other children who developed no severe problems” and later added that “domineering
authoritarian handling by the parents might make one youngster anxious and submis-
sive and another defiant and antagonistic.” Thus, “theory and practice of psychiatry
must take into full account the individual and his uniqueness” (Thomas and
Chess 1977). Furthermore, it is important to note that temperament in infancy and
early childhood is influenced not only by heredity but also by environmental experi-
ences (Emde and Hewitt 2001). A review of the literature regarding child tempera-
ment reveals that much research has evolved in developmental psychology since the
early work of Thomas and Chess 30 years ago, although some controversies remain
(Kagan 2008, Rothbart and Bates 2006, Zentner and Bates 2008). In essence, the
matter of temperament is multifactorial—it involves genes, neurobiology, and the
individual’s capacity to interact with others in an acceptable manner—and “its regu-
lation is culturally dependent” (Paulussen-Hoogeboom et al. 2007).
Temperament Styles
In Thomas and Chess’ New York Longitudinal Study of 141 youth (Thomas and
Chess 1982), they described temperament as having four general styles; 45 % were
classified as “easy or flexible,” 15 % as “slow-to-warm-up,” 10 % as “difficult or
feisty,” and 35 % as “mixed,” a combination of the three (Thomas and Chess 1999).
While this may not seem surprising, the knowledge of these temperament styles
may guide the child and adolescent psychiatrist or clinician in having realistic expec-
tations based on the understanding of how genetic and biological factors contribute
to the variability of a patient’s psychological responses to life events. When recog-
nized, certain clusters of temperament traits can be predictive. In a given situation,
for example, the combination of negative mood, high intensity, irregularity, and slow
adaptability might point to a “difficult” child who is likely to have and cause prob-
lems during their life and who may have difficulties with a two-person relational
psychotherapeutic approach and may be best suited for behavioral approaches.
Conversely, those with a cluster of positive mood, positive approach, and high adapt-
ability usually can benefit from a two-person relational psychotherapeutic approach.
The Easy or Flexible Temperament Style
This style was found to be present in approximately 45 % of the children studied by

Thomas and Chess (1999). The child or adolescent with an easy or flexible tempera-
ment style typically has a history of being happy overall and not easily upset by
negative news or events. They typically can transition, with a display of healthy and
mild forms of anxiety, from conflicted situations to a positive stance and engage in
a cooperative approach with others. Generally, children with this type of tempera-
ment who have grown with secure internal working models of attachment do not
show up to our office unless an adverse life event occurs that creates disequilibrium
in their self-regulatory abilities or in their family system.
Jason was a 13-year-old adolescent who had an easy and flexible temperament and a secure
form of attachment. He had been doing well until the unexpected death of his father in a car
accident 1 month before his referral for psychotherapy. Although Jason was doing well in
school, his mother brought him to psychotherapy because “since his father died, his person-
ality has changed.” When the family learned of the father’s death, Jason began to wear his
father’s T-shirts to school, stating that “they help me keep going on.” Jason was of above-
average intelligence, empathic, and eager to talk about his feelings because “I know my
father’s death is bothering me” (Delgado 2008).
The Slow-to-Warm-Up Temperament Style
The child or adolescent with a slow-to-warm-up temperament style (present in 15 %

of the children studied) can quickly withdraw when faced with new and difficult
situations that involve complex issues with some degree of uncertainty. Children
and adolescents who present with anxiety and shyness may have the temperament
style conducive to two-person relational psychotherapy in which the psychothera-
pist learns to match intersubjectively the patient’s tempo of interaction, which
allows for an atmosphere of safety to cocreate healthy models for self-regulation.
Bobbie was a 5-year-old girl who was referred by her pediatrician due to severe constipa-
tion not due to a medical condition. A trial of laxatives, including mineral oil, were not only
8.5 Temperament 221
unsuccessful but also made her feel “embarrassed and sad; she would leak the mineral oil
all over herself and not have a bowel movement.”
Bobbie’s family was by all standards well adjusted and healthy. Bobbie was an intelligent
and shy girl who related well to her family. She demonstrated a slow-to-warm-up tempera-
ment, in that she feared playing with friends and preferred to stay close to home due to her
abdominal pain from constipation. Her slow-to-warm-up temperament was also evident in the
evaluation process. Bobbie began a two-person relational play therapy in a rather constricted
manner, as was expected. Over a short period of time, she felt comfortable with the psycho-
therapist and began to enjoy the vitality cocreated through their play. The new emotional
experience permitted her to develop healthier ways of managing her anxiety (Delgado 2008).
The Difficult or Feisty Temperament Style
The child or adolescent with the difficult or feisty temperament style (present in
10 % of the children studied) often avoids or refuses to interact with others unless
they can control the interaction. They often create distance when not feeling they
are in charge of the interaction and at times resort to aggression. This temperament
style is often thought of as being part of a continuum with disorganized internal
working models of attachment, and it is diagnostically thought of as having opposi-
tional defiant disorder (ODD) or disruptive mood dysregulation disorder (DMDD).
The child with difficult/feisty temperament style frequently behaves poorly in the
child and adolescent psychiatrist’s or clinician’s office and makes statements like, “I hate
being here. I am not going to cooperate; I don’t need this torture.” In approaching this
child, it will be important to determine the degree to which the difficult/feisty tempera-
ment style is typical or if this reflects the child’s fear and anxiety attributable to the evalu-
ation process. This can be achieved through a here-and-now intersubjective experience.
Ernie, a 5-year-old boy, had persistent behavioral patterns with an angry and irritable mood.
He was also argumentative and displayed defiant behavior toward authority figures. He was
expelled from two day care centers due to the intensity of his negative behavior toward oth-
ers. When redirected or when limits were set, he would yell and blame the day care provid-
ers for being angry at him. His parents believed that the day care center children were
provoking their son and that the day care staff was instigating the difficulties because they
did not like their son. The parents and son viewed the world through the lens of a difficult/
feisty temperament and disorganized internal working models of interaction.
The Mixed Temperament Style
This style of temperament was observed in 35 % of subjects studied by Thomas and

Chess (1982) and, as the name implies, reflects that children and adolescents uti-
lized a mixture of the nine temperament traits that did not allow for a classification
into one of the three groups.
Mary was a well-adjusted and healthy 9-year-old girl. She was intelligent and related in an
easy/flexible manner with her family and peers, but she was slow-to-warm-up and anxious
around adults she did not know, including teachers and medical providers.
8.6 Cognition
The human brain is the center of the cognitive abilities that influence the emotional
and behavioral regulations within the social context. In understanding a patient, it
is important to take into account their cognitive abilities, particularly with regard
to the norms of their age and developmental milestones (see Appendix A). In rou-
tine practice, clinicians commonly perform a mental status examination and may
write a brief comment about the patient’s cognitive function (e.g., fund of knowl-
edge, logical process). Such an evaluation may be disadvantageous, though, as the
clinician may remain unaware that core cognitive capacities are the root of the
problem. The issue of cognition is multifaceted and should not be thought of as a
static finding. Cognition may be influenced by many factors during the life of a
child.
In a DSM-5-style interview, a patient’s “mental status” may be reported as “aver-
age intelligence.” This reduction would fail to capture the cognitive deficits in
receptive language that would likely place the patient in a below-average range for
reciprocal verbal exchanges. In short, when one embarks in clinical decision-
making, it is critical to assess the patient’s cognitive abilities. Not only can cognitive
strengths and weaknesses affect a patient’s ability to share personal experiences
with others, they can also significantly influence the patient’s understanding of oth-
ers’ intentions and states of mind. Children and adolescents need to view “the world
as a safe and predictable place and seeing oneself as a competent agent in that world
are important psychosocial resources for handling stress” (Turner and Roszell
1994). In extreme cases of bereavement, depression, or trauma, the patient may
present with what appears as severe cognitive deficits, and having access to a base-
line cognitive evaluation can help the clinician discover and appeal to the patient’s
innate strengths.
Cognitive Weakness and Learning Disorders
The authors wish to emphasize the importance in assessing the impact a learning
weakness or a formal learning disorder can have on how a clinician understands a
child or adolescent in a CDI. As Delgado et al. (2011) state: “Patients who present
with impairment in academic, cognitive, social, and vocational functioning might
be struggling with an unrecognized learning disorder. Ten percent of the US popula-
tion has some form of learning disability, and up to 40 % of those with learning
disorders may meet diagnostic criteria for a psychiatric disorder.” This will have
significant repercussions in how we understand the patient and the treatment recom-
mendations we make. Moreover, by some reports, 10 % of the general population
has learning weaknesses, and among this group, many have formal learning dis-
abilities (Altarac and Saroha 2007; Cooper et al. 2007).
Considering these statistics, it is not surprising that children and adolescents with
learning disorders or learning weaknesses may frequently be described by child and
8.6 Cognition 223
adolescent psychiatrists or clinicians as “difficult to connect with” or cause them to

say, “I am not sure about their motivation.” The intersubjective experience created
by this type of patient in the child and adolescent psychiatrist or clinician is of frus-
tration. The feelings of frustration may also occur in their family members, who
may not recognize that the poorness of fit is due to the patient’s cognitive limita-
tions. At times, the parents’ own cognitive deficits may prevent them from appreci-
ating their child’s struggles.
Delgado and Strawn (2014) illustrate this in a vignette: A learning-disabled
16-year-old girl who was admitted to a general pediatric inpatient unit for the
treatment and management of her diabetes shares that she was feeling over-
whelmed trying to manage her diabetes. The patient and her mother had usually
been agreeable to recommendations made by doctors, “even though sometimes
we have trouble understanding them.” They both feared being seen as difficult and
had withheld their problems with memory and verbal comprehension in order be
perceived as a pleasant and compliant family. Although they were “willing,” they
were not “able” to assume full responsibility with the treatment recommendations
made. When the social worker from the diabetic clinic was made aware of the
patient’s and mother’s learning problems, she was asked that the treatment recom-
mendations be shared in visual from. The social worker’s response—“We have
never approached matters this way”—was discouraging in that it suggested that in
subspecialty clinics, limited attention is generally given to cognitive skills, and
this may explain the frequent issues of noncompliance by children and adoles-
cents with chronic conditions.
It is mostly agreed that children like to attend school if it is an area of safety and
where they make progress cognitively, emotionally, and socially. There are many
children and adolescents with learning weaknesses that struggle with school and
present to our office in the form of school refusal, school phobia, and somatic com-
plaints depending on their age. Children and adolescents with learning weakness
typically use their fingers to count and recite the alphabet in song form, typical of
young children, to recall letters. They typically state that their favorite classes are
recess, gym, music, and art. Therefore, it is important that the clinician not conclude
that all forms of school refusal are due to psychological or family problems. Without
a careful assessment of cognition and cognitive flexibility, the treatment approaches
may further increase the child’s feeling of inadequacy and increase his or her school
avoidance. Thus, in these difficult situations, the family or clinician may benefit in
obtaining formal cognitive testing. In these situations, families who have a secure
attachment (see Chap. 5) are usually relieved to have concrete evidence of their
child’s relative strengths and limitations; once these strengths and limitations are
understood, their anxieties diminish. With cognitive testing results in hand, the cli-
nician can best tailor the treatment interventions and improve the child’s
self-esteem.
We are not advocating for the child and adolescent psychiatrist or clinician to
be proficient in interpreting cognitive testing results. Rather, it is essential to col-
laboratively work with skilled psychologists or educational specialists that can
help translate the results into clinically practical information (e.g., what behaviors
can be expected at home and school due to their cognitive limitations). We believe
that for a child or adolescent with cognitive weakness, to feel emotionally safe, an
individualized education plan (IEP) should be designed to be used at home by his
or her parents or caregivers. This plan will help parents know what realistic expec-
tations are and how to best provide the emotional and educational support they
need.
Assessing Cognition and Learning in a CDI
At this point, it is necessary to briefly outline some interventions we have found

helpful in using a CDI to tease out matters of cognition and learning in children and
adolescents.
The CDI conversation style of interviewing permits assessing whether the
patient and their parents or caregivers are able to give developmentally appropri-
ate responses or if their responses are poorly formulated due to cognitive weak-
nesses that have contributed to their feelings of being misunderstood or picked on
by others. When the child and adolescent psychiatrist or clinician notices that the
patient’s and/or the parents’ or caregivers’ conversations have poor sentence struc-
ture—syntax—it should alert to a few possibilities: a lack of education due to
socioeconomic or cultural barriers, cognitive limitation, and/or a learning disor-
der. As such, the clinician will be rewarded by continuing to use a conversational
CDI approach to tease out these factors in order to later be aware of the likelihood
that perhaps the signs and symptoms they endorse may not be accurate or reliable,
at which point collateral information is essential. Additionally, difficulties in
understanding basic humor or the flow of the conversation should also alert the
clinician to these issues. As such, information obtained through a structured inter-
view (e.g., K-SADS-PL) may provide inaccurate information and may explain
why some children and adolescents do not respond well to certain pharmacologi-
cal interventions.
There are several ways that a child and adolescent psychiatrist or clinician may
choose to assess cognitive abilities. This is best done using a conversational
approach, and to illustrate this, we will describe several inquiries that we have found
helpful. We start with the Mother’s Day conversation (May in the United States) and
a Super Bowl conversation (February in the United States), although this can be
tailored to the month in which the interviews takes place (e.g., if in June, a Father’s
Day conversation is appropriate). This line of inquiry can also be used during rele-
vant holidays (e.g., Thanksgiving, Christmas, New Year’s). As you read through the
examples, note the complex interplay as this approach to assessing cognition also
intertwines clues on a child’s early childhood experiences, social cognition, and
current relational sphere.
Mother’s Day Conversation

In the United States, during the month of May, it would be appropriate to explore
with a child over the age of 4 how their family will be celebrating Mother’s Day.
8.6 Cognition 225
Cognitive level Possible responses

Above average We are going to take her out to eat at her favorite restaurant and then go
visit her mother. She will like that. [Sense of pride]
Average I like my mother. I might make or buy something for her.
Below average When is it?
I don’t know? [Some frustration or lack of interest]
Learning disorder Not sure what my mother wants. When is it? [Puzzled]
Nonverbal LD Not sure what my mother wants. When is it? [Uncertain and
embarrassed]
Intellectual disability Is unable to understand, and the clinician will need to find a more
reasonable form of verbal interaction
Super Bowl Conversation

In the United States, during the month of February, it would be appropriate to won-
der with a child over the age of 7 who in their family will be watching the Super
Bowl, the country’s national championship professional football event. If over 12, it
would be appropriate to explore which team they think will win the game.
Who in your family watches the Super Bowl?
Above average I will watch the game with my friends, and my dad is going to watch it
at home with my family.
Average My dad and his friends.
Below average I don’t know. [Feeling frustrated with clinician]
Learning disorder I think my dad. [Conveys uncertainty on how to respond]
Nonverbal LD Responds with a topic vaguely connected to the Super Bowl
Intellectual Is unable to understand, and the clinician will need to find a more
disability reasonable form of verbal interaction
The clinician may follow this line of inquiry with:

Which team do you think will win?
Above average Clearly, [name of team] will win; they have a better defense, although the
other team has great offensive players.
Average I like both teams. [Patient wonders if he or she is correct in which teams
are playing]
Below average When is it? [Looking puzzled]
Who’s playing? [Feeling embarrassed]
I don’t know. [Indifferent to question and interviewer’s affect]
Learning disorder Not sure who’s playing. Not sure when it is.
[Displays a sense of failure, an experience he or she seems to be
familiar with]
Nonverbal LD Begins sharing their view of the game, and within a few sentences, they
changed topics and likely did not realize
Intellectual Is unable to understand, and the clinician will need to find a more
disability reasonable form of verbal interaction
Assessing Visual–Spatial Abilities
The importance in assessing visual–spatial abilities in children and adolescents has

not received the importance it deserves (Table 8.2). Children and adolescents with
deficits in this area will have difficulties in school performance and completing
chores, and they are frequently criticized by their parents and teachers. Visual–spa-
tial ability is having the capacity to understand and remember the position of objects
in relation to other objects and to themselves and is required to understand direc-
tional verbal descriptions. This ability is necessary to know where to find things
(e.g., one’s home), where things go, and how to get to places. Unfortunately, many
times these deficits are viewed by parents, caregivers, or teachers as stubbornness or
moodiness. This has implications on how the type of internal working models of
relating to others these children develop, as they typically feel criticized and fre-
quently are ridiculed. When knowing this, the child and adolescent psychiatrist or
clinician can have a better grasp on the reasons why the child or adolescent not only
struggles academically but also has chronic low self-esteem.
A question that the authors frequently use to assess an adolescent’s visual–spa-
tial abilities is asking for directions from the clinician’s office to their home. Often
the patient’s response reflects what their cognitive abilities or weaknesses are. For
example, they may not know which direction their home is, they may not be able to
remember landmarks near their home, or they may remember taking an interstate
highway but do not know which one. In the case of these responses, it becomes clear
that the child or adolescent has deficits in visual–spatial abilities, which will nega-
tively affect their school performance and their ability to complete chores. In com-
pleting a CDI, the child and adolescent psychiatrist or clinician may find themselves
unknowingly and intersubjectively feeling frustrated and giving many leading ques-
tions, in a rapid-fire manner, hoping the adolescent will eventually “get it right,” as
if the adolescent is withholding their ability to think clearly. It is through
Table 8.2 Brief assessments of visual–spatial abilities in youth
Preschool children Ability to replicate simple block designs or pictures.

Stack or spell their name with blocks.
Ability to play with LEGOS with ease.
Elementary school age youth Ability to draw the floor plan/layout of their room.
Capacity to enjoy simple magic tricks or illusions with
playing cards.
Ability to play Jenga, Uno, Connect Four.
Adolescents Knowledge of directions to their home from the

clinician’s office.
Ability to give details of landmarks near their home.
8.7 Assessing Cognitive Flexibility (Sense of Agency, Theory of Mind) 227
here-and-now moments that the child and adolescent psychiatrist or clinician will
understand the reasons the patient unknowingly and implicitly is familiar creating
accomplices in the form of critics or enablers due to their cognitive weakness. This
sadly reinforces the implicit relational pattern of feeling unwanted and
incompetent.
In younger populations, the lead author of this book makes use of simple magic
card illusions diagnostically, utilizing what he calls the “wow moments.” Once he
establishes an atmosphere of safety and feels there is goodness of fit with the patient
and family, he proceeds to show a magic card illusion. Generally, children with
above-average and average cognitive abilities and good visual–spatial abilities
appreciate the illusions and genuinely are surprised—the wow moment—and smile
with excitement and approval. For other children, the same card illusion is difficult
for them to appreciate due to cognitive or visual–spatial limitations, and they do not
seem to know what is unusual about what transpired. We encourage the child and
adolescent psychiatrist or clinician to develop his or her unique skills that can be
useful in a CDI for similar diagnostic testing.
Another activity that is appreciated by elementary school age children is drawing
in a small easel board. This permits the clinician to assess visual–spatial abilities in
asking the children to draw or copy certain structures (e.g., shapes, cars, and a
house).
We remind the reader that the responses not only reflect the patient’s cognitive
level of functioning, but they are also influenced by the patient’s temperament, cog-
nition, and internal working models of attachment. Herein, the clinician will need to
allow the interaction to unfold so as to have the necessary intersubjective experi-
ences that allow him or her to use the CDI Case Formulation tool (see Appendix B)
based on here-and-now experiences between patient (and their parents or caregiv-
ers) and clinician.
8.7 Assessing Cognitive Flexibility (Sense of Agency, Theory

of Mind)
As part of any evaluation of a patient’s cognitive function, the capacity for cognitive
flexibility—also referred as social cognition, sense of agency, and theory of mind—
should be assessed. Cognitive flexibility encompasses the aspects of cognition that
allow the individual to psychologically approach situations with a degree of open-
ness about the fact that their experience is influenced by another person’s state of
mind and by the contextually, socially, and culturally appropriate norms, as well as
allow the individual to tolerate some degree of uncertainty (Delgado and Strawn
2014). At a minimum, the child and adolescent psychiatrist or clinician should
assess whether the patient has the ability to interpret the intent of others.
Cognitive flexibility involves several components: executive function, attention,
working memory, and emotion regulation (Johnson 2009; Schmeichel et al. 2008).
An example of cognitive flexibility would be a child who reacts with glee when he
or she infers that it is acceptable to play with the toys in the clinician’s office because
they are available in an open bin. Cognitive flexibility precedes the development of
language skills that typically emerge from the ages of 2–5 years old (Blackwell
et al. 2009). In addition, cognitive flexibility permits people to expand their aware-
ness and to accept the idea that there can be multiple solutions to novel or unpredict-
able events. Needless to say, complex situations are best handled when appraised as
opportunities for growth rather than as personal threats.
Assessing cognitive flexibility can be done briefly during an integrated develop-
mental biological, psychological, and social approach, as in a CDI. The child and
adolescent psychiatrist or clinician can assess cognitive flexibility by asking the
patient to share their view of themselves, their life achievements and accomplish-
ments, and the importance of their relationship to their parents, siblings, and friends.
The child and adolescent psychiatrist or clinician will be better able to know whether
the patient and family system will have the cognitive flexibility needed to make use
of a two-person relational psychotherapeutic approach.
Cognitive Flexibility in Adolescents
How a child and adolescent psychiatrist can best communicate with an adolescent
will depend on the adolescent’s level of cognition and cognitive flexibility.
Assessment in adolescents is less complex than with younger children, in that in
terms of development, adolescents begin to have cognitive capacities similar to
those of adults in understanding themselves and their environment.
Brief Assessment of Cognitive Flexibility in Adolescents
• History of the patient’s preferred activities with others, including parents, friends,
and those they have dated.
• History about the patient’s birthday celebrations, favorite persons that attended,
and gifts received.
• Review achievements and accomplishments they feel proud of.
• History of favorite video games and music played. Favorite sports events attended.
• Review what they are hoping to achieve in the future.
Cognitive Flexibility in Preschool and Elementary School Age

Youth
Assessment of preschool and school-age children’s cognition and cognitive flexibility

for social reciprocity is complex in that it needs to take into account the norms of their
developmental stages (developmental milestones, Appendix A) and make use of age-
appropriate activities (e.g., drawing and coloring books, board or card games, reading).
As with any patient, particularly children, there is no one-size-fits-all approach.
In working with children, and at times adolescents with some cognitive limita-
tions, the child and adolescent psychiatrist or clinician may utilize a “time-tested”
projective technique often referred to as the “three wishes scenario.” In this fre-
quently employed technique, children are asked to imagine they find a magic genie’s
lamp, from which they release a genie who will grant them three wishes. The chil-
dren are encouraged to request whatever they hope for. In using this technique, the
clinician can assess their cognitive flexibility while avoiding the anxiety produced
by direct questioning. The patient’s responses may be concrete and limited, indicat-
ing the impoverished age-related imaginative life of a child with cognitive weakness
or formal intellectual disabilities.
Brief Assessment of Cognitive Flexibility in Preschool

and Elementary School-Age Youth
• Elicit the child’s recollection of prior birthday parties and favorite gifts
received.
• Ask who the child enjoyed having attend the birthday parties.
• Review the child’s achievements and accomplishments as well as other experi-
ences that have made him or her feel proud.
• Obtain a history of their favorite toys, games, video games, and movies.
• Use the common “projective technique” of asking the child, “What would you
ask for if a genie granted you three wishes?”
• Ask what they hope to be when they grow up.
Another activity that elementary school age children enjoy is drawing a rudimen-
tary family tree in a small easel board (with the help of the clinician). This conveys
the child’s cognitive flexibility within the context of others in the family, as well as
his view of his role in the family.
8.8 Internal Working Models of Attachment (IWMA)
As covered in Chap. 4, Bowlby’s internal working model of attachment serves as a

template when relating to others and is an important element to obtain in a
CDI. Given the central role they play in determining the patient’s ability to interact
with others, the four attachment styles warrant further discussion (Table 8.3). Of
note, the attachment styles can be used to guide the treatment interventions the child
and adolescent psychiatrist or clinician may choose to recommend. Research has
demonstrated that children can create cognitive–affective schemas of self and others
that direct subsequent behaviors during the interaction with the caregivers
(Bretherton and Munholland 1999).
A more detailed description regarding the impact a patient’s and their family’s
internal working models of attachment have in a psychotherapeutic process is
reviewed in more detail in Chaps. 10, 11, 12, and 13.
Table 8.3 Experiences implicitly and nonconsciously expected from others according to internal
working models of attachment (implicit relational knowing)
Attachment Style Experience of others Typical interaction with others

Secure I know and feel cared by my family Interacts well with parents and peers.
and friends. Is in sync with emotional states of others and
I know that when I need help, I can follows themes of conversations.
ask others to help me. Recognizes when to ask for help.
Insecure
Anxious My parents don’t like me because I Avoids initiating interactions.
worry all the time. Shares many somatic complaints and uses
these to avoid being in school or social
I do not think I am good enough. activities.
Prefers to be near parents.
I can’t please anybody.
Dismissive I am ignored by the adults in my life. Gives one word answers.
Demonstrates lack of interest in others
They always think I am a failure. activities or discussions.
Disorganized I will be yelled at. Demanding of age inappropriate privileges,
i.e. activities without supervision, late curfew,
Nobody loves me. smoking with parents, and use of weapons.
Secure Attachment
The first type of attachment, secure attachment, occurs when the infant is cared for
by a person who provides a sense of safety and reciprocity. The caregiver also
exhibits empathic affective attunement and helps the infant handle normal periods
of distress with actions such as holding, soothing with touch, rocking rhythmically,
or singing with a melodic voice. The child develops a coherent discourse over time;
values attachments, whether pleasant or temporarily unpleasant; and is able to pro-
vide others a sense of reciprocity. We revisit the example of the 13-year-old adoles-
cent previously discussed as having an easy/flexible temperament because it coveys
how, in the same conversation, matters of cognition and attachment were also
elucidated.
Secure Attachment and a Traumatic Event

Jason was a 13-year-old adolescent whose father died in a car accident
1 month before his referral for psychotherapy. Although Jason was doing well
in school, his mother worried because “since his father died, his personality
has changed; he has become the class clown at school.” Jason was of above-
average intelligence, empathic, and eager to talk about his feelings because “I
know my father’s death is bothering me” (Delgado 2008).
Jason had a coherent discourse of his life over time; valued attachments, whether
pleasant or temporarily unpleasant; and was able to demonstrate his skills in social
reciprocity with his psychotherapist. In addition, he also demonstrates good cogni-

tive flexibility in knowing that his father’s death “is bothering me.”
Ambivalent/Anxious Attachment
Ambivalent/anxious attachment is an insecure form of attachment that occurs when

the infant feels anxious because the caregiver is mostly available but persistently
displays worry, anxiety, and inconsistent parenting. The infant develops a pattern of
relationships with others based on superficiality. The ambivalent/anxious infant
grows to be a child or adolescent that wishes for closeness with others but who often
fails to convey his or her hope for social reciprocity. As a result, the child or adoles-
cent is frequently rejected, repeating the original pattern established with the care-
giver and increasing their anxiety.
Ambivalent/Anxious Attachment
Rachel, a 9-year-old girl, was referred for psychotherapy by her pediatrician
due to severe anxiety. The child and her mother were anxious during the CDI,
as the conversational style invited a closeness they were not comfortable with.
The clinician’s attempt to explore day-to-day activities of their life was
fraught with anxiety by both. When the clinician shifted to a more intellectual
approach, they became less anxious, although still with a great deal of trepida-
tion. The child remained close to her mother and declined to engage in playful
activities. When she was invited to respond verbally, her mother interrupted
and answered for her, outwardly asking the child if her answers were correct.
Rachel’s mother stated, “You can answer if you want,” although subjectively
preferred her not to.
Parents who have ambivalent/anxious attachment styles often seek help for their
children because they have implicitly created an inadequate view of their role as
parents. They hope to alleviate their children from the normal disruptions needed to
promote a successful sense of independence.
Avoidant/Dismissive Attachment
Avoidant/dismissive attachment is an insecure form of attachment that occurs when

the infant is in a state of constant fear due to the unpredictable availability of the
relationship with the caregiver and cannot develop a stable internal working model
of attachment (Bowlby 1999). As the infant grows, he or she shows a tendency
toward passivity and avoids the expression of affect with others to prevent feelings
of rejection and to protect against the psychological distress when being ignored.
The avoidant/dismissive infant as a child or adolescent develops patterns of self-

sufficiency and independence and consequently has difficulties experiencing close-
ness with others.
With this form of attachment style, the child and adolescent psychiatrist or clini-
cian in a CDI will intersubjectively experience working more than the patient and
their parents or caregivers in developing a bidirectional dialogue. The child and
adolescent psychiatrist or clinician may find that the patient is implicitly withhold-
ing any form of reciprocity and the clinician begins to nonconsciously ask many
questions and has little to show for his or her efforts at the end of the interview. In
essence the clinician has been dismissed.
Avoidant/Dismissive Attachment
Joey, an 8-year-old boy, had persistent behavioral patterns of becoming upset
and avoidant when asked to participate in group activities or play sports, in
spite of his wishes to be included. He approached the interview in a distant
manner and would display defiant behavior toward the clinician when asked
about his new glasses, nice T-shirt, etc. His parents were distant and looking
at their smartphones, occasionally giving the clinician one-word responses
and blaming others for thinking their son was being difficult. The clinician
intersubjectively experiences them as rejecting his efforts for reciprocity (e.g.,
their implicit relational knowing, avoidant/dismissive).
Parents who have avoidant/dismissive attachment styles often decline to seek

help for their children because they have implicitly created an inflated model of
themselves with little awareness of the need to change how they or their children
affect other people. Some consider this as an early precursor of narcissistic person-
ality disorders (Bardenstein 2009).
Disorganized Attachment
Disorganized attachment is an insecure form of attachment that occurs when the

infant experiences a lack of coherent attachment patterns from their caregivers
and relates with a poor sense of reciprocity. There is a common history of aban-
donment or trauma in these children, who grow to be frightened of commitment
and have significant vulnerabilities that prevent them from sustaining stable
relationships, causing a repeating cycle of their incoherent life discourse. They
seek accomplices of their internal models of interaction by arguing, yelling, and
being defiant, which they experience as familiar actions. As adolescents, they
are prone to trauma and dissociative experiences. Some authors believe this is
an early precursor of borderline personality disorders (Bleiberg 1994; Kernberg
1990).
Disorganized Attachment
Ernie, a 5-year-old boy, is described above in the context of a difficult or feisty
temperament style. He had persistent behavioral patterns with an angry and
irritable mood. He was also argumentative and displayed defiant behavior
toward authority figures. He was expelled from two day care centers due to
the intensity of his negative behavior toward others. His parents requested a
psychiatric evaluation for their son, and early in the appointment, they begin
yelling at their son for not responding to the CDI comments made by the clini-
cian. When the clinician attempted to redirect the child as he was attempting
to use the clinician’s computer, the child looked back to his parents as if hop-
ing for their support. His parents loudly said, “Ask him if it is OK to use his
computer,” showing little appreciation for the clinician’s efforts to redirect
their son by making comments that it was his space and that would not let him
use the computer.
Parent’s Negative Reaction to the Treatment Recommendation

The child and adolescent psychiatrist shared that the child would benefit from
behavioral forms of psychotherapy, to which the parents became upset and
then escalated, stating that they had come to the appointment for the child
psychiatrist to prescribe medication “to control his anger.” They implicitly
and outwardly demonstrated a disorganized pattern of attachment with poor
capacities for affective attunement and self-regulatory capacities. The disor-
ganized form of attachment implicitly contributed to the child’s repetition of
the relational patterns: arguing with others as the parents were with the clini-
cian. The clinician intersubjectively experienced the poorness of fit between
the child and his parents.
Emotional Availability and Time-Outs
A note on time-outs, the authors teach parents that time-outs are for children to have
a moment to reflect and self-regulate. We explain to parents that the goal of a time-
out is for the child to be successful in self-regulating. A time-out should not be
intended as punishment, which implicitly leads to further battles down the road.
During a time-out, the child needs help from the parent or caregiver to self-regulate,
which seldom happens. We are sure the reader has seen or heard of time-outs being
extended, by adding minutes, when the child is unable to calm down and self-
regulate. By this point, the parent subjectively feels the need to win the “battle” and
uses the angry tone of voice and attitude they were hoping to model how to avoid.
In the end, the time-out is not completed and both parties are upset. We encourage
the reader to help parents find a pleasant manner to help children self-regulate and
not to treat the child with firm and anxiety-producing limit setting. Herein, we
suggest that a time-out should be a minute or less (30–45 s), and parents should help
the child learn how to settle and calm down. When successful, the parent will ben-
efit from saying “god job” upon completion of the time-out. At the end of the time,
both child and parent will have stored in nondeclarative memory how to self-regu-
late, and at a later time, the child may ask the parent to help. As an example, a col-
league shared with us that after a phone call in which she was visibly upset at a
friend, her 3.5-year-old daughter says, “Mommy needs a time-out.” The young child
had stored in nondeclarative memory what was helpful to self-regulate and con-
veyed it in the pleasant manner she had remembered her mother had.
8.9 Putting It All Together: The Four Pillars

of a Contemporary Diagnostic Interview
Beginning the Interview
The CDI is not based on a standard format to be followed as is common in a

structured interview. The questions suggested are broad and intended to be of
help to child and adolescent psychiatrists and clinicians to discern, in the here-
and-now moments of subjectivity, the patient’s and their parents’ or caregivers’
temperament style, cognition, cognitive flexibility, and internal working models
of attachment. Additionally, the clinician will need to consciously delay the use
of questions of a DSM-5-style interview, as this line of questioning is implicitly
experienced by the patient and parents or caregivers as demonstrating a lack of
genuine interest in them as people and instead considering them as a set of signs
and symptoms.
The art in using a CDI is for the clinician to make a concerted effort to approach
the patient and their parents or caregivers in a manner that allows for their interac-
tional process to emerge. As such, the clinician will be rewarded by approaching the
patient in a similar fashion as to when he or she approaches an infant or a young
family member they have not met before (e.g., a niece or nephew, grandchild). The
clinician will benefit from approaching them with vitality and genuine interest as
demonstrated by the tone of voice—akin to a parent with good ability for affective
attunement—body movements, and affect used. The clinician does not have prior
knowledge of what temperament style the patient and their parents or caregivers
have nor of their cognitive abilities. Thus, options on how to begin the CDI are
plentiful. We use brief examples to clarify this approach.
The interview goes well when the clinician takes a conversational approach to
assess the four pillars. There will be plenty of time for a structured interview after
the clinician feels he or she has a genuine understanding of the patient and their
parents or caregivers. Initially, the conversational approach may seem nonproduc-
tive and may even lead to some fear of creating some closeness with the patient and
their parents or caregivers. Although when subjective closeness is cocreated, it
allows the clinician to use his or her intersubjective experience as a guide regarding
how the patient and family relate to each other and with others, how they view their
8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview 235
problems, and what would be helpful for them. Herein, the initial comments made
should have the goal of eliciting the four pillars of two-person relational psychol-
ogy, which is the foundation for understanding other people and helps discern
whether their view of the problems is reliable and accurate. Thus, the opening
10–15 min of the interview provides the clinician a window into the four pillars of
the subjects interviewed.
In using a CDI, a common concern trainees describe goes as such: “This approach
seems like a regular conversation; the patient might not know they are talking to a
doctor.” This alludes to the fact that the information provided by the patient may not
be clinically or diagnostically helpful. It is important to recognize that the child and
adolescent psychiatrist or clinician using a CDI will need to allow himself or herself
to be immersed in the patient’s and his or her family’s subjective world, formed in
the subjects’ early years—internal working models of attachment—with their non-
conscious set of rules on how to relate to and what to share with others. In other
words, the child and adolescent psychiatrist or clinician is in essence asked to per-
form two tasks at once: (1) maintain a genuine and friendly attitude to allow the
patient’s nonconscious relational working models to emerge in the here-and-now
interactions and (2) use his or her intersubjective experience with the patient’s com-
munications to understand them from the inside out, by temporarily experiencing
being “like them,” improving his diagnostic acumen, and tailoring realistic inte-
grated treatment recommendations.
The reader may wonder which are the most useful comments or questions to use
in a CDI. The initial comments and questions suggested to open the interview are
designed to be easily changed to fit the personal qualities of each clinician. We will
describe the initial comments that we have found to be helpful in opening the CDI,
and later we demonstrate how we used the information gathered to develop case
formulations and tailor the treatment recommendations.
It is detrimental to begin with open-ended questions about the reasons patients
or parents are seeking help, such as, “How can I help you?” “What brings you
here?” or “How do you understand your problem?” This style of questioning is
conducive in making the patient and their parents or caregivers feel broken rather
than people who are seeking help within the context of a larger system. The value
in joining and holding their anxieties before one delves into stressful aspects of
their life is that it facilitates increased reliability, consistency, and accuracy in the
description of the signs and symptoms they endorse (Delgado and Strawn 2014).
In teaching child and adolescent psychiatry trainees, we emphasize that as part of
initial CDIs, the first question or comment should not be the reason for coming to
the appointment.
In using a two-person relational model for a CDI, rather than asking questions in
the third-person style, it is best to begin with phrases like “I would like to know,” “I
wonder if,” etc., to help the patient and their parents or caregivers feel that the clini-
cian is part of the process and not only an observer; this style implicitly validates the
importance all members have during the interaction. This step involves more than
just being empathic and friendly; it is recognizing the contribution a clinician has on
how they experience the interview process, which will guide how it will unfold.
Attending to the External Attributes of the Patient

and Parents or Caregivers
The initial comment used during a CDI is helpful when it attends to the external
attributes of the patient and their parents or caregivers—shy, tired, appearing angry,
etc.—and the clinician’s subjective experience of them. If the patient and family
look tired, it is helpful for the clinician to openly acknowledge the experience. On
one occasion, a child’s parents shared that they had rushed to make it to the appoint-
ment on time as they lived 2 h away and had to leave early, which did not allow them
time to have breakfast. Without giving attention to nuances of human interaction,
their presentation may have easily been misconceived and inferred that “the family
looked depressed or cognitively slow.”
It is well received when the child and adolescent psychiatrist gives positive rec-
ognition to some of the outward attributes of the child, such as their age, height,
eyeglasses, clothing, backpacks, etc. In doing so, the psychiatrist can assess whether
the child feels safe interacting with others and also their capacity to cognitively be
able to understand the back-and-forth of a typical conversation, something that is
not captured in a symptom base interview.
Easy/Flexible Temperament, Good Cognitive Flexibility, and Secure

Attachment
Clinician: Good morning. I am Dr. Jones. Please come in. [Tone of voice and
body movements demonstrate excitement and vitality of the encounter]
Clinician: [While walking to the office] I really like those eyeglasses, they
look good on you. [To the patient]
Patient: Thanks, I’ve had them a long time. [Smiling and pleased to share the
information]
Clinician: I wonder who took you to buy them and who helped you chose the
frame. [Continues demonstrating excitement through tone of voice and
facial expressions]
Patient: My mother took me and I choose them myself. [Happy to share and
turns to look at her mother, and they implicitly attune (e.g., mother con-
firms by nodding in agreement)]
Clinician: Nice. Does anybody else in your home also wear glasses?
Patient: Yeah, my older brother and my mother. [Turning toward her smiling,
and by this moment, she is very engaged and at ease in the process]
In this brief interaction, we notice that the clinician has allowed the patient and
mother to demonstrate their implicit attuned relationship; the mother allows the child
to give details of the family and nonverbally supports and approves. Used clinically,
we see the emergence of what appears to be an easy and flexible temperament in both
(reciprocity of excitement), good cognition and cognitive flexibility (recalls details

and the affective state in which they occurred), and an implicit internal working model
of secure attachment between them. This exchange also provides the clinician the
ability to notice the ease in establishing a bidirectional here-and-now experience of
mutuality and subjectively noticing the likability of the patient and mother. This also
allows the clinician to know that the information obtained throughout the interview
will be accurate and reliable and that the patient and family will be able to follow
through with the treatment recommendations at the conclusion of the evaluation
process.
Difficult/Feisty Temperament, Limited Cognition, and Cognitive Flexibility and

Insecure Attachment
Clinician: Good morning. I am Dr. Jones. Please come in. [Tone of voice and
body movements demonstrate excitement and vitality of the encounter]
Clinician: [While walking to the office] I really like your T-shirt, nice logo.
[Tone of voice and body movements demonstrate excitement and vitality of
the encounter]
Patient: I don’t know what it is. [Unable to engage in affective reciprocity]
Clinician: I notice your hair is short. [Affectively implying “I like your short
hair”]
Patient: [Does not respond, appears not interested in engaging with the
clinician]
Clinician: I would like to know what you do for fun on weekends.
Patient: I am always grounded; my parents don’t let me do anything.
[Demonstrates anger]
Parents: You know why you’re grounded. You never do what we tell you to do,
and you break things. [Raising their voice and implying that he is a bad
child]
Patient: Whatever, you guys are stupid. [They engage with the same implicit
relational knowing model]
Clinician: Wow, looks like we have some work to do here. [Subjectively feels
that they genuinely do not have the ability for implicit recognition of the
clinician’s attempt to use nonverbal communication of excitement and
notes that they rely on established insecure internal working models of
attachment, likely due to difficult/feisty temperaments, limited cognition,
and limited cognitive flexibly]
Parents: He always has bad mood swings, anger issues, and doesn’t do his
homework. [Continue blaming and using similar interactive patterns the
child uses—implicit relational knowing]
Patient: I hate school; nobody helps me. I need you guys to get off my
back.
In this brief interaction, we notice that the clinician has allowed the patient and
parents to demonstrate their implicit style of interaction: The parents berate their
child in front of the clinician and do not have a spirit of inquiry as to the reasons
why he may be difficult. Used clinically, we see the emergence of a feisty or diffi-
cult temperament style in all family members, average to below-average cognition
and cognitive flexibility (sentence structure is limited to a few words), and a lack of
understanding that their negative interactions in the presence of the clinician implic-
itly reveal their inability to view the other person as helpful (internal working model
of insecure attachment among them). This exchange also allows the clinician to
notice the inability to establish a bidirectional here-and-now sense of mutuality, and
he subjectively notices the dismissive and disorganized nature of their interactions.
This permits knowing that the information obtained throughout the interview will
likely be inaccurate and not reliable, giving more importance to the need for col-
lateral information.
An alternative way of opening a conversation is by making a comment about the
child’s name and wondering if they know how their name was chosen and whether
they like their name. This approach helps in several contexts; it allows the patient to
feel recognized as important, it gives context to their experience within their family,
and it provides the opportunity to assess whether the patient is able to respond with
depth and details or in a cognitively limited manner.
An engaging 6-year-old girl

A 6-year-old girl was seen for possible separation anxiety disorder, as she had
been crying when being taken to school, although her teachers shared that
once she arrived, she stopped crying and adjusted well to school activities and
peers. The child psychiatrist approached the child in a jovial manner and
stated that he liked her name, Madison, and wondered if she liked it. She
cheered up and said that her parents choose the name and that she liked it
because “it is fun to say.” The child psychiatrist proceeded to wonder if she
liked to write her name at school. She replied that she liked writing her name
at the top of all her assignments and that she liked her teacher, who was very
funny and polite. During the interaction, her parents nonverbally supported
her and encouraged her to feel free to engage in a conversation with the
clinician.
In this vignette, the child psychiatrist intersubjectively quickly experiences the

child as very likeable, engaging, and easy to affectively attune with. The patient also
demonstrates secure internal working models of attachment, with above-average
cognitive and affective skills. During the dialogue, he also finds her parents to be
supportive of their child’s relational efforts with the child psychiatrist. In this quick
conversational approach, the child psychiatrist has been able to assess many
elements of the CDI, and after a few more comments about her personal attributes
(e.g., color of hair, height), he continues to have the same subjective experience of
her not having any developmental interference in her cognitive and psychological
growth. The clinician intersubjectively recognizes the likelihood of a formal separa-
tion anxiety disorder and proceeds with a DSM-5-style structured interview to
assess the severity and tailor the treatment: cognitive behavioral and/or a
pharmacological.
Furthermore, it is important to gauge how adolescents respond when the child
and adolescent psychiatrist or clinician uses a jovial and empathic approach, as not
all will appreciate this approach, instead finding it to be an experience of “too close
too soon.” In attending to the intersubjective experiences, the child and adolescent
psychiatrist or clinician may say, “I sometimes think that teenagers feel comfortable
when I try to share my excitement in doing my work, and I forget that when I was a
teenager it was very difficult to talk with professional adults. I notice you seem cau-
tious, and I will need your help in knowing how you experience being here with
me.” This creates a moment of meeting, where the adolescent reads in the behavior
of the clinician his willingness to repair the disruption of their attunement (BCPSG
2010).
The adolescent that regulates affective states

A 16-year-old male sought help for his feelings of sadness after breaking up
with his girlfriend. By all standards, he was a successful adolescent; he helped
in his family’s landscaping business, did well in school, and had many good
friends. During a CDI, the child and adolescent psychiatrist or clinician stated,
“I see that you have a lot going on for you. I think that you now know that
having a girlfriend and later breaking up is very confusing and painful,” to
which he replied, with excitement of being understood, “Yeah, I love my par-
ents and sisters. I just don’t know why breaking up hurts so much.”
The adolescent that cannot regulate affective states

A 16-year-old female sought help for her feelings of sadness after breaking up
with her boyfriend. She presented in a parentified manner, stating that she
helped her father and stepmother take care of her young half sisters (ages 10
and 12) and that she thought that school was “a waste of time.” During a CDI,
the child and adolescent psychiatrist or clinician stated, “I see that you help
your parents a lot and they let you decide what to do with school and friends,
including your boyfriend.” She replied in a dismissive manner and with indif-
ference, “Yeah. As long as I help my parents they don’t care what I do. I am
Table 8.4 Example of familiar clinician’s subjective experiences in the intersubjective field dur-
ing a contemporary diagnostic interview (CDI), and how they can be used diagnostically
Psychotherapist subjective experience Diagnostic impression of patient/family
I have the urge to fix the patient’s problems. Limited cognitive flexibility
I do not feel I have the patience I typically do. Learning difficulties
I experience myself being a parent to the patient Anxious attachment
and wanting to give advice about what he or she Learning difficulties
should do to get along with others.
I am feeling bored; the patient continues to repeat Cognitive deficits
the same story and is not aware.
I experience the patient as dismissive of my Dismissive or disorganized internal
comments. working models of attachment
I would rather not interact with the patient as I feel
like a punching bag.
I feel I am a friend to the patient and parents. Secure or anxious internal working
models of attachment with possible
formal psychiatric disorder
really not that sad; they brought me to see you because I got mad when they
took my smartphone away. They thought I was suicidal. I was mad because I
wanted to text to a new guy I like.” She did not have the internal self-regulatory
tools to negotiate conflicts with her parents and resorted to extreme behaviors.
When the clinician is aware of an adolescent’s history of maladaptive behaviors

(e.g., hitting others, running away, use of drugs, shoplifting), it would be appropri-
ate to openly recognize having this information and wonder in an empathic manner
if it is correct, with the implicit “joining” message that it seems unlikely the infor-
mation is correct. This allows inquiring, in a noncritical manner, about the patient’s
cognition and implicit relational view of their world.
Once the clinician becomes familiar using a two-person relational approach, the
differences between a child’s responses if securely attached, with good cognitive
abilities, in contrast to a child that struggles with disorganized forms of attachment,
poor temperament, and cognitive weaknesses, will be evident. The second and third
comments or questions are influenced by the clinician’s intersubjective experience
with the patient’s responses to the first (Table 8.4).
Other Approaches
There are many ways of opening a CDI that allow for engaging with patient and
their parents or caregivers. We have shared some of our favorite approaches and
now provide the reader with a list of alternative comments that he or she may find
fit better with their personal attributes and of their patients (Table 8.5).
8.10 Diagnostic Formulation and Treatment Plan 241
Table 8.5 Examples of comments and questions that may be used when beginning a contempo-
rary diagnostic interview (CDI)
I really like your glasses, hair, backpack, smartphone, etc.
I wonder where you bought the [glasses, backpack, smartphone, clothing, etc.].
Do you remember who took you to buy [the item]?
You know, I feel better when I remember a funny or happy memory. I would like to hear one
of yours.
Who do you live with?
When is your birthday?
I wonder what you got on your last birthday.
Who bought the gift for you?
What do you want for your next birthday?
I wonder who your favorite person is.
I wonder what you like to play with your parents.
I wonder what you like to play with your friends.
I wonder what you do for fun after school.
Are you on any team?
Have you joined the Boy Scouts or Girl Scouts?
I wonder what your best friend is like.
Do your parents show love for each other?
I wonder if you remember your first boy-/girlfriend.
8.10 Diagnostic Formulation and Treatment Plan
Diagnostic Formulation
After the child and adolescent psychiatrist or clinician has intersubjectively eluci-
dated the patient’s and their parents’ or caregivers’ temperament, cognition, cogni-
tive flexibility, and internal working models of attachment, he or she can embark in
formalizing the diagnostic formulation and tailoring the treatment plan sequencing
for best outcomes. The integrated CDI has served as the foundation by which the
child and adolescent psychiatrist or clinician has identified the reliability of the
signs and symptoms endorsed and the likelihood of the patient and family to adhere
with treatment interventions recommended: psychotherapy, pharmacotherapy, or
request for formal cognitive testing (Fig. 8.1). As Adler-Tapia (2012) masterfully
captures, “To enhance treatment efficacy and improve the trajectory for children’s
lives, case conceptualization in child psychotherapy must integrate developmental
theory, neuroscience, and best practice models into clinical practice.”
With the use of the CDI Case Formulation tool (see Appendix B), the child and
adolescent psychiatrist or clinician will have a visual representation of the strengths
and weaknesses of the patient and family and can proceed to address the areas that
require intervention with the knowledge of what type of interaction would provide a
new and corrective emotional experience for the patient and family system in order to
develop healthier adaptive patterns of self-regulation and interaction with others.
Fig. 8.1 A contemporary Contemporary diagnostic interview (CDI)

diagnostic formulation
CDI formulation
Cognitive Attachment
Temperament Cognition
flexibility style
Formal psychiatric disorder
CDI treatment planning and interventions
Psychotherapy Cognitive testing Pharmacologic
Two-person Alternative therapies Best practices

relational (OT, PT, speech) based on
diagnosis
Cognitive Classroom
Accommodations
Behavioral Compliance
Parent training monitoring
Disclosure by the Child and Adolescent Psychiatrist or Clinician
In completing the CDI, we suggest that the child and adolescent psychiatrist or cli-
nician disclose his or her diagnostic formulation about what has been shared by the
patient and their parents or caregivers. This allows them to be the child and adoles-
cent psychiatrist’s or clinician’s consultant. It encourages them to give an opinion
about their problems and may shed light about their ultimate willingness to adhere
to the treatment recommendations.
We have noticed that in academic settings, some child and adolescent psychia-
trists and clinicians share the diagnostic formulation in a direct and paternalistic
approach. To a child they may say, “You need to obey your parents,” and to the
adolescent, “You need to make sure you stop [arguing, smoking marijuana, etc.].”
They may say to a parent, “You need to stop being critical of your child” or “You
need to be firm and give the child time-outs, a minute per age,” which is an eternity
for 3- to 5-year-olds. Needless to say, the paternalistic approach is implicitly famil-
iar to the child and their parents or caregivers who experience the clinician as stand-
ing in for critical persons of their past—nondeclarative memory—and dismiss the
suggestions. In contrast, generally child and adolescent psychiatrists or clinicians
who are actively practicing psychotherapy, in all its forms, have the innate tempera-
mental attributes and implicit relational models that help create an atmosphere of
safety for children and their parents or caregivers to engage in a process that facili-
tates the bidirectional approach to obtain the information needed to know how to
8.11 Treatment Planning 243
disclose an in-depth diagnostic formulation in a manner that allows for input from
the patient and family.
8.11 Treatment Planning
Psychotherapies
It would be beyond the scope of this book to review the many forms of psycho-
therapy that can be considered for children, adolescents, and their parents or care-
givers who present to our office with mental health and relational problems. Instead,
we will narrow our focus to the forms of psychotherapy that are most commonly
considered for children and adolescents.
Two-Person Relational Psychodynamic Psychotherapy
Patients that benefit from a two-person relational model of psychodynamic psycho-

therapy are those that have innate abilities for curiosity, exploration, cognitive flex-
ibility, novelty seeking, and creativity. Two-person relational forms of psychodynamic
psychotherapy are best suited for those with easy and flexible, slow-to-warm-up, or
mixed temperaments; above-average cognition; average or below-average intelli-
gence; good to fair cognitive flexibility; and internal working models of attachment
in the form of secure, anxious, or dismissive, assessed through a CDI intersubjec-
tively by the child and adolescent psychiatrist or clinician.
The reader may notice that we have intentionally excluded two-person relational
psychodynamic psychotherapy of children and adolescents that likely would benefit
from a behavioral approach. There are situations where the use of traditional or con-
temporary psychodynamic theories may be of limited assistance or, in some cases,
may be counterproductive, as in the case of children or adolescents who have signifi-
cant cognitive difficulties, severe learning disorders, or autistic spectrum disorders
(ASDs). While some may say that traditional one-person psychodynamic principles
also apply to these children and adolescents, we disagree in that the limitations and
impairments in social reciprocity, affect regulation, and/or mentalization have a neg-
ative impact on the patient’s awareness of others. Nevertheless, further longitudinal
research about the outcomes regarding children’s progress and the view from parents
is needed. We are aware that there have been some case reports in both traditional
one-person and two-person relational psychology where a psychodynamic approach
is used for children with autism and other developmental disabilities (Sherkow 2011;
Tustin 1988). In our opinion, these children and their families are best served by an
integrated biopsychosocial developmental and behavioral approach. The integrated
approach encourages active collaboration among all other disciplines that provide
services to help the child—developmental psychologists, occupational and speech
therapists, school base behavioral programs, etc.—in contrast to a psychodynamic
approach that may lead to further isolation during their formative years.
As a note, we have made it clear throughout this book that in a two-person

relational model, the characteristics of children who would benefit from psycho-
therapy are based in the integration of innate genetic, biological, and psychoso-
cial factors and that the intervention must occur at an implicit level without the
goal of insight through verbal communication. This approach is distinct from a
traditional one-person model that characterizes children who would benefit from
psychodynamic psychotherapy as those that have intrapsychic drive or object
relations conflicts that have led to their symptoms, conflict-free areas of func-
tioning, some awareness of their symptoms, a wish for change, the ability to use
metaphor, and some capacity for ambivalence, all of which require the capacity
to verbally understand what is learned in the psychotherapeutic process (Delgado
et al. 2012).
Cognitive and Behavioral Therapies
Typically, these forms of psychotherapy are appropriate for those with all forms
of temperament and cognitive abilities, although for the children or adolescents
with intellectual disabilities, as in autistic spectrum disorders, specialized behav-
ioral psychotherapeutic interventions are instrumental in helping them develop
skills needed to help with their integration to mainstream education and
socialization.
Criteria for Psychotherapies
In using Table 8.6, the child and adolescent psychiatrist or clinician can quickly
identify which forms of psychotherapy may be best suited for children and adoles-
cents when the four pillars of a CDI are considered as they tailor and sequence the
interventions according to the integrated approach.
Table 8.6 Visual guide matching contemporary diagnostic interview (CDI) with treatment options
Cognition Temperament Cognitive flexibility Internal working
models of attachment
Above average Easy/Flexible High Secure
Average Slow-to-warm-up Adequate Anxious
Below average Mixed Limited Dismissive
Intellectual or learning Difficult/Feisty Impaired Disorganized

disability
Green boxes indicate that two-person relational psychotherapy and cognitive approaches may be
considered as first choice. Red boxes suggest that the psychotherapist might consider behavioral
and pharmacologic approaches as first choice and may need formal cognitive testing
8.11 Treatment Planning 245
Formal Cognitive Testing
Although it is recognized that children and adolescents with below-average intelli-

gence and intellectual disabilities benefit from formal cognitive testing, for the two-
person relational psychotherapist, it is important to note that those with average or
above-average intelligence may also be struggling with weakness in cognition.
They may have cognitive weaknesses that can impact their social reciprocity, self-
esteem, and problem-solving skills and, at times, can lead to formal depressive
states. The children and adolescents who would benefit from formal cognitive test-
ing before embarking in a psychotherapeutic process include the gifted student in
math with deficits in receptive language, the pleasant child with good temperament
and secure forms of attachment who has dyslexia, the adolescent who is “streetwise
bright” but who struggles educationally (e.g., a nonverbal learning disorder), to
name a few.
Additionally, some cases that may require an integrated approach include chil-
dren or adolescents that display the following: innate or acquired cognitive weak-
ness or disabilities, temperamental difficulties, and limited cognitive flexibility that
has negatively shaped the patient’s and parents’ or caregivers’ internal working
models of attachment (implicit relational knowing, see Chap. 5) in maladaptive
ways. The treatment plan for these cases will require an integrated approach of all
of the parties involved—parents, psychotherapist, case managers, teachers, special
education specialists, troop leaders, etc. The interventions should be based on the
results from the information gained through formal cognitive tests. This allows for
the improvement of their fragile sense of self and prevents others from becoming
critics of or accomplices to the patient and family’s maladaptive patterns.
Criteria for Formal Cognitive Testing
identify which patients can benefit from a referral for formal cognitive testing.
Pharmacological Interventions
Children and adolescents who have a formal psychiatric illness will also have sig-
nificant self-regulatory (anxiety and mood) or behavioral (impulsivity and aggres-
sion) deficits that may benefit from the integration of pharmacological and
psychotherapeutic interventions tailored to be sequenced for best outcome. For
some, the use of medication is needed for the stabilization of their anxiety and mood
in parallel with providing education to their parents about what to expect during the
course of their child’s illness before a psychotherapeutic intervention can be intro-
duced. For others, providing education to the parents and engaging the child or
adolescent in a psychotherapeutic process can help them overcome the fears about
the use of medication. When the child and adolescent psychiatrist is also the
psychotherapist, he or she is in a unique position to provide both psychotherapy and

pharmacological interventions, with the added ability to monitor the benefits or
problems of each, rather than feeling that one is better than the other (Kaplan and
Delgado 2006).
Criteria for Pharmacological Interventions
identify the patients that may benefit from a formal pharmacological consultation as
part of the sequence of interventions in an integrated approach.
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Setting the Frame
9
Let us be grateful to the people who make us happy; they are

the charming gardeners who make our souls blossom.
—Marcel Proust
In this chapter, we discuss some of the everyday challenges facing the psychothera-
pist who embarks upon the regular practice of two-person relational psychodynamic
psychotherapy. By actively “setting the frame” for the patient and parents, a psycho-
therapist starts the psychotherapeutic process on a strong foundation. There is con-
sensus that in most forms of psychotherapy, the psychotherapist benefits by
providing an outline of what the patient and his or her family can expect once they
agree to participate. It is best to launch the psychotherapeutic process after the psy-
chotherapist sets the frame with the patient and their parents or caregivers so they
can have some predictability about what will occur during the process and avoid
having surprises when conflict arises.
Many of our practical suggestions, including those on confidentiality, compensa-
tion, and time, will be useful to clinicians of any psychodynamic persuasion.
However, as we will discuss, there are certain key contrasts between traditional one-
person and the two-person relational form of psychotherapy.
In traditional one-person psychotherapy, the frame is clearly set by certain prin-
ciples. The psychotherapist will attempt to preserve some form of neutrality, pro-
vide empathy judiciously, observe for inner conflicts of the patient (as well as those
present within the parents), attend for maladaptive defense mechanisms, and infer a
patient’s object relations through a child’s play or through verbal interactions in
adolescents. Further, frequently missed appointments are generally understood to
be a form of an unconscious resistance by the patient or parents.
For the two-person relational psychotherapist, matters are not as clearly defined.
The psychotherapeutic process occurs in the intersubjective field, a space that is
cocreated by all parties’ subjectivities (temperament, cognition, cognitive flexibility,

DOI 10.1007/978-3-642-40520-4_9
250 9 Setting the Frame
and implicit relation knowing), including the patient, the parents or caregivers, and
the psychotherapist. Each member brings a unique set of nonconscious internal
working relational models of attachment on how they implicitly chose to interact
with others. Thus, it is quite possible that when the same child and his family are seen
by two different relational psychotherapists, a different intersubjective field would be
cocreated as a result of the unique sets of temperament, internal working, and implicit
relational models of each. An inherent “sloppiness” forms as these intersubjective
experiences brush into each other (Chap. 5).
9.1 What to Expect from the Psychotherapist
The following section is intended to succinctly remind the reader of the role the
psychotherapist has within the psychotherapeutic relationship as envisioned by two-
person relational theory. Though a relational psychotherapist may strive to be
empathic, it is more important to recognize that the psychotherapist has a crucial
role in the development of the psychotherapeutic process itself. Rather than relying
on an approach that “discovers” the patient’s diagnosis or conflicts, the relational
psychotherapist must carefully attend to the intersubjectivities in the treatment rela-
tionship so as to cocreate interventions that account for the patient’s cognition, tem-
perament, and internal working models of attachment. That is, the inquiry occurs in
the form of mutual here-and-now interactions, which allows the psychotherapist to
know subjectively the patient’s and their family’s implicit relational models of relat-
ing. As an atmosphere of safety sets in, a mutual alliance is created, and new and
different information may then be available to the psychotherapist.
For example, there are psychotherapists that are natural at using humor with their
patients across a wide range of ages. They may be comfortable using a melodic tone
of voice, allowing for a here-and-now mutual subjective experience that facilitates
a new emotional experience to unfold in the psychotherapeutic process. Other psy-
chotherapists are less flexible and, although empathic, are somewhat more cautious
in their approach toward children, which may not initially provide the atmosphere
of safety needed by the patient.
The inquiry of maladaptive patterns is through the active participation by the
psychotherapist in the process. To give a broad example, when a family begins to
demonstrate conflict during their first appointment and the psychotherapist inter-
subjectively wants to step in and “join in the conflict,” this becomes a warning sign.
It reflects on how the family system nonconsciously seeks to elicit negative interac-
tions from each other, although the family unit outwardly hopes to stop the mal-
adaptive patterns of relating.
9.2 “Setting the Frame”: The Contemporary

Diagnostic Interview (CDI)
As we have stressed throughout this book, performing a contemporary diagnostic

interview (CDI, Chap. 8) does not necessarily imply a future commitment to begin
psychotherapy. Rather, the purpose of the diagnostic interview is to provide a critical
9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 251
form of psychiatric triage and to help guide the patient and family to the best possible
setting to fit their needs, which in some cases may not be regular psychotherapy.
We would recommend completing the CDI over the course of two or more
appointments if possible. In our experience, this allows the psychotherapist the nec-
essary time to learn about the patient’s and the family system’s strengths and weak-
nesses. Rather than depending on a verbal history or a review of medical records, the
relational psychotherapist must carefully examine the intersubjectivity, which will
yield knowledge about the internal working models of attachment and implicit rela-
tional knowing. With this information in hand, the psychotherapist can examine the
goodness of fit needed to work in a relational psychotherapy approach and embark
on the process of providing a new emotional experience in a safe atmosphere.
9.3 “Setting the Frame” in Two-Person

Relational Psychotherapy
After the decision has been made and agreed upon by all parties to start an ongoing
two-person relational psychodynamic psychotherapy process, it is important to
directly address some of the formalities of the treatment relationship.
Many patients and families, especially those who are in treatment for the first
time, may not understand the logistics of how psychotherapy works. These parents
may be more accustomed to regular doctor visits, such as with a pediatrician or even
a psychiatrist for medications, which are quite different in structure and function
than a course of psychotherapy. We have laid out important matters that should be
discussed with the family before entering into psychotherapy (Table 9.1).
Consent to Treat
We strongly encourage the child and adolescent psychiatrist and psychotherapist to

provide a written contract in the form of “consent to treat” for the patient and their
parents and/or legal caregiver to review and sign, which is then placed in the medi-
cal record. This contract should include, but is not limited to, language about the
risks and benefits of psychotherapy. Many of the logistical issues of treatment may
be spelled out in this document and discussed with the patient and family in an
organized fashion. Relying on verbal exchanges may lead to misunderstandings and
disrupt the overall psychotherapeutic process, which may be particularly frequent in
persons with temperamental difficulties, cognitive weaknesses, or disorganized
attachment styles.
The reader is strongly advised to have his or her personal attorney review any
legal document before he or she implements a binding document. There are a wide
variety of business practices among child and adolescent psychiatrists and psycho-
therapists that include differences in payments (e.g., self-pay, insurance), treatment
settings (e.g., academic, community based, private), and emergency availability.
There are also many state and local regulations and laws that govern certain institu-
tional settings, such as hospitals and mental health clinics, that are different than
those governing a private practitioner.
Table 9.1 Pragmatic aspects of “setting the frame”

Necessary discussions for Discussing communication
establishing a treatment Discussing the before psychotherapy is
relationship appointment frame initiated
Obtain consent/assent for Discuss frequency of Discuss frequency of telephone
treatment sessions, including the calls, when the patient should
frequency of parent expect return phone calls
sessions
Establish goals of treatment Discuss time demands Discuss voicemail procedure
with regard to
psychotherapy
Discuss fees and payment Review cancellation Discuss e-mail (and text
policy (e.g., fees for “no messaging, if applicable) with
shows”) regard to HIPAA compliance,
confidentiality, etc.
Assure confidentiality and Familiarize the patient Obtain consent for video
discuss situations in which with the office, including recording
confidentiality may not apply toys, etc.
(e.g., child abuse, suicidality)
Discuss medical records with Waiting room and Discuss electronic devices with
regard to disclosure etiquette regard to their use in the session
If medications are a component Discuss policies regarding Families as ambassadors for
of treatment, discuss frame “out-of-office” visits two-person relational
(e.g., refills) psychotherapy
Provide contact information Special situations
(see next column)
Goals of Treatment
After the CDI, the psychotherapist should be able to share his or her initial goals
with the patient and family and ask if the goals are consistent with their expecta-
tions. The most important goal of a two-person relational psychodynamic psycho-
therapy will be to provide the child or adolescent with the opportunity to develop a
healthier sense of self and more adaptive patterns of social reciprocity—ability to
love, play, and learn.
Working with Parents
In our experience, working with parents regularly is essential. We recommend that

the psychotherapist schedule appointments with the patients’ parents individually
after every three to four sessions with the child or adolescent. This provides the
parents or caregivers a sense of relief in knowing that they will have time to speak to
the psychotherapist after he or she has become more familiar with their child or
adolescent. In preparation for meeting with the parents, it is important to ask the
child what they think should be shared with the parents about their work together and
whether they have ideas about what the parents may be asking the psychotherapist.
Contemporary Contemporary Session with child

diagnostic interview I diagnostic interview II
Session with child

preparing
Parent session Session with child
psychotherapist to
meet with parents
Session sharing
with child topics
reviewed in Session with child Session with child
meeting with
parents
Fig. 9.1 Suggested course of two-person relational psychotherapy
Asking the patient to be a contributing participant in the parent session without being
present is a valuable model of the new adaptive ways of trusting others, which is
stored in the patient’s implicit nondeclarative memory. Then, after meeting with the
parents, it is helpful to review with the patient what had been discussed with the
parents (Fig. 9.1).
It is expected that some disagreements will occur among the patient and the par-
ents as a result of these meetings, and this will likely occur more frequently in fami-
lies that have poor internal working models of relating with others to begin with.
Their disagreements should be considered as an example that the process is begin-
ning to serve the cocreation of new adaptive ways of relating—communication
rather than isolation or distancing—that the psychotherapist has influenced.
Oftentimes, their disagreements are the result of their desire to collaborate in help-
ing to achieve the goals set out when the process began, although early in the pro-
cess they will continue to be influenced by maladaptive relational patterns.
Time
The matter of time is an important aspect of the psychotherapeutic process. It not

only involves the length of the appointment but also the frequency of the appoint-
ments. Typical appointments last about 50 min and are scheduled either once or
twice a week. The appointment length and frequency should be agreed upon jointly
by all parties. The patient and parents will appreciate knowing that they have a voice
in the decision-making process. In fact, there are occasions when a 25-min appoint-
ment is best, particularly for patients with severe forms of anxiety.
The matter of setting the time for the appointments is influenced by many factors
and should be addressed sensitively up front. We have intimately learned about the
importance of recognizing the difficulties for parents in managing time constraints,
especially if there is significant distance between the psychotherapist’s office, the
child’s school, and the parents’ place of employment. When the psychotherapist does
not have available appointment times that are convenient for the parents, an open
discussion may reveal the realities of the constraints—distance, employment con-
flicts, etc.—and it may be best to transfer the patient to a colleague with more flexi-
bility. Similarly, if the patient needs more than one session per week, this is also an
opportunity to consider a referral to colleague with a more convenient location, rather
than set the stage for financial hardship or missed appointments (e.g., risk of the
ubiquitous traffic problems in urban settings). For any patient in attendance during
the school day, it is good practice to work with the patient’s schedule to find a regular
meeting time, such as an activity period before lunch, to avoid academic conflicts.
Once the frequency and appointment times have been agreed upon, it is impor-
tant to review office policies involving late arrivals, cancellations, inclement weather
rules, and any dates on which the psychotherapist may be out of the office.
Unlike in cognitive behavioral therapy (CBT), considered a short-term psycho-
therapy process in which termination is defined by the achievement of goals and by
the number of sessions, two-person relational psychotherapy is more open ended.
Plans for termination are typically made after all parties have had an opportunity to
learn how to develop adaptive patterns as they “dance” together (Delgado and
Strawn 2014).
Fees for Service
The child and adolescent psychiatrist or psychotherapist that wishes to work in a

private practice, and if not part of a group, should discuss with his or her colleagues
what the customary charge is for psychotherapy in the local community.
Discussing matters relating to payment is likely one of the most sensitive issues
and should be handled with a great deal of openness. The child and adolescent psy-
chiatrist or psychotherapist should discuss the reason why the fees for the initial
consultation are typically higher and then explain the fees for an ongoing psycho-
therapy process openly. The child and adolescent psychiatrist or clinician should be
prepared for parents that had hoped that the evaluation process would have “cured”
the child’s problems or provided the pharmacological intervention to “fix” the con-
cerns. The parents and their child will need to be educated about how the psycho-
therapeutic process can help meet the proposed goals.
How the parent or caregiver will be billed and how and when payments are
expected must be agreed upon at the beginning of the process. Some psychothera-
pists prefer payment at the time the session is held, while others prefer it to be
delivered on a monthly basis.
The psychotherapist should be prepared to accept multiple forms of payments,

including cash, checks, and credit cards via a service on a tablet or other mobile
device.
Families should know in advance that the step of using legal means to secure the
payment may be taken by the psychotherapist when their account has not been paid
for more than 60 days.
It is not unusual to have a provision in the treatment contract to state what
patients will be charged if the psychotherapists provide additional services, such as
taking phone calls, reviewing legal documents, writing reports, and/or participat-
ing in legal proceedings. Other provisions may include collaboration with teachers
or other physicians, as well as visits outside of the office, such as the patient’s
school.
It is also important to review the policies regarding charges the psychotherapist
has for explained or unexplained missed appointments (e.g., cancellation fees). It is
common for psychotherapists to have policies wherein if the patient or parent can-
cels a set number of days in advance and the psychotherapist can schedule a differ-
ent patient in that vacated hour, the family will not be charged. We emphasize that
in two-person relational psychotherapy, there will be ample opportunity to discuss
these matters in an atmosphere of safety, as we have found that, at times, early can-
cellations are due to financial hardships and parents have shame or guilt in admit-
ting to this. For many years, those of the traditional one-person school considered
cancellations as having a layer of an unconscious resistance to the treatment, which
we posit that the reasons for cancellations are more complex and strongly influ-
enced by the realities of the patient and family.
A side note on this matter: For the newly minted child and adolescent psychia-
trist, the task of graduating and beginning a private practice or joining a group is
daunting, as this is their first experience in collecting payment for their service (e.g.,
to play or talk with children and adolescents), which can elicit some feelings of
guilt. The trainee had been accustomed to seeing their psychotherapy patients in an
academic setting, where it is typically not appropriate to charge for the service. We
encourage the newly minted child and adolescent psychiatrist or psychotherapist to
consult with prior supervisors (see Chap. 13) and colleagues available who can
share valuable personal experiences regarding this familiar matter.
Third-Party Payers
Given the complexity among insurance policies, if the child and adolescent psychia-
trist or psychotherapist accepts payment from insurance companies, it should be
explained clearly to the parents how this process is handled. For many clinicians in
a private practice, the parents will have to do much of the legwork in terms of sub-
mitting their claims. In some group practices, as well as large hospitals, this may be
processed by ancillary staff. Insurance plans are often limited to short-term treat-
ment approaches designed for specific Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition DSM-5 (APA 2013) categories. It should not be assumed that
the matter of co-pay is clearly understood by the parents or caregivers or that it is

not a hardship for them.
The family should also be aware that most insurance companies require treat-
ment plans that include a clinical diagnosis and, at times, a copy of the medical
record to authorize reimbursement. To this, some families may choose to pay for
services out of the pocket to avoid potential issues, as they would rather not have the
insurers handle this sensitive material.
It should also be noted that many insurance companies have a set limit on certain
types of treatment, including psychotherapy. It may be necessary for the psycho-
therapist to complete defined treatment plans to submit and to request approval for
additional psychotherapy sessions from the insurance company. This should be dis-
cussed ahead of time in the case that this request may be denied.
Finally, if the insurance company denies reimbursement, the parent should be
well aware that they will be responsible for the full payment of fees. Some families
may not be able to afford the weekly co-pays or the full fee, and depending on the
practitioner’s judgment, the family should be referred for continued care at a low-
fee clinic or a child and adolescent psychiatry or psychology training program psy-
chotherapy clinic.
One cannot be prepared for all situations, which is why an atmosphere of safety
provides the space necessary to share and cocreate realistic solutions in the best
interest of the child or adolescent.
The Office
The child and adolescent psychiatrist’s or psychotherapist’s office will become

an important relational space for the patient and parents; it becomes the environ-
ment that they hope will provide the tools to feel better emotionally. They implic-
itly bestow the psychotherapist with trust. As such, the office shall be in a safe
location, featuring adequate space and a comfortable environment. Attention
must also be given to parking, to bus routes, and to the rules of where can the
child be safely dropped off and picked up if 14 years of age or older and by
whom. (For patients under the age of 14, it is essential that a parent or other
approved adult be present in the waiting room with the child, both before and
after the appointment.)
In regard to trainees, it is important to disclose to the patient and their parents or
caregivers if they are using offices that are not unique to them. This allows for an
open discussion of the impressions created by the office used, as in the case of a
small office that may not capture the personal subjective experience of the trainee’s
character. It is also important to disclose that the tools accessible for the process—
toys, Crayolas, paper, etc.—are not the trainee’s, and both parties can openly and in
the here and now discuss their experiences of the situation if it proves to be limiting
(e.g., very few toys) or overwhelming (e.g., abundance of toys and games). This
allows both the patient and trainee to have the freedom to compliment or criticize
aspects about the borrowed office.
The Waiting Room
The waiting room will need to have comfortable chairs for adults and children; read-
ing material for parents and adolescents; and toys, games, or access to television for
younger children. Fortunately, in this time of advanced technologies, many patients
and their parents bring their own electronic devices while they wait for
appointments.
If the waiting room is shared with other psychotherapists, the patient and parents
would likely appreciate the psychotherapist’s disclosure about whether they should
expect other children or adults to be present. It is also important when the psycho-
therapist’s office is within a pediatric environment that the patient and parents know
where they can wait to avoid the fear of becoming ill if sick children will be
present.
Confidentiality (HIPAA)
Confidentially is paramount for mental health-care providers, who have a profound

responsibility for its safeguard. There are federal and state laws that protect the
privacy and confidentiality of medical information. To this end, the Health Insurance
Portability and Accountability Act standards were established in 1996 and imple-
mented in 2003 as the Privacy Rule (HIPAA 1996). The Privacy Rule assures that
individuals’ health information is properly protected while allowing for the flow of
health information needed to provide quality health care. The Privacy Rule is
designed to be flexible and comprehensive. In the modern medical centers, however,
there are varying levels of confidentiality and potentially conflicting edicts related
to its enforcement. Clearly, this is a complex process when parents are divorced, and
interventions should be tailored to best help the patient maintain his or her treatment
confidentiality.
Herein, patients and their parents or caregivers benefit in knowing that the front
office staff will have their privacy in mind. Some offices refer to patients and parents
only by their first name, others allow them to press a button to alert the psychothera-
pist they have arrived, while others use a paging system. There are many opportuni-
ties for their privacy to be compromised, especially in larger settings, so measures
to minimize this from happening should be used when possible.
Communication
How to communicate with the psychotherapist in between appointments is an

important piece of knowledge for the patient and family. The reasons for families
and patients to reach out are many, so it is helpful for the psychotherapist to share
their basic rules of communication in order to set realistic expectations with the
patient and family. Typically, telephone calls are received during office hours by
front office staff, confidential voicemail, or an answering service. Patients and
families need to know what time frame they can expect to have their phone call
returned (e.g., same day, before a certain time, 48 h). They should also be made
aware of the process for handling after-hours telephone calls, common procedures
for when emergencies occur, and how to access local emergency rooms for assess-
ment of the patient’s safety.
There are some psychotherapists that use e-mail or a smartphone as a practical
vehicle of communication with patients and their families. Each clinician will need
to be thoughtful on setting some parameters on how these methods are used, and
they must consider matters of confidentiality and HIPAA discussed above. In its
most simple form, the use of e-mail is best when the patient, parent or caregiver, and
psychotherapist are using a personal account from a secure server.
The use of social media is not recommended for communication, as it is not care-
fully regulated and can easily lead to misuse in a psychotherapeutic process.
Communication with other important sources can help the treatment process,
including pediatricians, subspecialty physicians, school personnel, and social agen-
cies. To this, the psychotherapist and their front office staff should routinely request
parents and adolescents to sign a release of information (ROI), which gives the psy-
chotherapist and their office staff permission to communicate with the important
sources. It should be noted that the release of information can be tailored to the needs
of the patient and family, such as allowing the psychotherapist to obtain information
without disclosing information about them. Further, the ROI is generally time limited
(e.g., 60 or 90 days), and a new form must be signed if needed at a later time. The
patient and their family or caregivers have the right to cancel the form at any time.
Office Rules
As we have described throughout this book, how we approach our patients and their
families is influenced by our own unique set of internal working models of attach-
ment and temperament. We briefly reviewed how we practice and encourage the
reader to reflect on their office rules vis-à-vis the patient’s needs (e.g., wheelchair
bound, needing a therapeutic dog).
In our practice, an academic hospital setting, we do not recommend the use of
puppets or sand trays, as these allow for easy cross-contamination of viral processes
during viral high seasons, which is not appropriate for our patients. To this point, we
use toys, character figures, dry erase markers with small easel boards, and games
with plastic figures, all of which can easily be washed or cleaned with instant hand-
sanitizing wipes. As with most issues, no one size fits all, and appropriate decisions
to preserve the medical health of patients should be made at each practice.
A special situation that is important for the psychotherapist to keep in mind is
when a child attempts or succeeds in destroying personal property in the office, a
very complex aspect of psychotherapy when working with young children. This is
attenuated in two-person relational psychotherapy, as it assumes that the psycho-
therapist’s efforts are to teach the child, at the implicit level, to self-regulate in more
adaptive patterns that are not conducive for regression, often seen in the verbal and
interpretative insight-oriented work of the traditional one-person model (see Chap. 2).
However, aggression may still appear without warning. How this is managed in the
here and now and the possible financial repercussion to the parents or caregivers is
best handled when discussed early and during the consent for treatment.
A 6-year-old boy’s wrestling match with the psychotherapist

A 6-year-old boy in two-person relational psychotherapy was playing with the
psychotherapist using wrestling character figures, and he began to jump on the
wrestling play ring with force that could break it. The psychotherapist uses his
own wrestling character and said with excitement to the boy, “I am going to
show you how we can play and be tough guys without breaking the ring,” and
proceeded to demonstrate how. The child seemed relieved; they cocreated a
moment of meeting that became a new and corrective emotional experience at
the implicit level.
Interestingly, when we shared the video recording of this play sequence to the
trainees, it was brought up that perhaps the psychotherapist could have interpreted
the boy’s aggression as wanting to be strong and protect himself from his abusive
father. We refer the reader to Chaps. 3 and 4, where we explain that this way of
formulating is very much a traditional one-person form of psychotherapy. We do not
adhere to it since it implies knowing the intrapsychic reason of the play rather than
it being a pattern the child had stored in implicit nondeclarative memory, of which
the observer cannot know its multifaceted origins.
Consent for Video Recording
The lead author frequently uses video recordings for teaching purposes, which is
helpful for allowing the in vivo demonstration of how the patient’s and psychothera-
pist’s subjectivities can be experienced in the here and now by the participants.
There are several aspects in regard to the consent of video recording that are impor-
tant to be familiar with. It must be clarified if the recording is for teaching purposes
and, if so, with whom it will be shared. It is best to disclose if the recording will be
shown in the academic setting where the psychotherapist works, which is different
than if it is also planned to be used at a national conference. In these situations, a
new consent will be needed that specifies the new purpose. There are some signed
consents that expire, and this will need to be discussed with the patient and family,
as well as legal counsel when possible.
Use of Electronic Devices
The use of electronic devices and smartphones is ubiquitous among children and
adolescents nowadays. As such, we believe it is no longer helpful to have a rule in
place that prohibits the use of electronic devices during sessions, since that prevents
the psychotherapist from knowing what the child is like in the context of his or her
world. We suggest that it is best to convey the subjective experience the two-person
relational psychotherapist has when the patient uses the electronic device, thus
allowing the patient to learn how their actions have had an impact on the here-and-
now mutuality of their interaction.
Telepsychiatry
Regarding the use of telepsychiatry (e.g., Skype, VSee, FaceTime), the American
Academy of Child and Adolescent Psychiatry (AACAP 2008) has developed prac-
tice parameters for this type of intervention, and we encourage the child and ado-
lescent psychiatrist to familiarize themselves with these parameters before
engaging in this form of communication. Telepsychiatry is guided by medical
state boards.
Home and School Visits
The authors recommend that when possible, trainees should meet their psychother-
apy patients both at home and at school. It is a great learning experience seeing
patients in their natural surroundings. Most of the time, patients and families are
grateful for the home visit. An in vivo visit speaks louder than words in regard to
intersubjective experiences of patients and families with two-person relational psy-
chotherapists. However, it becomes a complicated issue when the psychotherapist is
not a trainee, as the visit to the home or school will need to be agreed upon due to
issues of billing for the time involved, which may include travel time.
Use of Medication
Many patients in two-person relational psychotherapy, including children and ado-

lescents, may benefit from the use of medication (e.g., for depression, anxiety,
ADHD). This is a complex issue that needs defined parameters that can be shared
with parents or caregivers up front to avoid misunderstandings. To this point, the
child and adolescent psychiatrist or psychotherapist will need polices that explain
how to request refills and the time frame in which the parents or caregivers can
expect the medication to be called into their pharmacy. This issue is very important
in the case of stimulant medications, which is more complex and bound by state
pharmacy laws. We suggest that the child and adolescent psychiatrist develop stimu-
lant medication refill policies that are reviewed up front. If the patient is being
treated by a nonprescribing psychotherapist, it is necessary to have the parents sign
a release of information so the clinician can collaborate with the prescribing psy-
chiatrist or pediatrician.
As previously stated, the psychotherapist should not underestimate the possibil-

ity that the cost of medication may be a financial hardship and a possible reason for
noncompliance rather than a resistance to treatment.
Medical Records
Most states have laws that require mental health professionals to keep and maintain
treatment records. Patients and their parents are entitled to a copy of their records,
although sometimes a summary will suffice, as complete records can be misinter-
preted. In line with two-person relational psychotherapy, reading the medical record
together with the patient and their family can be helpful, as it can provide them with
a feel for the psychotherapist’s view of the progress.
Special Situations
Special situations are part and parcel of the work with children and adolescents. It
would be beyond the scope of this book to encompass them all. Suffice it to say, the
two-person relational psychotherapist will need to reflect on the comprehensive
treatment formulation developed through an integrated contemporary diagnostic
interview (CDI) and then focus on the new emotional experiences needed by the
patient and family. In most difficult situations, the patient and family’s implicit rela-
tional model will nonconsciously attempt to turn the psychotherapist into an accom-
plice of their maladaptive patterns. The most common special situations that arise in
child and adolescent psychotherapy are the separation or divorce of parents, custody
disputes, self-destructive or suicidal behaviors, bullying, and chronic medical con-
ditions. We would encourage consultation with a colleague when the situations lead
the psychotherapist to feel intersubjectively pressured into action in the space with
the patient or parents.
An unhappy father attempts to sabotage his daughter’s treatment

A 16-year-old Caucasian female—who had been in weekly two-person rela-
tional psychotherapy for being unhappy due to her parents’ conflicts after
their divorce 4 years prior—was hospitalized after voicing serious suicidal
ideation during her psychotherapy session. Her parents were successful pro-
fessionals and had two older children that were doing well academically—
achieving honors—and socially. The patient’s father asked her inpatient
physician to find a new psychotherapist, stating, “She is not making progress;
she is becoming suicidal, and I pay for her insurance,” in spite of the fact that
the patient shared to her mother and inpatient treatment team that her psycho-
therapist was instrumental in allowing her to share her suicidal ideation “with-
out feeling ashamed.” The patient asked if she could see her psychotherapist
while on the inpatient unit at her regular times. For this to occur, the parents
would need to agree to cover the fee for the psychotherapist, as it was likely
their insurance would not reimburse due to her being in the hospital.
Furthermore, the inpatient treatment team suggested that the parents and psy-
chotherapist attend a meeting to discuss the patient’s discharge plans, which
would also involve the parents covering the fees for the psychotherapist to
attend. Although the patient’s father refused to help pay for the psychothera-
pist’s fees, he agreed she could attend the meeting, saying: “I guess she really
connects with my daughter.” The patient’s mother recognized the importance
of the psychotherapist and stated, “I will pay for her [the psychotherapist’s]
time; my daughter needs her support.”
This case conveys the importance for a psychotherapist to have a clear and com-
plete treatment contract before launching the psychotherapeutic process. The par-
ents understood the importance of signing a release of information for the hospital
treatment team to communicate with the psychotherapist who had a good therapeu-
tic alliance with their daughter and was instrumental in helping the parents take her
suicidal ideation serious. Although the parents were aware of the fees involved in
having the psychotherapist see their daughter and attend the treatment team meet-
ing, the patient’s father’s implicit relational problems, which his daughter had dif-
ficulty with, became apparent to all.
A brief comment of caution: In this case, the psychotherapist was allowed to see
the patient in psychotherapy while on the inpatient unit, as she had hospital privi-
leges to do so. If this had not been the case, the psychotherapist may have only been
allowed to see her patient as a visitor and would legally not have been able to prac-
tice psychotherapy or charge for her services, as this would not be considered a
professional service. This may vary in many hospital settings, and it is best to
request formal privileges of the hospital likely to be used with child and adolescent
acute care inpatient units.
Families as Ambassadors for Two-Person Relational

Psychotherapy
Occasionally, we find that parents wish to obtain information from other families—
similar to a letter of reference—that supports our ability to help. They hope to find
a person that has traveled the road before who can help them with their apprehen-
sion in engaging in a psychotherapeutic process. We have found this to occur more
often when play psychotherapy is recommended, as most parents do not have a
frame of reference about how this can be helpful. To this, the lead author has found
that many families are eager to discuss their personal experience regarding the rela-
tional psychotherapy process. In fact, some adolescents are eager to share their
References 263
experience with others. These families openly share the complexities regarding
appointment time management during the process and the benefits of the treatment.
As a reminder, if this is to be pursued, the psychotherapist will need to have signed
consents for release of information from both parties to communicate with each
other. Clearly, not all families wish to share their experiences, for a variety of rea-
sons, including privacy, guilt for their child’s psychological problems, etc.
9.4 Summary
Setting the frame is one of the most important elements in psychotherapy. Langs
(1988) eloquently states that the psychotherapist’s use of ground rules constitutes
his or her most fundamental form of intervention, which influences all other dimen-
sions of the therapeutic encounter and experience.
Finally, we provided the reader with many practical suggestions, including those
on confidentiality, compensation, and time, which are useful to clinicians of any
psychodynamic persuasion.
References
American Academy of Child and Adolescent Psychiatry (2008) Practice parameter for telepsy-
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5th edn DSM-5. American Psychiatric Association, Washington, DC
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Two-Person Relational Psychotherapy:
Infants and Preschool Age Children 10
Every child at play behaves like a creative writer, in that he creates

a world of his own, or, rather, rearranges the things
of his world in a new way which pleases him.
—Sigmund Freud
We open this chapter with Freud’s masterful quote that captures the role children
have as active participants in their development. For many years, infants were
thought of as being dependent and unaware of the world around them (Mahler et al.
1975). The work by early developmental researchers—including Bowlby, Spitz,
Emde, Stern, etc.—helped elucidate that infants were hardwired to develop com-
plex abilities for social reciprocity, and if raised by parents with “good enough”
capacities for affective attunement, the infants were quite busy in meaning-making
processes. Tronick and Beeghly (2011) state, “In developing systems, such as
human infants, sufficient resources must be obtained to enable them to increase
their coherence and complexity and to self-organize new capacities.” Further,
Bretherton and Munholland’s (1999) work reinforced the notion that interactions
between infants and their parents gave meaning to their shared experiences, with the
development of internal working models of attachment giving coherence to their
relationships. When infants have emotionally available and affectively attuned par-
ents, they develop secure working models in relating with others. When parents
provide a secure base for the infant, it increases the likelihood of the infant acquir-
ing the emotional resources needed in the short run, and in the long run, these
growth-promoting social interactions will contribute to self-regulatory capacities
and resiliency. Over time, infants become part of a larger and more complex system,
and they become more flexible and better able to reorganize when confronted by
day-to-day discontinuities in their care.

DOI 10.1007/978-3-642-40520-4_10
266 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children
Two busy, securely attached infants

We informally asked two of our colleagues, who had each recently given birth
to a child, how many people had held and jovially interacted with their child
during their first three months of life. The first colleague laughed and said, “In
our culture we have very close and large families; my son has interacted with
more than 30 family members and friends. He loves all the excitement.” The
second colleague shared that her son had interacted with more than 10 family
members and also loved the excitement.
This example aptly captures the idea that the emotional experiences that can
promote the infant’s self-regulatory capacities are dependent on the variations in the
quality and intensity of early social interactions. These capacities are sculpted by
the relationship between the infant, parent, and family within the backdrop of con-
textual and cultural factors. Brief periods of disorganization in everyday life of the
parent–infant relationship are inevitable and normative. The two healthy and secure
infants described in the example will learn to develop self-regulatory abilities that
allow having the psychological skills needed to tolerate everyday demands, such as
being hungry, needing their diaper changed, etc. Infants attempt to make coherent
meanings of the variations in the environment, through a combination of their own
unique temperamental traits and the self-regulatory abilities they develop. It is not
surprising that infants who have limited exposure to growth-promoting social inter-
actions have difficulties with self-regulation and closeness throughout their life.
When life is not as idyllic for the infant and their parent’s emotional availability
is unpredictable, the infant will have difficulty developing meaning-making pro-
cesses and self-soothing abilities. The experience from chronic parental inconsis-
tency can lead to altered brain development, compromised socioemotional
functioning, stunted mental growth, and even death (Nelson et al. 2007). As an
example, infants that avoid interactions with other people for fear that these people
may have similar characteristics as the original intrusive parent may experience
short-term relief from anxiety. However, in the long run, it will be detrimental and
lead to limited growth-promoting social engagements with others and potential
long-term developmental consequences (Beeghly and Cicchetti 1994; Tamis-
LeMonda et al. 1996; Sroufe 2009). As such, these infants exhibit affective and
behavioral reactions consistent with sadness, anger, withdrawal, and disengage-
ment. Furthermore, they likely experience significant anxiety and fear due to the
loss of organization, they become easily dysregulated, and their sense of self is
threatened. Parental depression and anxiety, as well as infant medical, behavioral,
and temperamental issues, can result in prolonged periods of dyadic disorganization
and maladaptive infant outcomes. Child health clinicians can help parents anticipate
the normal periods of disorganization and assist parents to develop optimal parent–
infant relationships (Beeghly and Tronick 2011). Infants with harsh and unrespon-
sive parents learn that by minimizing the interactions with their parents, they
increase the likelihood of survival, albeit without developing the adaptive
10.2 Adam 267
self-regulatory mechanisms needed for continued psychological growth (Cicchetti

and Barnett 1991). This significantly increases their risk of long-term maladaptive
and insecure attachment relationships with others in later life (Fraley and Shaver
2000). Andersen (2003) describes early periods of development as critical windows
of opportunity essential for “brain wiring.” Further, Pearson et al.’s (2013) work
with depressed mothers and their babies finds that “treating maternal depression
antenatally could prevent offspring depression during adulthood, and that prioritiz-
ing less advantaged mothers postnatally may be most effective.”
10.1 Psychodynamic Psychotherapy in Infants

and Preschool Age Children
The reasons why parents of infants and preschool age children seek help are gener-
ally due to feeding, developmental, or behavioral difficulties. As such, the child
psychiatrist or clinician will benefit from using the contemporary diagnostic inter-
view (CDI, Chap. 8) in order to understand the child’s unique attributes—tempera-
ment, cognition, cognitive flexibilities, and internal working models of
attachment—albeit in a rudimentary form due to age and within the context of the
environment in which they live (including family and culture considerations).
Careful attention should be given to the norms of development (see Appendix A).
During this age, meaning-making processes, social reciprocity, and the ability to
regulate affective states, as well as the improvement of their motor skills, become
central in the infant’s or child’s development. It is important to note that the matura-
tion process can be uneven with regard to innate temperamental and cognitive attri-
butes, further influenced by the availability of the parents or caregivers for the
affective attunement needed for maturation. Language is a major milestone that
typically occurs at the 18-month-old mark. Consequently, the two-person relational
psychotherapist of infants and preschool children will need to understand the role
parents and caregivers have played in the child’s developmental process.
10.2 Adam
History of Present Illness
Adam was an 11-month-old male infant referred by his pediatrician for failure to
thrive. Though no organic cause was identified, the pediatrician was concerned that
if no behavioral solution were found, a gastrostomy tube (G-tube) would have to be
placed for feedings. The pediatrician recognized the psychological consequences of
such intervention. It is not unusual for child psychiatrists to be consulted in such
cases.
The week prior to the appointment, the family had celebrated Thanksgiving at a
friend’s house. However, Adam became very upset and irritable. Despite many
efforts by his parents to comfort him, he refused to eat for over 14 h. As this pattern
was becoming more common, his pediatrician placed a nasogastric (NG) tube
(which was present at the time of the appointment) in Adam for involuntary
feedings.
Past Medical History
Though his birth and delivery history was unremarkable, Adam had a long history
of diagnoses and medical procedures despite his young age. Soon after birth, he was
diagnosed with milk protein allergy and acid reflux. Within the first few months of
his life, he was diagnosed with severe craniosynostosis (a birth defect in which one
or more of the suture lines between the bones of an infant’s skull close prematurely,
before their brain is fully formed). By his fourth month, he had undergone an esoph-
agogastroduodenoscopy (EGD), a chromosome analysis, a computed tomography
(CT) scan of the head, and a magnetic resonance imaging (MRI) scan of the brain.
The results confirmed severe craniosynostosis. After having corrective surgery, at
his follow-up appointment with the surgeon, it was noted that Adam’s surgical site
was healing normally, although “the infant cried repeatedly during the exam. His
mother reports this is typical in new environments for him.” Five months later, the
surgical team felt that the defect had been adequately corrected, although they noted
a mild developmental delay “due to the fact that he was quite a poor eater.” He had
fallen below his weight and height developmental curves, and their pediatrician
gave him the diagnosis of “failure to thrive.”
Past Family History
Adam’s father was a 32-year-old man who worked as a delivery driver. He spoke
about having a conflicted relationship with his own parents. As a child, he suffered
from low self-esteem, which worsened when, as an adolescent, he developed motor
tics—eye blinking, oral–buccal movements, and chewing fingernails. “They always
made fun of me. I was and am always anxious.”
Adam’s mother was a 27-year-old woman who struggled with a significant
amount of pain due to endometriosis and polycystic ovarian problems. She also had
a history of an anxiety disorder that she did not have treated, “I was ashamed to get
help for it.” She reported that she had never flown in an airplane and said that she
would never fly, because she would be sure that it would be time for her demise due
to anxiety: “I couldn’t handle it.”
Adam’s First Appointment with the Child Psychiatrist
Upon greeting Adam’s parents for the first time, the child psychiatrist noted that the
parents seemed ready to share their anxieties, as they promptly exclaimed, “No
offense, but we feel very bad that Adam has to see a child psychiatrist; he is not even
10.2 Adam 269
a year old.” The parents experienced the consultation as an ominous sign of their
failures, rather than as an opportunity to find ways to help their child. The child
psychiatrist’s first intersubjective experience was that of genuine sadness for the
parents; they conveyed a pervasive feeling of being inadequate as parents.
From a two-person relational psychology perspective, the parents intersubjec-
tively were experienced as using an internal working model of ambivalent/anxious
attachment, and both displayed a slow-to-warm-up temperament style. As the inter-
view progressed, it became clear that the parents had frequently cocreated experi-
ences in which they conveyed to physicians and other caregivers the implicit sense
of insurmountable fear they had of not being adequate parents. The child psychia-
trist intersubjectively felt that there were actually three people in the office that
needed consoling.
Within the framework of a contemporary diagnostic interview (CDI, Chap. 8),
the child psychiatrist made use of comments that helped create an atmosphere of
safety for the anxious parents. He complimented the parents about the nice outfit
their son was wearing and the sophisticated stroller they were using. From a nonver-
bal standpoint, when the parents conveyed a sigh of relief, the child psychiatrist
intersubjectively experienced in the here-and-now moment that he had helped them
feel validated as caring parents. They proudly shared that they had saved money for
such a high-quality stroller because they wanted “the best for our first child.” With
this, the child psychiatrist intersubjectively felt hopeful for them. Nevertheless, in
the next comment, they conveyed the nature of their chronic patterns of an ambiva-
lent/anxious internal relational knowing: “With all this stress, he will likely be our
only child. We are not good parents.” With these comments, the child psychiatrist
intersubjectively experienced them as having constant feelings of anxiety and feel-
ing inadequate as parents.
As anticipated, the parents’ affect became more anxious as the consultation
evolved. Exasperated, they said: “We don’t know how to be good parents. He started
vomiting almost every day since he was 10 months old. By the end of the day, we
would run out of outfits; we had to keep buying more. Our families told us we were
not good parents. We now know they were right.”
Allowing Subjectivities to Meet: Developmentally

Informed Mental Status Exam
Adam was a cute and likable 11-month-old child. Surprisingly, in the first appoint-
ment, he was eager to interact with the child psychiatrist and had a full range of
facial expressions for most of his affective states. He stuck his tongue out, imitating
the child psychiatrist. He smiled and allowed for gentle touch. The child psychiatrist
subjectively felt surprised at the child’s resilience and sophisticated capacities used
to engage in social reciprocity with a stranger. It was as if he were hungry for inter-
action. The child psychiatrist asked the parents if they would allow their child to
crawl in the office. The child psychiatrist proceeded to sit on the floor, and as soon
as Adam was allowed to crawl, he began to play with some of the age-appropriate
toys and looked with a smile at the child psychiatrist for social referencing. In the
next interpersonal sequence, after the child psychiatrist asked Adam’s parents’ per-
mission to hold him and reached out for him, Adam expressed discomfort and
became anxious and irritable. Intersubjectively, the child psychiatrist felt that Adam
had found the optimal distance comfortable for him when relating with others.
When the distance was infringed—when the child psychiatrist tried to hold him—
he noticeably let others know that this was not comfortable. He was playful and
engaging as long as there was a safe distance between him and the other person.
These in-session interactions highlight the value of nonverbal communication.
Without losing sight of the parents, the child psychiatrist noticed their excite-
ment seeing their son happy and playful, although it was also noticeable that they
seemed unaware that they had been invited to join in the playfulness. What inter-
subjectively puzzled the child psychiatrist was that Adam’s parents had shared that
they were overwhelmed with their child being difficult to console in new environ-
ments, which was not the case in the child psychiatrist’s office, also a new
environment.
Contemporary Case Formulation Following Use of the CDI
After the first appointment, the initial impression of Adam by the child psychiatrist
was that of a complex case with severe medical problems within the context of his
parents’ anxieties, compounded by his sensitivity and anxiety to social situations.
Given his multiple medical procedures that required periods of time in which he
needed to be separated from his parents during his first 10 months of life, this likely
played a contributing factor to his failure to thrive and his developmental delays.
Eating disorder of infancy and an acute stress disorder were diagnosed. Early infant
feeding problems are often best understood through the complexities of the relation-
ship between parents and their infant (Daws 1993).
Contemporary Case Formulation Following Use of the CDI: Adam

Summary: An 11-month-old Caucasian boy who presents with functional
feeding impairment timed with the onset of his medical problems
Internal working models of attachment (IWMA): Ambivalent/anxious
Temperament: Mixed; predominantly easy/flexible with some slow to
warm-up
Cognition: Average (see developmental milestones Appendix A)
Cognitive flexibility: Average for his age during consultation
Formal psychiatric disorder: Eating disorder of infancy and an acute stress
disorder
Treatment recommendation: Begin parent–infant two-person relational
psychotherapy to help the parents provide the tools necessary for Adam to
develop self-regulatory functions and to improve his eating behaviors.
10.3 Case Conceptualization from a Traditional One-Person Model 271
Contemporary Case Formulation Following Use of the CDI: Adam’s Parents

Summary: A 32-year-old Caucasian male and a 27-year-old Caucasian
female who presented with functional impairment in providing the affective
attunement needed by their 11-month-old son. Of note, their families of origin
were not supportive of their role as parents.
Internal working models of attachment (IWMA): Ambivalent/anxious and
avoidant/dismissive
Temperament: Slow to warm-up
Cognition: Average
Cognitive flexibility: Limited by their anxiety
Formal psychiatric disorder: Parent–child relational problem
Treatment recommendation: Begin parent–infant two-person relational
psychotherapy to help the parents provide the tools necessary for Adam to
develop self-regulatory functions and to improve his eating behaviors.
The formulation based on the CDI was consistent with an infant with an average
to above average cognition, some decreased cognitive flexibility (likely further
restricted by the limitations imposed by his medical conditions and treatment), and
a slow-to-warm-up temperament. There were also symptoms that met the diagnostic
criteria for formal psychiatric disease, including an eating disorder of infancy and
acute stress disorder. The predominant internal working models of attachment in the
child’s parents were that of an ambivalent/anxious style, although it was less so in
Adam, who seemed more willing to seek secure forms of relatedness if the person
was able to spark his curiosity for exploration, which the child psychiatrist was eas-
ily able to provide. That is to say Adam may have not been as pleasant and willing
to explore if a child psychiatrist with different attributes were evaluating him. We
are reminded of Emde and Harmon’s account of the growth-promoting discontinui-
ties for the infant when the parents or caregivers are available to repair the tempo-
rary ruptures of the interactions (Emde and Harmon 1984). Adam had been exposed
to many discontinuities in his care, although he seemed to actively seek engagement
with the child psychiatrist, which spoke to his resiliency and willingness to tem-
peramentally tolerate emotional disruptions.

One-Person Model
When Adam’s first appointment is viewed through the lens of a traditional one-
person model, we can consider several hypotheses to understand the interactions. At
the most basic level, Adam used oral-level ego defenses—refusing to eat, scream-
ing, etc.—to cope with the gratification-seeking intrapsychic pressures. This was
further complicated by his parents’ inability to provide “good enough parenting,”
due to their own intrapsychic conflicts and constitutional weak ego capacities,
which contributed to Adam’s developmental delays. Another reasonable way to

understand the interaction between Adam and the child psychiatrist is that he repre-
sented a good intrapsychic object, which had seldom been available to Adam.
Further, when the child psychiatrist invites Adam for closeness, intrapsychically he
may have represented the bad intrusive object in the parents and medical personnel.
Thus, Adam splits off the child psychiatrist—a good object but only at a distance.
In Kleinian theory, this is characteristic of children who remain in the paranoid
position.
From a traditional one-person model, Anna Freud states that early in life, the
infant has no concept of where he ends and the environment begins. For Freud, the
only important principle in the infant’s life is the pleasure principle. As such, Adam’s
refusal to eat may have been a defense against unpleasure. Salomonsson (2012)
argues that infantile sexuality plays an important role in many mother–infant distur-
bances. Thus, Adam’s difficulties may have been understood as a result of constitu-
tionally having weak ego development, which prevented the emergence of the
autonomous ego functions needed to manage the pressures from his drives (id) in the
form of wishes for gratification of his oral needs. Further, the introjections of his
early primary object relations were unstable due to his chronic state of anxiety from
the inconsistencies in care by his parents and the many medical problems and proce-
dures. Adam’s refusal to eat represented primitive ego defenses, against the psycho-
logical pain experienced from his rejecting parents’ demands. Both Adam and his
parents were threatened by each other’s rejection and were locked in mutual avoid-
ance. The growth of Adam’s personality by imitation and identification with his par-
ents was impaired. From a psychosexual point of view, he remained fixed in the oral
phase and was unable to successfully make steps needed to move onto the anal phase.
From the perspective of traditional one-person psychoanalytic treatment inter-
ventions, it likely would have involved working with the parents in exploring their
own intrapsychic conflicts rooted in their past experiences that interfered in provid-
ing an average expectable environment for Adam. The parents’ ghosts in the nurs-
ery (Fraiberg et al. 1975) interfered with their ability to successfully parent and
provide Adam the transitional space needed to negotiate his struggles with the
development of adaptive ego functions. A traditional one-person child psychoana-
lyst or a psychoanalytically informed psychotherapist may have considered begin-
ning with a combination of parent–infant work with some individual play
psychotherapy with this young child with the goal of helping the parents work
through prior unconscious conflicts interfering in their parenting skills and improve
their ego function.

in Infants and Preschool Age Children
In two-person relational psychology, the psychotherapist takes an active role to first

become an ally of the patient’s and parents’ subjectivities and implicit relational
knowing during the sessions. Two-person relational psychotherapy has evolved
10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool 273
from the traditional one-person model and taken it a step further. It is now well
known that child and adolescent psychotherapy must account for the contributions
of early attachment to mental health and behavioral issues. That is, the intersubjec-
tive experience becomes a construct of the patient’s and psychotherapist’s person-
alities—temperament, cognition, cognitive flexibility, and internal working models
of attachment—brought into the context of a here-and-now therapeutic relationship.
This bidirectional process allows the patient to implicitly, over time, become a part-
ner to the psychotherapist’s healthier and more adaptive way of interaction with
others. In essence, the psychotherapist provides a new and corrective emotional
experience for the patient and their parents or caregivers when appropriate, which is
stored in their nondeclarative memory at an implicit level. Rustin and Sekaer (2004)
aptly state that the experiences in a relatively healthy environment enable the
unfolding of genetic programs that promote the child’s relational needs at an implicit
level. From a two-person relational perspective, the work will be primarily to first
learn about the child’s capacity for meaning making and affective attunement and
subsequently helping the parents implicitly provide the infant or preschooler the
physical and emotional tools necessary to resume their self-regulatory developmen-
tal process successfully.
Facilitating Enactments Cocreating New Relational Schemas
With Adam and his parents in mind, the child psychiatrist sequences his interven-
tions: (1) He will need to help Adam’s parents implicitly learn to develop secure
models of attachment in order to feel at ease in helping their son be curious and
explore the world with them. (2) He will need to provide Adam encouragement to
explore and be curious about his surroundings, initially with the child psychiatrist and
later with the parents after they learn to manage their anxieties in a more adaptive
manner. (3) He will need to explore the possibility of seeking family members or day-
care facilities that could provide Adam the affective attunement needed to increase
his social referencing abilities, which was difficult for his parents to provide.
In the second appointment, the child psychiatrist began to sing children’s songs
to Adam, which Adam liked and expressed excitement for as he began to follow
with body movements in sync with the melody. Additionally, the child psychiatrist
would ask the parents to join in, to which they would anxiously state that they did
not know any children’s songs. The child psychiatrist proceeds to invite the parents
to sing Adam familiar songs to them. The parents began to laugh and then shared
the names of the songs of their era. They started singing first toward each other and
later, with gentle help from the child psychiatrist, they sang to Adam. They stated
that they had been so overwhelmed by all the medical concerns and their own anxi-
ety as new parents; they had forgotten what it was like to be playful. Adam, in turn,
displayed both nonverbal and verbal signs of joy and excitement. Intersubjectively,
the child psychiatrist felt that implicitly things were moving along, and what
remained was to help Adam’s parents learn to use “motherese” to facilitate social
reciprocity.
In essence, the child psychiatrist carried out the treatment by focusing on the here-
and-now, moment-to-moment social experiences of the infant and his parents. Adam’s
parents needed to learn “how to attune with him emotionally,” which over time would
be stored in nondeclarative memory, so as to be retrieved automatically and noncon-
sciously when needed. In relating with an infant, parents and caregivers must actively
scaffold the infant’s intentions and meaning-making processes. This approach is
likely to succeed if it is begun early and repeated often, as an infant’s regulatory sys-
tems are open for change when growing in a secure and affectively attuned environ-
ment (Sander 2004; Gottlieb and Halpern 2008). As Anna Freud aptly stated, the goal
of therapy is to get children back on their developmental track (Freud 1974).
Timing Self-Disclosures
In two-person relational psychotherapy, after an atmosphere of safety and vitality is

created for the patient and his or her parents or caregivers, the genuine and active
psychotherapist will undoubtedly and unknowingly make implicit self-disclosures
or enactments which will be pointed out as helpful or disruptive. Additionally, the
psychotherapist can also make use of explicit and well-thought out enactments and
self-disclosures (Chaps. 3 and 5) to help the process develop.
Being aware that Adam’s parents conveyed a great deal of anxiety, which was
noticeable in their facial expressions, the child psychiatrist intersubjectively recog-
nizes that he needs to foster interactions that could visually convey to Adam a sense
that “things will be OK.” Herein, he has to be careful in cocreating enactments with
Adam’s parents. In looking at matters from Adam’s parent’s vantage, the child psy-
chiatrist allows himself to feel what it would be like “thinking like them.” He subjec-
tively thinks that what might be helpful to them is to self-disclosure as having “been
there” before, namely, taking care of a child that is crying and difficult to console.
With this in mind, the child psychiatrist begins singing nursery rhymes to Adam and
at the same time faces the parents and self-discloses that he had learned that singing
and rubbing his daughter’s back with baby oil helped soothe her when she was crying
inconsolably. He wondered if they—Adam’s parents—could try and see if the
approach might also help Adam at their home. In this intervention, the child psychia-
trist provides both a self-disclosure about what helped his own child and an enact-
ment by demonstrating how to rub Adam’s back while singing to him. The multifaceted
nature of infants’ meaning-making processes suggests that a wide variety of physical
interventions with infants can be useful (e.g., gentle touch, rocking, massage, and
holding) (Tronick and Beeghly 2011). Such approach is in contrast to a traditional
one-person model, in which the child psychiatrist may educate the young parents on
how to improve their care of the child and thus could inadvertently and implicitly
collude with familiar experience of others: being told they were inadequate parents.
Working with Parents Intersubjectively
In order to help Adam resume his development, it was important for the child psy-
chiatrist to work with Adam’s parents to promote their ability to provide Adam the
10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool 275
affective attunement needed to improve his self-regulatory abilities and promote his
curiosity for social reciprocity. For this to occur, it was necessary for the child psy-
chiatrist to model, in vivo, how to approach Adam with excitement. Tronick and
Beeghly (2011) aptly state, “In some cases, having infants develop a therapeutic
relationship with a person other than the disturbed caregiver may protect them
because it enables them to develop ways of being with others that not only are gen-
erative for future relations with others but also, reciprocally, may help induce change
in their caregiver(s).” To this, the child psychiatrist fosters a relationship with Adam
that serves as a model for his parents to change the manner in which they approached
him during the meaning-making moments. The parent’s anxieties confused and
impaired the growth-promoting attunement Adam was seeking. Therefore, the child
psychiatrist supports Adam’s parents and helps them cocreate mutual interactions
with new and more adaptive coping capacities to promote change in Adam’s behav-
ior and internal affective states. Tronick and Beeghly (2011) clarify the variability
in approaching the parent–infant dyad or triad: “Our focus on the dynamic moment-
to-moment interchanges between infant and caregiver highlights the concept that
every infant–caregiver relationship is unique, and therefore treatment plans should
not be overly formulaic or rigid but rather should focus on individual differences.”
Letting Go
During the initial phase of the treatment, the child psychiatrist saw Adam and his
parents weekly for three occasions, and then on a bimonthly basis, as they could not
afford to take off work and travel the one and a half hours each way weekly.
Nevertheless, weekly phone calls were scheduled to maintain contact and assess
Adam’s progress and his response to the medication.
The progress that occurred from month to month was remarkable. After eight
visits, the parents decided that “now that Adam can walk, smile, and go to parties
without freaking out. We think we will stop seeing you. We will keep you posted
and come back if we need to, if that’s OK with you.” Without a doubt, letting go was
difficult, as the child psychiatrist intersubjectively had a sense of ownership in help-
ing the family system improve. In a similar case, in which the child had feeding
difficulties that improved by the child psychiatrist helping the family manage their
anxiety and provide a growth-promoting environment with the affective attunement
necessary for the child, Delgado et al. (1993) state: “The case represents a good
success story where the family says, ‘I don’t need you anymore.’ The self-correcting
features of the family are taking over and empowering them. That is the best kind of
outcome.”
Follow-Up
We don’t always have the luxury of having a follow-up visit from our young patients
after they are helped and return to their healthy physical and psychological develop-
mental track, as they likely prefer not to be reminded of the difficult period they had
gone through. In Adam’s case, a follow-up visit occurred 2 years after his last
appointment with the child psychiatrist. His parents returned and happily said, “We
wanted to show off how well he’s doing, although we also have a few questions.”
Surprisingly, Adam was eager to hug the child psychiatrist, demonstrating the
importance of implicit nondeclarative memory (“my implicit memory system
remembers you”). He was happy and spontaneously began to count to 10. His par-
ents then said, “Give the doctor his gift.” Adam proceeded to count to six in Spanish.
It is difficult to do justice, in written form, describing the excitement in the intersub-
jective here-and-now moment between Adam and the child psychiatrist. There was
glee in Adam’s eyes, as well as those of his parents and the child psychiatrist, in his
being able to count in Spanish. During their work together, the child psychiatrist had
sang a few songs in Spanish, which he shared he had sang to his daughter, as a way
of “being like them” in the here-and-now moments—we are all parents with our
own personal styles raising our children.
Further, the parents shared that the only time Adam had been overwhelmed was
during the Christmas family gathering, “but it only lasted a few minutes and he was
back to normal.” At the end of the follow-up session, they stated that they had
brought Adam to make sure he could recognize the child psychiatrist, in case “he
needs help when he is in school.”
There must be recognition that the process of making sense of the world we live
in is a lifelong one and early experiences or genetics alone do not determine later
outcomes (Kagan 1998). We remind the reader that we are not proposing that
Adam’s improvement was solely due to the work during the parent–infant process.
Rather, we believe that his improvement was due to many factors within his envi-
ronment that worked in synergy and provided support to the parents. For example,
the fact that Adam could count to 10 in English and to six in Spanish suggests that
his preschool was a growth-promoting environment. In two-person relational psy-
chology, knowing, not knowing, and sort of knowing (Petrucelli 2010) is something
we must be comfortable accepting. It is known that the developmental tasks infants
have are multifaceted and include the maturation of sensory, perceptual, and motor
functions, as well as emotional and social attachments through the meaning-making
process with others. The importance of the influence emotional availability of oth-
ers has on the infant is underscored by the fact that a wide variety of infant therapies
have proven to be useful (e.g., gentle touch, massage, holding, play, parent–infant,
and other psychosocial interventions) (Tronick and Beeghly 2011). Thus, we pro-
pose that the concept of internal regulation models that have inherent plasticity can
change through a variety of new emotional experiences and that this holds true for
contemporary two-person relational infant psychotherapy.
We are cognizant that from a traditional one-person model, Adam’s parents’
return to see the child psychiatrist may be considered to represent residual transfer-
ence manifestations of the parents to the child psychiatrist. Furthermore, it may
reflect their unconscious request for the child psychiatrist to provide a holding envi-
ronment and an invitation to resume a psychotherapeutic process. In this case, the
child psychiatrist intersubjectively viewed matters differently; they returned because
they needed a here-and-now moment of meeting that said, “Look, we are better
parents now. We want you to be happy with us.”
References 277

Psychotherapy
Without a doubt when a child psychiatrist makes a recommendation for the use of
medication in an 11-month-old child, it is worrisome for any parent and at times
frowned upon by colleagues. The child psychiatrist working with Adam and his
parents had experience in treating infants with low doses of liquid SSRIs for the
management of their anxiety on a short-term basis, until they were able to resume
the healthy developmental process. Adam was prescribed 2.5 mg of fluoxetine liq-
uid every morning for 10 days, which was increased to 5 mg in the subsequent
30 days. His parents shared that they believed he had a good response to the medica-
tion, saying, “We can take him to play with other children and even go to the grocery
store.” Adam did not have any negative effects from the medication. In following the
recommendation that if improvement was noticeable within 40 days, the medication
would be gradually discontinued on day 41, the fluoxetine began to be tapered off—
reverse sequencing. Over the next several months, Adam continued to do well.
Whether the positive changes seen in Adam were a result of the combination of
the psychotherapeutic process and the medication is difficult to be certain. We
would like to clarify that most would like to think that what made the difference in
Adam’s improvement was the result of the integrated relational biopsychosocial
parent–infant approach taken. As any contemporary two-person relational psycho-
therapist knows, we have to learn to tolerate that there will be many uncertainties
about the reasons why one patient improves and others do not. The extent of the
interplay in the process of nature and nurture in each person will remain difficult to
define. When we do not have a formal way to measure our outcomes, we rely on the
development of observable new and more adaptive ways of managing adversity by
our patients.
It is important to note to the reader that the many implicit and nonverbal interac-
tions that occurred in the psychotherapeutic process are difficult to capture with the
use of written language. Nonetheless, we hope to have provided, implicitly, the
reader a glimpse into the vast amount of nonverbal communication that transpires in
a two-person relational psychotherapeutic process, with ubiquitous disruptions and
moments of meeting.
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Elementary School Age Youth 11
It’s crucial that we start our children off on the right foot in school.
The stakes are high in these first years and what we
do really matters.
—Margaret Spellings, Secretary of Education
Children typically begin elementary school—primary education—at 5 years old,

after kindergarten. Elementary school generally goes through the sixth grade, typi-
cally to 11 years old. In elementary school, children learn the basics of reading,
math, science, and other subjects on which later learning will build. Socialization
skills are an important aspect of this period. Granic and Patterson (2006) eloquently
stated, “Parents and children are confronted with a variety of daily tasks (e.g., clean-
up time, playing games, problem solving when conflict arises, eating dinner
together). From our perspective, the extent to which parents and children can flexi-
bly and appropriately respond, emotionally, cognitively, and behaviorally, to shifts
in contexts may tap a repertoire of alternative strategies that correspond to how
children will adapt to future challenges at school and with peers.” Thus, during this
age, the child’s most skilled way in communicating his or her affective states is
initially through playing and making drawings, and later, in preadolescent years,
verbal communication takes hold.
In two-person relational psychology, importance is given to the innate variability
within the context of norms of development for a child and throughout his or her life
span, with attention to the influence by family systems and cultural factors.
Developmental research has provided evidence regarding the complex processes in
the scaffolding of physical and psychological competencies over time derived from
biogenetic developmental influences. More likely, children have a genetic develop-
mental blueprint that is strongly influenced by family and environmental factors,
which are interwoven and can act synergistically to promote further development
(Delgado et al. 2012). During elementary school age, the developmental milestones

DOI 10.1007/978-3-642-40520-4_11
280 11 Two-Person Relational Psychotherapy: Elementary School Age Youth
that children need to achieve are complex (see developmental milestones Appendix
A). Among the most salient developmental tasks are competition in games, enjoy-
ment of conversation in groups, increased interest in the opposite gender, and
respect of parents.
In traditional one-person psychologies, this period is viewed within the context
of psychosexual stages and is described as a latency period, “a biologically based
phase characterized by decreased sexual drive intensity (compared to the preceding
oedipal phase and the succeeding adolescent phase)…. During latency, a greater
equilibrium is established between defenses and drives” (Auchincloss and Samberg
2012). In traditional psychoanalytic theory, latency is defined as a period that
begins with the dissolution of the Oedipus complex and extends to the onset of
puberty, typically between the ages of 6 and 12 years old. It is believed that during
this period, there is intensification of repression, which brings in amnesia of the
early conflicts, development of sublimation, moral values including shame, and
aspirations for future activities. This phase was thought to be of relative psycho-
logical stability.
11.1 Psychodynamic Psychotherapy in Elementary

School Age Youth
The reasons for which school age children come to our offices are many, from inhi-
bitions—social and academic—to disinhibitions—verbal or behavioral. The child
and adolescent psychiatrist or clinician will benefit from a careful use of the con-
temporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s
unique attributes—temperament, cognition, cognitive flexibilities, and internal
working models of attachment—within the context of the environment in which
they live in, which includes family and culture.
During this age, play becomes central in children’s development. Virginia Axline
(1969) believed that children used play to communicate in a frank and honest man-
ner. Anna Freud and Melanie Klein were pioneers in viewing a child’s play as
equivalent to free associations of the adult. They believed that through the interpre-
tations of the conflicts caused by the pressures of the different developmental psy-
chosexual stages represented in their play, psychoanalytic treatment helped children
overcome their unconscious inner conflicts.
Consequently, the psychotherapist of young children will need to understand the
role play has in the child’s life, which allows using this form of communication in
the psychotherapeutic process. The authors agree with Krimendahl’s (2000) view:
“I do not view my role as finding ways to ‘get’ school age children to talk, for talk-
ing is not the most developmentally natural medium for children.” For children that
arrive to the psychotherapist’s office with play inhibitions, the task will be to implic-
itly help the child to be able to enjoy playing, as Krimendahl (2000) states, “getting
children to ‘play’ at playing games.”
11.2 Heather 281
The Association for Play Therapy (2014) defines play therapy as “the systematic
use of a theoretical model to establish an interpersonal process wherein a trained
play therapist uses the therapeutic powers of play to help clients prevent or resolve
psychosocial difficulties and achieve optimal growth and development.”
Additionally, Schaefer (2011) states, “Children use play to communicate when they
do not have the words to share their needs and look to adults to understand their
language.” From a two-person relational perspective, the use of play is a form of
communication that will always be influenced by the ever-present implicit contribu-
tion of the psychotherapist’s personal characteristics to the child’s choice of play. In
children who often bend the rules in their play, Krimendahl further states, “rather
than focusing on the child’s reasons for cheating, it is more important to assess why
we let a child win or not, for we are more swayed to do this with some patients than
with others.”
11.2 Heather
Heather, a 9-year-old girl, was referred by her pediatrician who noticed that she was
an anxious girl that worried constantly: “She just can’t stop worrying. I think this
child needs therapy.” Heather’s parents described her as a bright girl that worried
about completing her schoolwork, “even though learning comes easy to her. She
really doesn’t need to study that much.”
Heather was brought to the consultation appointment by her mother and father.
They said: “We know she needs help. She is a good kid but we can’t figure her out.
She suffers so much.” They added that she avoided going out with friends after
school or on weekends because she would spend hours completing schoolwork,
which at times was weeks in advance, or spend most of her time reading. They had
reassured her that she was doing well at school and wanted her to go out and have
fun with other children. They had attempted to arrange play dates with other chil-
dren for her although she would refuse to go. They noticed she was unhappy and
sought help from her pediatrician.
Heather would worry every morning before going to school, fearing she had
forgotten an assignment or a book and would anxiously say that she was not
happy. Her mother would feel guilt ridden after leaving her at school, although
somewhat comforted to know Heather was excelling academically and well
liked by her teachers. At school, the teachers noted she was overly self-critical.
She would become worried when a peer was corrected, fearing the child would
feel bad.
Her parents and extended family described Heather as an easy, jovial, and intel-
ligent child. At the time of the evaluation, her teachers described her as a very bright
and active fourth-grade student with excellent grades.
Past and Family History
Heather was the product of an uncomplicated full-term pregnancy who achieved

most of her developmental milestones on time. She was precocious in spelling,
reading, and math (reading and math were at a second-grade level when she was
5 years old). She was a healthy child in a close-knit family. Heather lived with her
stay-home mother, 32 years old, and her father, a 35-year-old engineer. Heather’s
parents had a good relationship and were well respected in their community. She
had a 6-year-old brother and a 4-year-old sister, who ostensibly were doing well.
The family was close to both paternal and maternal grandparents, who lived in the
same community. All family members were in good health.
Contemporary Case Formulation Following Use of the CDI: Heather

Summary: A 9-year-old female who presents with new functional impairment
timed with the beginning of fourth grade
Internal working models of attachment (IWMA): Secure and ambivalent/
anxious
Temperament: Mixed—slow to warm-up and easy/flexible
Cognition: Above average/gifted (see developmental milestones Appendix A)
Cognitive flexibility: Adequate
Formal psychiatric disorder: Symptoms of anxiety but did not meet DSM-5
criteria
Treatment recommendation: Twice a week two-person relational play psy-
chotherapy to address her anxiety and social inhibitions, and consider use of
formal cognitive behavior psychotherapy (CBT) or medication after 6 months,
if needed.
Contemporary Case Formulation Following Use of the CDI: Heather’s Parents

Summary: Parents were very caring and supportive of their daughter, and
were easy to engage by the psychotherapist. One possibility is that they may
have implicitly had contributed to her inhibitions during her early years by
implicitly rewarding her precocious abilities in reading and math at the
expense of playfulness.
Internal working models of attachment (IWMA): Secure and ambivalent/
anxious
Temperament: Easy/flexible
Cognition: Above average/gifted
Cognitive flexibility: High/adequate
Formal psychiatric disorder: Did not meet DSM-5 criteria
Treatment recommendation: Work with Heather’s parents as part of her
two-person relational play psychotherapy.

One-Person Model
From a traditional one-person model, Heather’s case conceptualization may take

several paths depending on whether it is viewed from a drive theory, ego psychol-
ogy, object relations, self-psychology perspective, or a combination of these theo-
ries, which is known as being pluralistic. What is common to pluralistic traditional
one-person approaches is that they rely on a wait-and-see approach by the psycho-
therapist in order to organize the information obtained through the play and verbal
narrative of the child. After which, the psychotherapist conceptualizes the case as
representing unconscious intrapsychic conflicts (those the patient is unaware of),
maladaptive ego defenses, and object relations conflicts. It would be beyond the
scope of this book to review all the possible case conceptualizations that may be
considered by a traditional one-person child psychotherapist. Thus, we limit our
review to a broad overview of the conceptualizations likely to be considered and
contrast them to the two-person relational model used in Heather’s treatment.
In traditional one-person psychoanalytic literature, Heather may have been
thought of as having an obsessional neurosis. That is, she unconsciously used ego
defense mechanisms to defend against the painful feelings from her unconscious
conflicts: isolation from peers, displacement onto schoolwork, reaction formation in
being an overly compliant child, and negation of her anger. With this in mind as a
diagnostic conceptualization, the psychotherapist would let the play develop and
wait for the correct time to point out the use of maladaptive ego defense mecha-
nisms used by Heather during the play, if they were thought to be interfering with
her ability to resume her healthy psychosexual developmental track.
In the school of self-psychology, Heather’s obsessional neurosis may have been
considered to be due to an empathic failure on the part of her parents and not because
of regressive and angry feelings directed at them. Soavi (1993) states, “The symp-
toms should be seen in connection with the attempt to defend oneself from various
forms of anxiety and with the failure to create within the self the capability of ori-
enting oneself in the world of affects.”
From a Kleinian view, Heather’s problems may have been conceptualized as due
to her angry feelings toward her objects—parents—who she unconsciously experi-
enced as rejecting. Her intense desire for knowledge and avoidance of play were
defenses against the destructive fantasies. Reading and knowledge represented her
anger at the internal representations of her parents as bad objects, an obsessional
neurosis (Klein 1932). The psychotherapist would help Heather work through these
conflicts by promoting strong transference feelings toward the psychotherapist, who
would later make comments regarding the unconscious ambivalence, guilt, and fear
of her angry and destructive fantasies toward her parents.
Regarding Heather’s parents, in the traditional one-person model, the psycho-
therapist may have provided regular educational sessions during the psychothera-
peutic process to help them understand their daughter psychologically and to
support the process. In the Kleinian model, there may have been little contact with
Heather’s parents during the psychotherapeutic process.

in Elementary School Age Youth
Two-person relational child psychotherapy has evolved from the traditional one-
person model. Two-person relational child psychotherapy has incorporated the con-
tributions of developmental research, attachment theory, and neuroscience to mental
health and behavioral issues. In a two-person relational model, the psychotherapist
takes an active role to first become “like them”: to be immersed in the patient’s and
parent’s subjectivities and implicit relational knowing during the sessions. It is
through this bidirectional process that occurs in the intersubjective field that allows
the patient to implicitly become, over time, an ally to the psychotherapist’s healthier
and more adaptive form of interaction with others. In essence, the two-person rela-
tional psychotherapist provides new emotional experiences for the patient and par-
ents, which will be stored in nondeclarative memory at an implicit level.
Allowing Subjectivities to Meet
Context Heather, in the presence of her parents, was a very charming young girl
during the consultation. The family readily agreed for Heather to begin a twice a
week psychotherapeutic process.
The psychotherapist, after first establishing an atmosphere of safety for Heather,
proceeds to sit on the floor and invites her to join him and choose what to play.
Heather joins him and sits on the floor. She notices that on the psychotherapist’s
desk there is a picture of a young girl.
Patient: Do you have children?

Psychotherapist: Yes, a daughter.
Patient: Is she your kid? [Pointing at the photograph]
Psychotherapist: Yes.
Patient: Do you play with her?
Psychotherapist: Yes I do, like I am playing with you right now.
Intersubjective The psychotherapist’s intent is to make use of his intersubjectivity

to guide him on how to cocreate experiences with the patient that implicitly provide
her with a subjective feeling that there is a blueprint on how to be playful with each
other, a sense of “We can play together.” Heather implicitly recognizes by the psy-
chotherapist’s gestures and excited tone of voice when talking about his daughter
that “he likes children and he is also playing with me.”
From a traditional one-person model, this interaction may be viewed as a coun-
tertransference enactment in which the psychotherapist self-discloses about having
a daughter, gratifying the patient’s wish to have her questions answered and know-
ing about the psychotherapist’s personal life. Further, it may be hypothesized that
the self-disclosure does not allow Heather to later work through feelings of anger
and jealousy of her psychotherapist’s daughter. We highlight that from a traditional
one-person model, the hypothesis will depend on the school of thought that the
psychotherapist adheres to. The traditional one-person model does not consider the
here-and-now mutuality of intersubjectivity—which guides the relational psycho-
therapist—as curative because it does not allow for the working through of the
child’s maladaptive use of neurotic or immature ego defenses (see Chap. 3).
Patient: Does she worry like I do? [Appears to be seeking for reassurance that she
is not alone in worrying]
Patient: What does she like to play?
Psychotherapist: Children, like you and my daughter, are happy about many things,
although they sometimes worry about other things. I think the best part of being
a child is that playing is a good way to forget about worrying. My daughter plays
with many of the games I have here. [Pointing at the games]
Patient: Does she worry about school assignments?
Psychotherapist: Only when they are difficult. Which are the most difficult for you?
Patient: I worry about getting things completed on time. I am a good student and I
like getting good grades.
Psychotherapist: I wonder what you would think if you were really good at playing,
just like you are at learning. What do you think?
Patient: I would worry that if I spend too much time playing, I might not complete
all the assignments. I think that my parents are happier if I get good grades, and
they might get mad at me if I play a lot.
Psychotherapist: Thank you, I think I understand. [The psychotherapist attends to
the nonverbal communication as the autobiography is influenced by her implicit
relational knowing. He knows that by cocreating playful moments of meeting,
they will implicitly allow her to develop more adaptive implicit relational pat-
terns and lead to change, rather than pursuing the insight-oriented verbal
dialogue]
Intersubjective The psychotherapist attempts to accomplish several issues at

once. First, the psychotherapist builds an atmosphere of safety, mutuality, and play-
fulness in the here and now. Second, he reinforces that anxieties are part and parcel
of everyday life for children. He further reminds Heather that pleasant experiences
can occur throughout the day, even though there may be moments of anxious feel-
ings at times. The implicit relational nonverbal experience is conveying, “Yes, I
know you are anxious at times, although I suspect that you have happy moments
throughout the day.” The psychotherapist does not take a neutral stance; rather, he
intersubjectively believes Heather is able to handle his moving the process along by
implicitly and verbally sharing that he is familiar with her struggles. In contrast, if
the psychotherapist had experienced intersubjectively that Heather was overly anx-
ious or inhibited, he may have chosen to point out with his facial expression and
verbally that he noticed her discomfort and suggests to play a game of her choice,
rather than engage in conversation. He used the here-and-now mutuality to guide
him in the action of moving the process along. Finally, he accepts the nonverbal
communication of Heather’s reason for not having time to play and understands that
for this to change, she will have to learn to enjoy playing, which he plans to help her
in vivo during the following sessions.
In a traditional one-person model, the psychotherapist may hypothesize about
the unconscious conflicts that contribute to her play inhibition and may choose, in
the right moment, to point out her dilemma—making the unconscious conscious.
Context In early sessions, Heather would come to the appointment and jovially
state that she had homework to complete and would then ask if she could do so dur-
ing the session.
Patient: Is it OK if I work on my schoolwork? I want to make sure I finish it all, and

I have a lot.
Psychotherapist: Of course. It will help me get to see how much work you have.
Patient: Good, I like to finish my work so I don’t have to worry when I go to bed.
Psychotherapist: I might even be able to help you, if it is easy of course. [Smiling
and joking about his ability to help] Do you mind if I ask questions about your
work? I like to know what you are learning. [Nonverbal communication: home-
work can be done playfully]
Intersubjective The psychotherapist is keenly aware of his intersubjective experi-

ence, wanting to fill in for a parent, and state, “No, let’s play and you can complete
your work later.” He also recognizes that it is best for him to initially engage in her
implicit relational knowing style and to see matters from her perspective, although
he is aware of his wish to say “something that will help Heather loosen up.” In tra-
ditional one-person model, this would be akin to interpreting her using studies as a
defense against becoming aware of her inner feelings, commonly thought of as an
obsessional neurosis.
The psychotherapist, in using two-person relational model, decides to intervene
in a manner that can serve as a new nonverbal meaning-making process and later in
their intersubjectivities become a moment of meeting. Herein, while she completes
her schoolwork, he proceeds to sit on the floor and play against himself in a card
game of Uno and at times plays with the game of Connect Four. While playing—
and while she completed her schoolwork—he shares with Heather his excitement
when he wins and with gestures of disappointment when he loses. The psychothera-
pist’s goal is to provide Heather, in a nonverbal here-and-now manner, a new
meaning-making process of the joyful aspects of playing in the presence of another
person–social referencing. The expectation was that at an implicit level, she eventu-
ally would wish to join.
Context In a later session, Heather uncharacteristically came to the appointment

somewhat anxious and wanted the psychotherapist to help her know what she should
play during the session.
Patient: I want you to tell me what I should play today. [Anxious and with unchar-
acteristic slight restlessness]
Psychotherapist: OK, how about drawing something that you enjoy doing.
[Implicitly appealing to something that was helpful to her, thus managing her
current state of anxiety]
Patient: Good, I like to draw. I can make drawings about the story we read at school
today. [Outwardly looks relieved and returns to her jovial self]
Psychotherapist: By the way, I noticed that you looked worried when you walked
in. Let me know if I can help you in any way. [Implicitly letting her know, “I
noticed you are anxious, but with my tone of voice and gestures, I hope to help
you feel your anxiety does not make me anxious and what you are experiencing
is part of life and bearable”]
Intersubjective The psychotherapist provides an intersubjective experience of

“sure I can guide you” and allows for curiosity and creativity to emerge. He will
keep in mind her early uncharacteristic anxiety and is aware it may have been due to
a wide range of possibilities: disagreement with her mother on her way to the psy-
chotherapist’s office, difficulties at school, something occurring in the waiting room
as there were other children, etc. In other words, in the here-and-now moment, the
psychotherapist intersubjectively felt that it would have been detrimental to focus on
her anxiety and opted for agreeing with her request to be guided on what to play. In
agreeing to guide her, it helps her feel safe. This provides the psychotherapist time
to allow the intersubjective experience to guide him on how to proceed. If he would
have noticed that her anxiety continued to bother her, he may choose to note, “You
are very anxious today, can I help?” If her anxiety subsides, he may mention he
noticed her anxiety when she arrived and compliment her on how she managed it.
Herein, he cocreates an implicit nonverbal moment of meeting “Look what you can
do on your own” rather than “I (the psychotherapist) believe that if you talk about it
you will feel better.” We recognize that some children would rather put into words
what troubles them, and in a two-person relational model, the psychotherapist would
have known to pursue this by his intersubjective experience in the here and now.
Later in the Same Session
Context The patient later in the session volunteered that her mother had surprised
her during their drive to the appointment that they were going to her same-age
cousin’s birthday party, which made her anxious and angry.
Patient: Why did my mother do that? She knows I don’t like parties. [Anxious
although less restlessness and more reflective and implicitly invites the psycho-
therapist for guidance]
Psychotherapist: Help me understand. Parties are events for children to have fun
and you are telling me you will not have fun, right? [Implicitly demonstrates his
excitement about parties]
Patient: I am afraid that I won’t have fun. I don’t know any of the other kids; I only
know my cousins. [The psychotherapist intersubjectively feels she actually
would like to go]
Psychotherapist: Let me tell you a story. When I was a kid, I always worried about
whether I was going to have fun when I was invited to parties. So I really under-
stand you. The funny part about it is that my parents and friends would encour-
age me to go, and I would always have fun. Later when I was a teenager, when I
would tell my parents that I was going to a party, we would laugh together
remembering the times I used to worry if I was going to have fun. [Implicitly
letting her know, “I noticed you are anxious, but with my tone of voice and ges-
tures, I feel you are ready to go to a party and I have the sense that you will have
fun. What you are experiencing is part of life and bearable”]
Patient: That’s a funny story. I know I have to go to the party. I am not promising
you that I will have fun.
Psychotherapist: I will have fun hearing to how it goes. If you have fun at the party,
that will be great. If you don’t, great as well, you will have more stories to tell
me. [Actively engaging and smiling. Intersubjectively feels the patient seems less
worried about going]
This interaction captures the sloppiness in a two-person relational psychotherapy

process. That is, allowing the patient’s subjectivities to guide the psychotherapist as
to how to proceed is essential and at times leads to unexpected moments of meeting.
The authors are frequently made aware by colleagues and students that the sloppi-
ness of a two-person relational model is difficult to tolerate, in contrast to a tradi-
tional one-person model. To this, we reply, “It may be initially difficult to tolerate
the uncertainty in knowing what here-and-now verbal and nonverbal interactions
mean or when they take hold. The advantages of cocreated new and corrective emo-
tional experiences are unique to each dyad, and the rich here-and-now experiences
that lead to change occur without us knowing and will be stored in nondeclarative
memory.” We commonly share with our trainees “Trust your heart; even if you don’t
know why things improve, you will notice the improvement intersubjectively.”
Two Months Later
Patient: I want to play Jenga. [She is jovial and demonstrates excitement]

Psychotherapist: Sure. [Matching her excitement]
Patient: I bet I can beat you. I have been playing after school with my friends.
Psychotherapist: You have practiced more than I have. [Accepting the challenge in
a playful manner]
Intersubjective In the two-person relational model, the psychotherapist experi-

ences intersubjectively that the child’s request in the here and now reflects her prog-
ress in enjoying playing with others. The psychotherapist matches her enthusiasm
in playing to move along the process.
In this scenario, from a traditional one-person approach, the psychotherapist may

have considered that Heather’s play may be unconsciously related to her being able
to work through issues of rivalry and anger, perhaps toward her father, hypothesized
as transference manifestations when she states “I bet I can beat you.”
Patient: Did you study a lot at school to become a doctor? My dad had to study a lot
to become an engineer, and he is really good. He reads a new book almost every
week.
Psychotherapist: Yes, I did study a lot. Although I remember that as a child, I also
enjoyed being outdoors and riding my bike to go play with my friends.
Patient: Did you have your schoolwork completed before you went out? [Active
moment of jovial curiosity]
Psychotherapist: Most of the time. [Smiling] Sometimes I had to make sure I com-
pleted my schoolwork after I returned from playing with my friends.
Patient: I am beginning to try that, and I really have enough time for both.
Psychotherapist: What I remember as being difficult was that I thought my parents
did not want me to spend too much time playing, even though they said they were
happy for me to play as long as I finish my schoolwork later.
Patient: [Interrupts psychotherapist—a moment of meeting] Yeah, I have the same
feeling. [Smiling] You know what? Even when we play in here, I still have time
to complete my school assignments at home.
Psychotherapist: [Matching her excitement with gestures and tone of voice] Great.
Psychotherapist: He subjectively notices the urge in wanting to say “And the days
you don’t come here, you could even play with your friends and still have time
for your schoolwork.” He recognizes that the urge to make the comment comes
from his role as a parent, and he is keenly aware that intersubjectively Heather is
asking him to enjoy her progress in the here and now, without the intrusion of the
psychotherapist’s own subjectivity.
Intersubjective When Heather asks how much the psychotherapist had to study to
become a doctor, he intersubjectively experiences Heather as asking whether there
is room for play in a good student. He chooses to self-disclose about his avid inter-
est in schoolwork when young and the ubiquitous dilemma of good students: Do
parents really mean it is OK to play? He affectively conveys the excitement in play
and how he learned to manage play and school. In a two-person relational model,
the psychotherapist experiences intersubjectively that Heather has begun to develop
more adaptive patterns in her life and has a wider sense of curiosity. The psycho-
therapeutic process has moved forward, reflected in the progress of her enjoyment
of being more engaged in play during the sessions, “Even when we play in here, I
still have time to complete my school assignments at home.” We note that at times,
self-disclosures and enactments occur unknowingly to the psychotherapist and its
presence is revealed by the patient, “Yeah, I have the same feeling”.
In contrast, from a traditional one-person approach, the psychotherapist’s self-

disclosure may have been frowned upon, as it would prevent understanding the
nature of Heather’s inner conflicts about her play inhibition.
Context The parents say: “We are glad that Heather is seeing you. She doesn’t
worry as much, and we enjoy seeing her play with her friends. Why do think she
worried so much? She is only a child. Do you think we did anything wrong?”
Mother: Do you think we did something wrong raising her? We were always there
for her, and she was an easy baby.
Psychotherapist: I understand. It’s not easy to have a child that needs help with their
feelings, without feeling that in some fashion one is to blame.
Both parents: That is so true.
Psychotherapist: Heather has what we call play inhibition, due to her anxiety. It
does not meet the criteria for a formal psychiatric disorder, and it is poorly
understood.
Intersubjective The psychotherapist intersubjectively begins to review the four pil-

lars of a CDI (Chap. 8) and posits that her temperament and gifted cognitive abilities
at such a young age likely influenced her cognitive flexibility. He explains that her
shyness toward same-age peer playfulness may have led her to implicitly be more
attuned to adults, displayed by her being an avid reader and very compliant at school.
Mother: Do you know think that’s why she would spend hours reading and not
playing?
Father: That reminds me of how I was as a child, always reading, although I did
have a lot of fun playing with my friends. Is this what you mean about
genetics?
Psychotherapist: Yes.
Intersubjective The psychotherapist intersubjectively wonders if the parents had

been playful with Heather when she was a toddler. He chooses not to pursue this fur-
ther, as he is aware that what they recall may be different to what Heather implicitly
experienced, if due to her temperamental issues—goodness of fit—or other realities
in the family, at the time, that may be unavailable for recall. Additionally, intersubjec-
tively, the psychotherapist found Heather’s parents as jovial and with a good sense of
humor. Herein, as in any two-person relational psychotherapeutic process, the truth
regarding the origin of the patient’s symptoms will remain elusive, although the
changes in the form of a new emotional experience will be curative. During the pro-
cess, the psychotherapist met with the parents regularly to provide education on how
to support Heather’s efforts in balancing her playfulness with her schoolwork.
Letting Go
Context Heather used the psychotherapeutic process well and gradually began to
express her genuine excitement in developing more adaptive patterns of interaction
with her parents and peers, recognized by the psychotherapist as a result of a new
emotional experience. Heather became more involved in extracurricular activities,
and her parents had encouraged her to ask her psychotherapist if she could decrease
the frequency of appointments or stop the psychotherapeutic process. The psycho-
therapist agreed with stopping the process, with intersubjective feelings of “She can
manage without me now,” and they—the patient, parents, and psychotherapist—
agree to end the process after three more sessions.
Final Session
Patient: I really like you, your office, and your toys. I don’t think I need to keep
coming to see you. I will miss you and your toys. I feel a lot happier. [She is
actively seeking for the psychotherapist to respond to her comments]
Psychotherapist: I would agree with you. You are a lot happier. I like that you now
are able to play with your friends without it affecting your schoolwork. I will
miss seeing you too. I will also always remember how we played with the toys
and all the drawings you made.
Patient: I am happy you helped me. I might see you someday at a store or
restaurant.
Psychotherapist: I really like how you handle things now. If you become worried, I
am sure you will remember how much fun we had in here. [Smiles empathically
and with confidence]
Intersubjective The psychotherapist intersubjectively experiences Heather as hav-

ing stored in nondeclarative memory the progress made when she says, “I really like
you, your office, and your toys.” He notices not having the sadness that usually
occurs when there is a feeling the work is not complete; rather, he intersubjectively
felt, “We accomplished a lot.”
A note about why the psychotherapist agrees to end the process in three sessions.
In a traditional one-person model, it is hoped that the termination phase will allow
for the mourning in letting go of the “good object” in the psychotherapist and may
need resolution of transference manifestations that may have developed. In contrast,
in a two-person relational model, the letting go process is based on the accumula-
tion of cocreated moments of meeting that permit the psychotherapist to intersub-
jectively know when the corrective emotional experience has taken hold. For some,
it may have been done in a longer fashion. In this case, Heather had a very support-
ive family and good nucleus of friends in which the new adaptive patterns of implicit
relational knowing were welcomed. As Adler-Tapia (2012) states, “The best psy-
chotherapy is when it is no longer necessary.”
11.5 Summary
In this chapter, we have provided the reader a detailed description of the work that
transpired in the case example of a 9-year-old school age female child with anxiety.
We began with a description from a traditional one-person model and follow with a
contemporary two-person relational psychotherapeutic approach, with attention
paid to the patient’s and her parents’ temperament, cognitive and affective flexibil-
ity, and internal working models of attachment—within the context of intersubjec-
tivity with the psychotherapist. This serves as a broad review of the main differences
that exist between both theoretical approaches.
References
Achincloss EL, Samberg E (2012) Psychoanalytic terms and concepts. American psychoanalytic
association. Yale University Press, New Haven, pp 136–137
Adler-Tapia R (2012) Child psychotherapy: integrating developmental theory into clinical practice.
Springer, New York, p 267
Axline VM (1969) Play therapy. Ballantine Books, New York
Granic I, Patterson GR (2006) Toward a comprehensive model of antisocial development:
a dynamic systems approach. Psychol Rev 113(1):101–131
Klein M (1932) The psycho-analysis of children. The Hogarth Press, London, p 57
Krimendahl E (2000) “Did you see that?”: a relational perspective on children who cheat in analy-
sis. J Infant Child Adolesc Psychother 1(2):43–58
Schaefer CE (2011) Foundations of play therapy, 2nd edn. Wiley, Hoboken
Soavi GC (1993) Deficit of the structure of the ‘Self’ and obsessional neurosis fusional deficit and
the structure of the self. Rivista Psicoanal 39A:33–42
The Association for Play Therapy (2014) Play therapy makes a difference. doi:http://www.a4pt.
org/ps.playtherapy.cfm. Accessed 12 May 2014
Middle School Age Youth 12
The most important thing is to enjoy your life—to be happy—it’s all that matters.
―Audrey Hepburn
Middle school age youth are those from ages 10–14 years old. This period is also
referred as prepuberty, preadolescence, and early adolescence. During this period,
youth experience biological, psychological, and social changes. There are dramatic
changes in physical development, encompassing height, weight, and sexual devel-
opment. Although maturity during this period occurs at variable rates, generally in
girls it occurs 1.5–2 years earlier than in boys.
One of the major cognitive changes that occur during this period for youth is the
transition from concrete thinking to abstract thinking. According to Erikson’s the-
ory of psychosocial development (1968), during this period youth undergo conflicts
of industry versus inferiority. During this stage, youth experience mixed feelings
about where they fit into society and may experiment with several different roles
until they achieve a sense of identity (McDevitt and Ormrod 2010). Furthermore,
they develop a better understanding of higher levels of humor, are inquisitive about
adult roles, and often challenge their authority. During this period, youth are psy-
chologically curious and idealistic about the world and themselves. Regarding
morality, they develop their own personal values, which are consistent with those of
their parents.
Social relationships and roles change dramatically as they join youth programs
and become involved with peers and adults outside of their family. During this
period, they develop a sense of individuality by actively comparing themselves with
their peers and seeking approval from them. This facilitates having close friends
their own age, which can provide the sense of “belonging” to a larger similar group.
In traditional one-person psychology, middle childhood is thought to be a post-
latency period in which drive pressures increase and boys may have a reawakening
of anal humor as a defense, and the relationship to their father and male teachers
becomes less troubled, which facilitates ego-ideal identifications. In traditional

DOI 10.1007/978-3-642-40520-4_12
294 12 Two-Person Relational Psychotherapy: Middle School Age Youth
one-person psychology, for girls, this phase is believed to lead to a regressive attach-
ment to their mother to preserve the bisexual and postpone final acceptance of their
femininity (Call et al. 1979). This phase was thought to be of relative psychological
instability.
12.1 Psychodynamic Psychotherapy in Middle School

Age Youth
Middle school age youth are dealt the difficult task of balancing increasingly com-
plex interactions with parents, caregivers, teachers, and peers within exponentially
complicated environmental factors. This population is referred to our offices for
difficulties regarding self-regulatory abilities (e.g., problems with impulsivity and
aggression, difficulties with social reciprocity, and academic problems). The child
and adolescent psychiatrist or clinician will benefit from a careful use of the con-
temporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s
unique attributes—temperament, cognition, cognitive flexibilities, and internal
working models of attachment—within the context of the environment in which
they live, which includes family and culture. As such, the evaluation will rely on
collateral information from other sources familiar with the child and his or her fam-
ily. This information is essential to a complete CDI, as likely the problems origi-
nated at an earlier age and are now interfering with their psychosocial development
(see developmental milestones Appendix A).
During this age, the child’s cognitive abilities expand, and he or she is better
able to problem solve and hold two opposing viewpoints in mind. This allows for
the vitality needed to remain engaged in peer group activities, and difficulties in
this area frequently reflect cognitive and relational complications. Many times
difficulties in peer group activities are viewed from a traditional one-person
model as a result of neurotic or immature ego defenses against the angst experi-
enced. We propose that from a two-person relational model, the angst of children
at this stage is generally due to difficulties with temperamental, cognitive, or
relational abilities, influenced by innate internal working models and not from
unconscious intrapsychic pressures from the id and superego or object relation
problems.
12.2 Charlie
Charlie, an 11-year-old boy, was brought by his mother with a specific request to
help him cope with the inevitable death of his father, who was suffering with termi-
nal cancer. His mother shared that his worries were affecting many areas of his life.
After school, Charlie had begun to cry and yell at his mother for not helping his
12.2 Charlie 295
father seek treatment earlier to prevent his cancer from spreading. He was angry
with her for “thinking God is good.” He would cry, “I am angry with God because
it is not fair to lose my father!” He was troubled by a dream he had several weeks
before his appointment, in which he had a premonition that his father would die in
a car accident several months later and on a specific date. He was terrified that his
premonition would come true. He began to believe and worry that if his father died
on that day, it would be his fault, and others would think that he had wished for it to
happen.
Past History
Charlie was the product of an uncomplicated full-term pregnancy and achieved

his developmental milestones on time. He was an only child in a close-knit
family. His parents, teachers, and extended family described him as an easy,
jovial, and intelligent child. At the time of the evaluation, he was an active
sixth-grade middle school student. He was a good student with above average
grades, and he was involved in competitive swimming. Though overall he was
a healthy child, for the past 2 years he had been treated for attention deficit/
hyperactivity disorder (ADHD) with extended release methylphenidate with
good results.
Charlie lived with his mother, 40, and his father, 46, who were well-respected
professionals. Two years prior to the evaluation, his father was diagnosed with
Stage IV basal cell carcinoma. Despite numerous surgeries, chemotherapy, and
radiation treatments, his cancer was deemed terminal after metastases were dis-
covered in the liver and brain. Though several doctors provided the option for
hospice, concerned that Charlie might be burdened by seeing his father deterio-
rate, Charlie’s mother made the decision to care for Charlie’s father at home.
Contemporary Case Formulation Following Use of the CDI: Charlie

Charlie: An 11-year-old male who presents with new functional impairment
timed with the terminal illness of his father
Internal working models of attachment (IWMA): Secure
Temperament: Easy/flexible
Cognition: Above average (see developmental milestones Appendix A)
Cognitive flexibility: High
Formal psychiatric disorder: ADHD and met DSM-5 criteria for adjust-
ment disorder, acute with mixed anxiety and depressed mood
Treatment recommendation: Two-person relational psychotherapy. The
psychotherapist would promote the cocreation in the here and now of more
adaptive patterns to cope with his struggles in the midst of the tragic
circumstances.
Contemporary Case Formulation Following Use of the CDI: Charlie’s Mother

Charlie’s mother: A 46-year-old woman who presents with new functional
impairment timed with the terminal illness of her husband
Internal working models of attachment (IWMA): Secure
Temperament: Mixed—primarily easy/flexible, with some difficult/feisty
(see below)
Cognition: Above average
Cognitive flexibility: High
Formal psychiatric disorder: None
Treatment recommendation: Work with Charlie’s mother as part of
Charlie’s two-person relational psychotherapy to help her and her son cope
with his struggles in the midst of the tragic circumstances.

One-Person Model
When seen from a traditional one-person model, the case conceptualization may
take several paths, depending on whether it is viewed from a drive theory; ego psy-
chology; object relations, or self-psychology perspective; or a combination of these
theories, which is known as being pluralistic. To this, we provide the reader a broad
view from a traditional one-person perspective and hope that it can serve to contrast
the differences of case conceptualization and therapeutic interventions with the two-
person relational model used in this case.
In the traditional psychoanalytic literature, the death of a parent is considered to
have a significant impact on a child’s intrapsychic processes, which leads a child to
use defensive mechanisms to deny the reality of the death. Menes (1971) captures
this masterfully: “There is also wide agreement that a particular set of responses
tends to occur in children who experience the death of one of their parents. These
reactions include unconscious and sometimes conscious denial of the reality of the
parent’s death; rigid screening out of all affective responses connected with the par-
ent’s death; marked increase in identification with and idealization of the dead par-
ent; decrease in self-esteem; feelings of guilt; and persistent unconscious fantasies
of an ongoing relationship or reunion with the dead parent.” Further, Menes believes
that the child’s responses serve to avoid the acceptance of their parent’s death and
there is a need for a reorganization of the object attachments that such an acceptance
would require. For Furman (1964), mourning in children occurs only when a psy-
choanalytic treatment is initiated in order to facilitate the mourning process to
develop through the transference to the analyst.
Further, it is suggested that the death of a parent reawakens oedipal conflicts.
This is best captured by Gill (1987): “Death of the oedipal rival results in a confu-
sion of the unconscious wish with an external happening. The child, unable to cope
12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 297
with the consequent guilt, resorts to repression. Thus, the critical aspects of the
oedipal triumph remain potentially operative in the unconscious, hindering the
patient’s functioning in all closely associated areas.”
Therefore, in the traditional one-person model, Charlie may have been thought
as defending himself from the painful mourning process with a decrease in self-
esteem and unconscious feelings of guilt for his anger at his mother and at God. To
this, the psychotherapist’s interest in the verbal narrative of the events with some
attention to neutrality allows for transference manifestations to develop and be best
understood. The psychotherapist will likely be initially experienced as the good—
father object—which Charlie unconsciously and in the transference will use to deny
the reality of his own father’s imminent death. This will also be noted by an increase
in ego-ideal identifications and idealizations of the ill parent, likely to increase after
his death. The traditional one-person psychotherapist will be attentive to the patient’s
use of ego defenses and be alert to pressures from his superego, typical during this
phase of development; his fear about the death of his father; and his guilt for his
age-appropriate anger and possible unconscious feelings of oedipal triumph.
Regarding Charlie’s mother, in the traditional one-person model, the psychotherapist
may have provided regular educational sessions during the psychotherapeutic process to
help her understand her son psychologically and to support the process. She may have
initially been seen as also struggling in not wanting to be reminded of the loss of her
loved object (her husband) by her son’s need for psychotherapy. In the Kleinian model
there may have been little contact with her during the psychotherapeutic process.

in Middle School Age Youth
The two-person relational psychotherapy is a rich and complex process that has
evolved from the traditional one-person model. For an in-depth definition of con-
temporary two-person relational psychotherapy, we refer the reader to Chap. 3. In
short, it is an interaction between patient and psychotherapist that promotes the
cocreation of more adaptive experiences for the patient in the form of a new emo-
tional experience, from the psychotherapist’s personal healthy attributes, which is
then stored in nondeclarative memory. The relational psychotherapist makes careful
use of timed self-disclosures and occasional enactments. We note that at times self-
disclosures and enactments occur unknowingly to the psychotherapist and its pres-
ence is revealed by the patient.
Context During the first appointment, Charlie was invited to draw a family geno-
gram with his mother guiding the process, a common technique used by the authors
that provides an intersubjective experience of the family’s affective states when
referring to other family members (Delgado and Strawn 2014).
Observations of the Patient Charlie appeared happy as he drew the genogram

of his family. He beamed with pride as he demonstrated his knowledge about his
extended family, despite the many medical illnesses in them. He stated, “You
(psychotherapist) are going to be surprised by all the cancer in my dad’s fam-
ily!” While drawing the genogram, he frequently showed interest in his moth-
er’s comments about each family member. He appeared pleased to know more
about his extended family. He was reminded that both his paternal grandparents
had passed away when he was an infant. His paternal grandfather, a heavy
smoker, died of lung cancer, and his paternal grandmother had died of brain
cancer. Charlie demonstrated an ability to reflect and empathize with his father’s
genetic vulnerabilities, as he wondered, “I can see why my dad has cancer; it
runs in the family.”
Intersubjective The clinician’s initial intersubjective experience of Charlie and his

mother, when they were creating the genogram, was a great feeling of sadness as well
as recognizing their resilience, in particular a deep sympathy with Charlie’s grasp of
his family’s long-standing history with terminal cancer. In contrast, Charlie’s attitude
in the room conveyed a sense of “Life is good and must go on.” He seemed able to
easily retrieve implicit memories—positive and adaptive cocreated moments of hap-
piness from his past—in the midst of his father’s severe illness.
A significant moment of meeting occurred when Charlie shared with the psycho-
therapist about being pleased he could begin his own psychotherapy. In these
moments, Charlie appeared to be communicating to the psychotherapist, “So far, I
perceive you as being able to be a good fit with me and my family. You continue to
demonstrate interest in me, even though I have a great deal of sadness in my family.”
He implicitly demonstrated that he was able to hold in mind the positive and adaptive
cocreated moments of meeting in his past relationships. Stepping back and viewing
the larger implicit relational field, the psychotherapist’s subjective experience was, “I
feel you are close to your family members. Your mother recognizes your strengths
and does not fear sharing matters from your vantage point.” In this way, the psycho-
therapist—observing the child’s easy temperament, high cognitive flexibility, and
secure internal working models of attachment—concludes that they can work with
each other to help the child (and the family) cope with the tragic sadness.
Context After several sessions, Charlie shared his fear about how he was going to
feel after his father’s death.
Patient: I am feeling really bad because my dad is not doing well; he is looking
worse. He is in a lot of pain [genuinely sad and worried].
Psychotherapist: Your feelings are difficult to have, even if they are normal [inter-
subjectively also feels sad].
Patient: Will I get over all of this after he dies?
Intersubjective The psychotherapist feels Charlie has a good grasp of matters.

Rather than listen further, the psychotherapist chooses to self-disclose and cocreate
a moment of meeting that will be needed in future encounters, as his father’s condi-
tion was deteriorating.
Psychotherapist: I think your dad is a good teacher to you about matters of life. With
your dad not doing well, I can see why you feel bad; you must know how he must
be feeling, and you feel it too. I am impressed on how well you understand what
you and he are going through. You will be able to overcome your sadness.
Patient: I am glad you think I will get over the sadness and be OK after my father
dies.
Intersubjective The psychotherapist implicitly provides Charlie a subjective feel-

ing that there is a blueprint on how to cope with the death of a loved one. Charlie
implicitly recognizes by the psychotherapist’s gestures and tone of voice that he is
attuned to his painful feelings when sharing about his father deteriorating, “he
knows how I feel and is not upset with me. He knows this will pass.”
Context Charlie shares a dream he had where he has a premonition about his
father’s death on a specific date.
Patient: I know it sounds crazy to think my dreams can come true. When I was
younger, I dreamt about my best friend being in a car accident, and when I woke
up, I found out that he was in a car accident. He wasn’t hurt though.
Psychotherapist: I am not sure what your dream means, but dreams are typically
about what people are happy or worry about [intersubjectively feels Charlie is
engaging in age-appropriate curiosity].
Patient: Yeah, I know I worry about my dad—it sounds crazy too, but he will be
happier after he dies. He hurts so much.
Psychotherapist: I know of many people who worry about what is going to happen
in the future and think of random events as lucky premonitions, like when base-
ball players carry a rabbit’s foot for good luck. It is difficult to make sense of
those two events, a dream about a car accident and the actual car accident hap-
pening. I would like to think that your dreams are a way for you to put your wor-
ries in pictures and that in the dream there is a kernel of truth; your worry about
your best friend and worry about your father.
Patient: I guess you are right. I worry about my dad when I go to sleep, and some-
times I wish God would take him so he doesn’t have to go through all the pain he
is going through. Maybe I want God to give me a date of when my Dad will die
so I can wait and cry when it happens.
Intersubjective The psychotherapist’s intersubjective experience with Charlie

is that he was aware that his dreams captured his worry and that he had a good
grasp that his premonitions were nonconscious attempts to prepare him for the
inevitable death of his father. The psychotherapist chooses to self-disclose and
cocreate a here-and-now moment of meeting that can be nonconsciously accessed

in the future as his father’s condition is deteriorating. The importance of the
interaction described is not only on what transpires verbally but what occurs at
the implicit nonverbal level. The psychotherapist and patient are attuned, and
their tone of voice, gaze, and affective states allow both to know each other’s
state of mind.
In a traditional one-person model, this intervention may have been considered a
countertransference enactment that circumvented Charlie’s further associations
about his dream and worries with his father’s death. In encouraging associations,
this may have allowed the psychotherapist to understand the child’s inner life or
attune to possible transference manifestations available for working through. In a
two-person relational model, it is best to understand the patient’s reference to his
past within the context of the here-and-now mutual subjectivities of each person in
the dyad, as each has influenced what is remembered and has a front seat to their
relevance in moving along the process to form new, more adaptive patterns of self-
regulation and interaction with others. We reiterate the importance of what tran-
spires at a nonverbal implicit level.
Subsequent Session
Context By the sixth session, Charlie’s father required a feeding tube and was
deteriorating rapidly. Charlie shared that he had been crying during classes and was
having difficulties paying attention at school.
Patient: I can’t stop feeling sad and worried. It’s going to happen very soon. Have
you seen kids whose parents are dying?
Psychotherapist: Yes, I have, and I can tell you that for children, losing a parent is
very difficult [intersubjectively feels Charlie is engaging in age-appropriate
curiosity about his future without his father and is hoping for here-and-now gen-
uine affective attunement].
Patient: I have a feeling this is also very hard on you. [An example of sloppiness:
Intersubjectively Charlie becomes aware of the impact he has on the psycho-
therapist, and he demonstrates his use of prior moments of meeting between
them by providing a new moment of meeting with the psychotherapist, which
implicitly provides the experience of closeness, “We are in this together.”]
Psychotherapist: You are right. I also feel sad that you are losing your father [inter-
subjectively allows Charlie to recognize that the psychotherapist genuinely feels
sad and that it is normal for Charlie to have his feelings].
Patient: I like it that you are honest. You know, my mom tries to hide her sad feel-
ings from me. I want her to show that she has sad and angry feelings like I do. I
worry about her.
Psychotherapist: Thank you. You know, many people handle happy and sad feelings
differently. Some, like you and me, are open about them. For others, they are
better at keeping them inside, and sometimes they think that it is better for their
children to not see them cry or get angry.
Intersubjective The many moments of cocreation and the goodness of the implicit
relational fit between Charlie and his psychotherapist played an important role in
this sequence of interactions. Charlie intersubjectively knew that his reactions to his
father’s worsening would be difficult on the psychotherapist, as if “I know it affects
you because you have feelings too.” The psychotherapist experienced the moment
of meeting as Charlie makes use of the experience of closeness, keeping in mind the
psychotherapist’s belief in his strengths.
Context Charlie shared that being successful in his swim competition on his trip to
Washington, D.C., was difficult for him.
Patient: It was difficult to do so well and not being able to share it with my father. I
also felt bad that I actually did well and had fun with my friends. It was helpful
to have planned a phone call to talk to you while I was there [smiling in a jovial
manner], like a lucky ritual.
Psychotherapist: [Joining in mutuality with a smile] A lucky ritual that you had the
control of whether you used it. Sounds like you are proud of the decision you
made.
Patient: Do you have any lucky rituals when you are stressed? [Smiling and feeling
connected]
Psychotherapist: Great question. Although I do not see myself as believing in them
now, I do chuckle to think of when I was your age, I had thought that certain
pencils and pens were luckier than others when taking exams. Even in college, I
believed that certain shirts brought me luck during exams. I guess it helped me
as much as it is helping you. It is all about who we are inside, right?
Patient: It is good to know they worked. [laughing] You must have done well in the
tests; you are a doctor who helps kids. [It is difficult to capture the nonverbal
here-and-now feeling of relief and comfort the patient had.]
Intersubjective The psychotherapist chooses to cocreate a moment of meeting by

self-disclosing a personal experience as a way to convey “I am glad that you allow
yourself to ask me personal questions about how I manage difficult moments in life.
It allows you to know that you are not alone; we all have stressful situations.” The
psychotherapist intersubjectively notices Charlie’s comment about the psychothera-
pist doing well in exams and becoming a doctor and feels “Charlie sees himself in
the future as a successful adult” and decides to join in laughter to implicitly convey
“You (Charlie) will do well in school also.”
Context Charlie’s father was expected to die within a week.
Patient: I don’t mean to be rude, but you are old like my parents [appears worried
about whether what he is saying will hurt the psychotherapist’s feelings], and I
wonder if your father is still alive [has a sad and serious look].
Intersubjective Acknowledging his worried and serious look, the psychotherapist

experiences the question as meaning Do you really get over this uncomfortable feel-
ing? With this in mind, he decides to cocreate a moment of meeting with
self-disclosure with the intent of helping Charlie tolerate the experience of when his
father passes.
Psychotherapist: No, my father passed away some time ago. Even now, just talking
about him makes me have a good feeling inside. I remember many things he helped
me with. I also feel sad and a little teary eyed that he is not here [noticeable].
Patient: It really helps me know that you still miss your dad. I was worried that I
would forget my dad when I grew up.
Intersubjective The psychotherapist intersubjectively experiences Charlie as

being relieved in knowing that the sadness does pass and that he will recover. He
also experiences Charlie as recognizing that even his psychotherapist cries when
sad and it is not a feeling to avoid.
Traditional One-Person Model
The above sequence seen from the lens of a traditional one-person model may have
led the psychotherapist to address the many transference manifestations, such as in
the comments “You are old” and “I wonder if your father is still alive.” These com-
ments may have been viewed as Charlie also wondering about the psychotherapist’s
mortality, which may have been further influenced if Charlie were angry at the psy-
chotherapist or if experiencing him as tired and weak like his father. Additionally,
Charlie saying, “I was worried that I would forget my dad,” may also have been
considered as a transference manifestation to be addressed at some point. Herein,
from a two-person relational model, the matters of transference are understood as a
hypothesis emanating from the psychotherapist’s mind as an observer of the verbal
and autobiographic constructs by the patient and not as an active participant of their
mutual subjectivities. The relational psychotherapist intersubjectively notices that
Charlie likely is reflecting on issues of mortality of elders, including the psychothera-
pist. The psychotherapist chooses to affectively and in a nonverbal manner move
along the process by conveying to Charlie “Deaths are painful, but you are resilient
and will be fine,” accepting the possibility that Charlie may be worried about the
psychotherapist’s mortality, which is best left as an implicit communication, and not
to be addressed through an insight-oriented comment or interpretation.
The importance in meeting with parents throughout the psychotherapy process is not
only for the gathering of past historical data and information about how the child is
doing outside of the sessions. It also allows the psychotherapist to have here-and-now
experiences with the parent to learn the likely blueprint of the relational schemas used
when communicating with their child. That is, it allows for the possibility that the
style of relating with the psychotherapist is a replica of the relational model of attun-
ement used with their child and is being nonconsciously repeated.
Context In the second appointment, the psychotherapist meets Charlie’s mother

alone. The psychotherapist found her to be a very caring woman who recognized the
struggles her son was having. However, when the psychotherapist asked about her
son’s early childhood experiences—exploring Charlie’s temperament and internal
working models of attachment—she was upset and the psychotherapist initially
experienced her as somewhat emotionally distant and with a “let’s get on with it”
attitude seen also in Charlie.
Psychotherapist: What was Charlie like as a child?

Mother: She abruptly states, “How is this relevant? He has had a good life and has
always been happy. He has done very well, even with his ADHD. He doesn’t
need help with his past. I brought him for help with the stress of his father dying.”
Intersubjective The psychotherapist’s initial intersubjective experience is that

Charlie’s mother has a mixed type of temperament, predominantly easy/flexible
with some feisty/difficult. The psychotherapist also notices that his intersubjective
experience to Charlie’s mother initial comments is “Don’t tell me how to do my
job.” He uses this to recognize that his feelings reflect being attuned to her implicitly
seeking an ally to her relational style—let’s get on with it. This was further sup-
ported when she made it clear that she had paid for competitive summer activities
and did not want her son’s psychotherapy to interfere, as these activities were good
for his self-esteem because his father had been taking him to them before he became
ill. The psychotherapist further wonders whether Charlie has a similar implicit rela-
tional style and would want to get on with it once the psychotherapy began.
Psychotherapist: I am sorry. I was wondering about Charlie’s past because it would

help me know what he has accomplished with the help of his parents, which I can
use to capitalize on during the psychotherapy sessions. I hope it makes sense.
Mother: Yes, it does. I also apologize. It has been so stressful lately. I just know it is
important for me and his dad for Charlie to continue swimming. Recently, it is
one of the few things they are able to do together.
Intersubjective The psychotherapist subjectively worries because he recognized

that he had similar feelings to Charlie’s mother, in not wanting Charlie to miss swim-
ming as this represented an activity in which he was close with his father. Most of the
times he has available were after school hours, and it would conflict with Charlie’s
competitive activities. He also notices that intersubjectively he had unknowingly
agreed with Charlie’s mother’s pressure to “get on with it.” He used this to under-
stand that helping Charlie should be a result of his careful work with him, through
mutual understanding of their subjectivities and not on his mother’s schedule.
Psychotherapist: I will do my best but I do not have after school hours available for
a few weeks.
Mother: I apologize. The stress lately has made me so confused about what he
needs. I just know I need to trust you. He really likes you and that means a lot to
us. My husband and I think this is very important. I will make sure I get him here.
Intersubjective The psychotherapist intersubjectively experiences Charlie’s

mother as likeable and caring for being attentive and proactive in bringing in her son
for an evaluation, knowing it would involve regular psychotherapy appointments,
thus demonstrating some good capacity for affective attunement with her son.
The psychotherapist was surprised when Charlie’s mother said, “He really liked
you and that means a lot to us—his mother and father—we think this is very impor-
tant.” They had agreed that it was OK if he missed a swimming class once a week
(the second weekly session was during school hours). The psychotherapist experi-
ences the shift may have been a result of an earlier moment of meeting when the
psychotherapist apologizes for asking about Charlie’s early childhood that may
have implicitly helped her recognize “I can trust him with him to help my son.”
Throughout the process she is very respectful of the appointment times and
does not ask Charlie any questions about what he had talked about, which many
parents do in order to gauge the benefit from the process. The psychotherapist was
surprised that she became an ally to the process and would encourage Charlie to
call between sessions, as agreed, when his father’s illness worsened and required
palliative interventions. The psychotherapist recognizes intersubjectively that
Charlie had been in good hands all along—he had good and warm parents. In
reflecting on his first intersubjective reactions to the “get on with it” line, he
understands that the initial presentation was in essence how the family handled
their anxiety, which changed in the context of a safe and secure environment the
psychotherapist had provided.
Subsequent Session Weeks Later
Context Charlie’s appointment, scheduled the day that his father passed, was can-
celed. He called the psychotherapist as he got ready to go to the funeral. He shared
that he had cried for 4 h and needed reassurance that it was OK to cry and that he
will feel better.
Patient: I'm really going to miss my father. I started crying and I could not stop. I
eventually went to sleep while I was still crying. [He was happy that his father
was no longer in pain. He had an appointment 2 days later but felt he could not
wait to talk and was very appreciative that the psychotherapist was able to talk
to him over the phone.]
Psychotherapist: Thank you for calling me and letting me be of help in such a dif-
ficult time. I think your father would be very proud of you for crying, which
acknowledges how important he is to you. I can assure that you will feel better
later, but for now I think you deserve to be sad and cry as long as you need to. I
will see you in a couple of days, and I will remember this conversation.
Intersubjective The psychotherapist’s intersubjective experience was that Charlie

needed to hear something personal, genuine, and not general supportive comments.
We are aware that this intervention is similar to what a traditional one-person psy-
chotherapist would have chosen to do, empathic attunement that can be analyzed
later if necessary.
Two Months Later
Context Charlie’s mother begins dating.
Patient: Don't tell her, but I really hate that my mother is dating so quickly after my
dad died; I do not need a new dad. Can you tell her how it affects me? She just
tells me that I need to understand that she wants to be happy. I don’t care; I don’t
even know him.
Intersubjective The psychotherapist’s initial intersubjective reaction to

Charlie’s dilemma is “I agree with you. Your mother’s dating seems to have hap-
pened rather quickly.” He notices subjectively experiencing anger at Charlie’s
mother and recognizes that he feels like a protective parent, as if he were stand-
ing in for Charlie’s father, protecting his son. In the intersubjective field, the
psychotherapist experiences that Charlie is angry because he believes his father
is being replaced by a new person. He is uncertain about how to convey his anger
toward his mother, “my mother needs to know I am angry and that her dating
affects me.” The psychotherapist recognizes feeling attuned to Charlie’s anger at
his mother for dating.
The psychotherapist is reminded of his initial subjective experiences of Charlie’s
mother, at the beginning of the treatment, when she conveyed a “let’s get on with it”
attitude and wondered if this implicit relational style was being repeated.
Nonetheless, the two-person relational psychotherapist also recognized he could not
have been aware of the context of why she chose to begin a new relationship, and
developing a hypothesis of why this had occurred would, at best, be uninformed and
clearly speculative. With this in mind, the psychotherapist reflects on the fact that
the best way to help Charlie is to allow himself to be guided by the here-and-now
subjectivities in the cocreated intersubjective field. Charlie subjectively conveyed
needing help managing his contextual and age-appropriate anger, and the psycho-
therapist is aware of needing to allow for a “holding pattern,” at an implicit level
without need for insight-oriented comments. Charlie would need time to accept his
mother’s decisions.
Psychotherapist: I have the sense that you wonder why she decided to date so
quickly and why she likes this particular man. I also know that you have a
difficult time being angry for fear of hurting other people’s feelings, in this case
your mother. I suspect your mother is OK with you being angry.
Patient: Yeah. My mom tells me that she will never replace my father and that
she also misses him. She knows that I still miss my dad. She is trying to be
happy and said that she doesn’t want me to meet her friend until I let her
know that I am ready. [With noticeable anxiety in considering this a possibil-
ity] What if I don’t like him? Even worse, what if I like him? [Seems pleased,
smiles at the fact that he is now considering options of how things may
develop]
This example captures several important issues. Charlie is learning to implicitly

know that his anger is a normal experience and that the adults in his life can manage
his feelings, as was modeled by the psychotherapist. Charlie is able to accept his
angry feelings as being part and parcel of everyday life. Further, Charlie subjec-
tively conveys that he is aware that his mother is implicitly and explicitly asking him
to accept that her dating reflects her wishes to feel happier, without ignoring the fact
that they both recently lost their loved one.
Viewed from a traditional one-person perspective, Charlie’s mother’s dating may
have been understood as Charlie now having to cope with a new oedipal rival and
the guilt that he felt for his hostile wishes. Blos (1967) would consider that Charlie
was struggling with the second individuation process, by the reawakening of regres-
sive infantile ties to his mother with the threat of losing her psychological support.
This may have been further complicated by the recent death of his father, which
may have unconsciously led him to view the new situation as a threat to have his
mother’s affection diverted from him. The psychotherapist would need to be obser-
vant of Charlie’s comments and fantasies about his mother and her male friend, to
tailor insight-oriented interventions in the form of verbal interpretations of what
may be transpiring psychologically for Charlie. It is also likely the traditional one-
person psychotherapist will make some inferences about why Charlie’s mother
began to date (i.e., avoiding the mourning of the lost object, counterphobic reaction
to her depressive feelings, impulsive action due to superego pressures, etc.), which
is limiting as it does not account for the real-life complexities and context of the
many reasons influencing her deciding to date.
Letting Go
Context Charlie travels to the west coast to fulfill his father’s wish, to have his
ashes thrown in the ocean.
Patient: I knew it was going to be sad but I didn’t know that it was going to be so
hard. You were right…. You really helped me get through my painful feelings. I
can handle them now.
Psychotherapist: I am glad you had the courage to fulfill your father’s wish; he
would be proud of you. I also know that it must have been very difficult, but I
hope you know how well you managed things so painful. [Smiling, with an
implicit it is over and you can manage matters just fine]
Context He began to bring his smartphone to the sessions and would ask permis-
sion to text his peers.
Patient: They know I come to see you, and I like telling them what games we play.
[He later asked if it would be OK to text his girlfriend during the session.] She
wants to thank you for helping me.
Psychotherapist: Of course. Please let her know I thank her for joining the group of
people who are happy helping you with your feelings.
Patient: She is really nice. My mother likes her a lot. No offense, I really think I am
fine now. I don’t need to come and see you, if that’s OK.
Intersubjective The psychotherapist recognizes that Charlie has made remarkable

progress and felt better. He is happy going to school and recognizes that, at times, he
is angered by his mother’s reminders to complete his homework or chores, although
he knew it was normal. He is less worried about missing his father and talks to his
father before bed, hoping he could listen. The psychotherapist subjectively experi-
ences pride in Charlie’s progress and some sadness in letting go. After an open dis-
cussion, the psychotherapist intersubjectively recognizes Charlie is ready to move
on. They both agree to invite Charlie’s mother to share that his psychotherapy pro-
cess would end in four sessions, which occurred without difficulties.
In a traditional one-person model, this intervention may have been considered as
an abrupt termination, as it did not allow time for working through the mourning of
the relationship with the psychotherapist. Further, Charlie will need the psycho-
therapist to help him work through his reawakening of his oedipal strife. This is
noted when he introduces his girlfriend into the session by phone, this can be seen
as evidence of the resolution of the oedipal conflict with a sense of triumph: “I have
my own woman.”
In a two-person relational model, there is attention to here-and-now subjectivi-
ties. The introduction of his peers and girlfriend to the sessions via smartphone
reflects progress in his developmental milestones. Additionally, letting go is not
considered a termination; rather, it is considered a “Good-bye, I have provided a
new emotional experience that allows us to now hold in mind our unique subjectivi-
ties of our work together in implicit nondeclarative memory.”
Uncertainties A month later Charlie returned for one session. He shared that he
was having dreams of anxiety and premonition that his father was still alive. It was
clear that he was not in significant distress and was self-assured and confident.
Patient: I know exactly what you are going to say. I just knew that it would help if I
saw you and shared that I learned from you how to handle my feelings.
Psychotherapist: Thank you for coming and sharing that we made a good team.
When you said that you knew exactly what I was going to say, it felt similar to
my feeling that you knew you could return if you had anything you needed to
share, good or not so good. I am happy you are doing well.
Intersubjective The psychotherapist intersubjectively experiences Charlie return-

ing for one session as reflecting his desire to share that he was successful in manag-
ing his anxieties. He, by all standards, is doing well in all areas. The psychotherapist
recognizes wanting to ask about the reasons for Charlie’s return but quickly under-
stands that this had to do with his own curiosity and is not what Charlie needed. He
is able to stay present, in the here and now, and allow Charlie’s subjectivities to
guide him on how to proceed.
In a traditional one-person model, this session may have been considered as a
manifestation of Charlie’s unresolved transference feelings to his psychotherapist.
To this, the psychotherapist may have chosen several possible approaches. First, he
may choose to explore the unconscious meaning for Charlie’s return. Second, he
may not agree to only have one session, as unconsciously Charlie may have unfin-
ished work as represented by the reemergence of his dreams. In both of these
hypotheses, although many others are also possible, a traditional one-person model
does not rely on mutual subjectivities in the here and now to guide the process.
Rather, it requires the use of verbal communications to explore hidden meaning in
order to achieve some form of insight.

Psychotherapy
Clinical dilemmas in a two-person relational model of psychotherapy are ubiqui-

tous. Dilemmas are to be expected in any dyadic relationship where there is bidirec-
tional vitality and sloppiness. We are reminded of Shakespeare’s literary quote that
captures the ubiquity of uncertainty in life, as well as in clinical dilemmas, “To be
or not to be.” The set of relational schemas that a psychotherapist may hope to
implicitly represent (to be) to his or her patients is dependent on the context of the
interaction, and at times may intersubjectively learn that he or she represents a mal-
adaptive schema that had not been considered (not to be), and will need to be
repaired through a moment of meeting.
Context Charlie requested an urgent appointment the day before Father’s

Day—3 months after his last appointment—fearing he would “not be able to stop
crying.”
Intersubjective The psychotherapist experiences his request as demonstrating that

by the use of a here-and-now two-person relational psychotherapy processes, in
which intersubjective experiences are cocreated, it had provided Charlie an implicit
atmosphere of safety that he was able to return to when needed. Additionally, the
psychotherapist, a father himself, had plans to celebrate Father’s Day later that eve-
ning with his own grown child. He recognizes that internally he felt “It is just for an
References 309
hour, I can help Charlie,” as well as, “Why am I agreeing to see him on such an
important day for me? It may affect how I approach my own celebration.” The psy-
chotherapist decides to have a brief telephone encounter with Charlie in which they
both could gauge the urgency or if it could wait to be scheduled for another day,
which it was.
This interaction serves to demonstrate the complexities of how dilemmas can be
managed. As captured by Scaturo (2002), an ongoing two-person relational process
is “a constant series of clinical choices and recurring dilemmas for the psychothera-
pist. For the practicing clinician, such decision making is a part of everyday occu-
pational life.” We are not advocating that the decision made by the psychotherapist
is correct. Rather, we highlight the complexities of the present and active psycho-
therapist as a real person to real-life dilemmas.
References
Blos P (1967) The second individuation process of adolescence. Psychoanal Study Child
22:162–186
Call JD, Noshpitz JD, Cohen RL, Berlin IN (1979) In: Noshpitz JD (ed) Handbook of child psy-
chiatry, vol 1, Development. Basic Books, New York
Delgado SV, Strawn JR (2014) Difficult psychiatric consultations: an integrated approach. Springer
Heidelberg
Erikson EH (1968) Identity, youth and crisis. WW Norton, New York
Furman R (1964) Death and the young child: some preliminary considerations. Psychoanal Study
Child 19:321–333
Gill HS (1987) Effects of oedipal triumph caused by collapse or death of the rival parent. Int J
Psychoanal 68:251–260
McDevitt T, Ormrod J (2010) Child development and education. Pearson, Upper Saddle River
Menes JB (1971) Children’s reactions to the death of a parent: a review of the psychoanalytic lit-
erature. J Am Psychoanal Assoc 19:697–719
Scaturo DJ (2002) Fundamental dilemmas in contemporary psychotherapy: a transtheoretical con-
cept. Am J Psychother 56:115–133
High School Age Adolescents 13
Change is the law of life. And those who look only to the past or
present are certain to miss the future.
—John F. Kennedy
Adolescence is a developmental period of life that commences with the onset of

puberty and artificially ends with adulthood. The twenty-first century saw sub-
stantial advances in understanding the biological, psychological, and sociological
aspects of adolescent development. Moreover, accumulating data support the
notion that adolescent behavior cannot be reduced to purely psychological or bio-
logical phenomena. Rather, an understanding of any aspect of adolescence is best
derived from an appreciation of biology and psychology and their respective
interfaces. For example, imaging studies of adolescent brains confirm aspects of
fluidity in decision making and a number of other cognitive capacities (Giedd
et al. 1999). Giedd explains that during adolescence, the area of the brain respon-
sible for organization, planning, and strategizing is not fully developed, as the
gray matter continues to thicken. In turn, these neuroanatomic changes likely
occur in tandem with changes in the implicit relational memory processes.
Further, the scientific literature confirms the belief that adolescence is a period of
inordinate risk taking and complexities in decision-making processes (Reyna and
Farley 2006).
Thus, the psychodynamic understanding of adolescence has evolved consider-
ably over the last century, from a foundation rooted in Freud’s structural and drive
theories to a more contemporary understanding that has been informed by tempera-
ment, attachment, and relational theories. Adolescence has been reconceptualized
from a period of instability and psychological turmoil to a period in which most
adolescents successfully regulate the shifts in affective states and negotiate the com-
plexities of the environment, developing the capacity for intimacy and stable inter-
personal relationships (Delgado et al. 2012).

DOI 10.1007/978-3-642-40520-4_13
312 13 Two-Person Relational Psychotherapy: High School Age Adolescents
In this chapter, we provide the reader a case example of an adolescent receiving

treatment in which a contemporary two-person relational psychotherapeutic
approach is used, with attention given to the patient’s and her mother’s tempera-
ment, cognitive and affective flexibility, and internal working models of attachment,
all within the context of intersubjectivity. A detailed description of the work that
transpired is provided with additional comments about how the intersubjective
experience in the here and now guided the psychotherapist interventions during the
process. We also provide the reader with a view of the case from a traditional one-
person model to serve as a broad review of the main differences that exist between
both theoretical approaches.
As a reminder, much of what transpires that promotes changes and moves along
the process occurs at an implicit nonverbal level and is strongly influenced by the
patient’s and psychotherapist’s tone of voice, posture, and nonverbal expressions in
the here-and-now moments.
13.1 Psychodynamic Psychotherapy in High School Age

Adolescents
Contemporary psychodynamic understanding of the adolescent is strongly influ-

enced by attachment theory and intersubjectivity, the interaction between implicit
nonconscious relational experiences of the self and others. The adolescent’s
developmental task is to successfully regulate the shifts in affective states in order
to develop the capacity for intimate and stable interpersonal relationships.
The reasons for which adolescents seek help are typically due to emotional or
behavioral problems. The adolescent psychiatrist or clinician will benefit from a
careful use of the contemporary diagnostic interview (CDI, Chap. 8) in order to
understand the adolescent’s unique attributes—temperament, cognition, cognitive
flexibilities, and internal working models of attachment—within the context of the
environment in which they live in, which includes family and culture. Furthermore,
the contemporary psychodynamic theory has helped define periods of healthy
turmoil, with episodic moments of intense anger and isolation, as well as unhealthy
turmoil as a result of adolescent psychopathology, with persistent patterns of acting
out, self-defeating behavior, academic failure, substance abuse, and promiscuity.
13.2 Michelle
Michelle, a 16-year-old Caucasian female, was brought by her mother with a

specific request to help her daughter cope with the sad feelings due to the breakup
of a 2-year, long-distance relationship with a 17-year-old female peer—whom she
13.2 Michelle 313
never met in person. Since the breakup, Michelle spent much of her time in her
room crying and requested that her mother “find someone I can talk to. It is not right
to feel this bad.” After the breakup, she had begun to struggle at school, and her
mother found her to be more “moody at home.”
Michelle ostensibly was happy during the 2-year relationship, and the couple had
planned a summer trip to meet. The relationship was her first same-sex experience.
She had earlier dated a male adolescent, although she reported that she found him
“boring.”
Past and Family History
Michelle was the product of an unplanned, uncomplicated full-term pregnancy

when her mother was 16 years old. During the pregnancy, her mother lived with her
parents, who were described as being unsupportive of the circumstances. After
Michelle’s birth, due to the increased conflict with her parents, Michelle’s mother
moved in with her daughter’s 17-year-old father, who lived at his parents’ home.
Michelle achieved her developmental milestones on time and was overall a
healthy child. At the age of 3, she was sent to live with her maternal grandparents,
as both of her parents were unable to care for her and had begun to use drugs
heavily.
Michelle’s grandparents proved to be very supportive of her care and covered the
costs for her education in private Catholic schools. She remained with her maternal
grandparents until she was 13 years old, at which point her mother asked that she
once again live with her. Her mother had completed her substance abuse treatment,
had remarried, and felt better able to care for Michelle. Michelle’s mother reported
having a history of bipolar disorder with several hospitalizations as an adolescent
and as a young adult. She was no longer in treatment, stating she had mastered the
illness and was in the process of finishing nursing school.
Throughout her early childhood, Michelle had a conflicted relationship with her
mother, who would visit Michelle on weekends—although inconsistently—and
would generally use Michelle as her supportive friend. Her father would visit her
inconsistently, and when she was 10 years old, he stopped all communication
without explanation, for which she was angry: “I clearly have issues with
abandonment.”
According to her mother, Michelle’s maternal grandparents, extended family,
and teachers described Michelle as an easy, jovial, and intelligent adolescent. At the
time of the evaluation, Michelle was an honors student. She had hoped to pursue a
career in soccer, but due to a sport injury, she was in constant pain and required
biweekly physical therapy, and she was told that she likely would not be able to
return to competitive sports.
Michelle was living with her 33-year-old mother, 38-year-old stepfather, and two
half-sisters, ages 3 and 1 year old.
Contemporary Case Formulation Following Use of the CDI: Michelle

Michelle: A 16-year-old Caucasian female who presents with new functional
impairment timed with the breakup of a 2-year relationship with a female peer
Internal working models of attachment (IWMA): Ambivalent/anxious
Temperament: Mixed—predominantly easy/flexible with some feisty/
difficult
Cognition: Above average (see developmental milestones Appendix A)
Cognitive flexibility: High/adequate
Formal psychiatric disorder: Symptoms of dysthymia, although did not
meet full DSM-5 criteria
Treatment recommendation: Two-person relational psychotherapy to help
her develop new and more adaptive models of interaction with others with
improved affect regulatory functions
Contemporary Case Formulation Following Use of the CDI: Mother

Michelle’s mother: A 33-year-old Caucasian female who presents with func-
tional impairment in regard to providing the affective attunement needed by
her 16-, 3-, and 1-year-old daughters
Internal working models of attachment (IWMA): Avoidant/dismissive
Temperament: Mixed—predominantly feisty/difficult with some easy/
flexible
Cognition: Average
Cognitive flexibility: Average to limited
Formal psychiatric disorder: History of mood disorder and relational prob-
lems that, although did not meet full criteria, are within the realm of cluster B
traits, predominantly borderline
Treatment recommendation: Participation in her daughter’s psychothera-
peutic process; suggest her own individual psychotherapy to help her develop
new and more adaptive models of interaction with her daughter.

One-Person Model
In conceptualizing this case from the lens of a traditional one-person model, the
formulation may be seen from several angles, depending on whether it is viewed
from a drive theory, ego psychology, object relations, self-psychology perspective,
or in a pluralistic manner—a combination of theories but without a clear delineation
among them in spite of their differences.
In the traditional psychoanalytic literature, abandonment by parents in early
childhood is considered to have a significant negative impact on the intrapsychic
psychological processes of the child. Abandonment from parents contributes to a

child making use of maladaptive ego defensive mechanisms to cope with the reali-
ties of the situation. They generally deny the reality of their abandonment, identify
with the parental internalizations (e.g., being abandoned for being a bad child), or
create a false sense of self to prevent closeness with others in order to prevent fur-
ther abandonments. The patient generally presents to psychotherapy for the treat-
ment of poor self-esteem and feelings of guilt for the abandonment.
Further, in the case of Michelle, the diagnostic formulation of her problems may
be viewed at many different levels. For example, her parents were adolescents when
she was born, and the abandonment occurred at a young age. This clearly had sig-
nificant negative repercussions in her psychosexual development. Her environment
was not conducive to providing the necessary warmth and mirroring, and as a young
child she learned to make use of immature ego defense mechanisms to prevent feel-
ings of loneliness. She likely developed narcissistic character traits to manage feel-
ings of despair. The developmental interference in her growth further led to
unresolved oedipal conflicts due to the abandonment by both her mother and her
father, which did not allow for a successful work through the developmental tasks
of this phase. The repercussions from her abandonment during this phase can be
surmised by repressing her anger toward her father and wishes for reunion with an
available mother (object representation). Thus, she had significant problems negoti-
ating the second individuation process of adolescence.
As a note, Michelle’s struggles began at the same age that her mother gave birth
to her. This can be considered a generational unconscious repetition of the problems
of adolescent individuation. Additionally, it may lend to be viewed from the per-
spective of generational family issues, typical in family therapy schools.
In a traditional one-person psychotherapeutic model, the treatment of an adoles-
cent is best achieved by the psychotherapist’s empathy and self-object mirroring to
help the patient feel safe and improve the therapeutic alliance. In this case, there
may be the need for occasional moments of neutrality if Michelle’s projection of
negative affect occurred, which would allow for the transference to develop and
later be amenable to interpretation. The psychotherapist will likely be initially expe-
rienced as the helpful father or mother object, noted by an increase in positive iden-
tifications and idealizations of the psychotherapist. Further, by maintaining some
neutrality and not gratifying Michelle’s wishes for closeness, the psychotherapist
can help Michelle work through her anger toward her parents in the transference to
the psychotherapist.
Regarding Michelle’s mother, in the traditional one-person model, the psycho-
therapist may provide regular educational sessions to help Michelle’s mother
understand her daughter psychologically and to support the psychotherapeutic pro-
cess. Michelle’s mother may have initially been thought of as struggling with
unconsciously not wanting to be reminded of the loss of her own loved object (her
daughter’s father), akin to parents with “ghosts” in the nursery (Fraiberg et al.
1975), which interfere with their ability to successfully parent and help the child
develop adaptive ego functions. Additionally, in the traditional one-person model,
Michelle’s mother’s phone call to the psychotherapist (see below) may have
represented jealousy of her daughter’s biweekly sessions with the psychotherapist,

hoping to also have a relationship with the psychotherapist to feel validated as a
good mother.

in High School Age Adolescents
Two-person relational psychotherapy has evolved from the traditional one-person

models of psychoanalytic treatment for adolescents. What began as a journey of
discovery of the adolescent’s unconscious conflicts has now broadened to be an
asymmetrical interaction between patient and psychotherapist based on mutuality
that promotes the cocreation of more adaptive experiences for the patient in the
form of a new emotional experience, which is then stored in nondeclarative memory
systems. The asymmetry refers to the psychotherapist’s personal healthy attributes,
relative to the patient’s maladaptive attributes. The asymmetry allows the psycho-
therapist to be guided by the intersubjective experiences provided by the patient in
the here-and-now moments. The relational psychotherapist makes careful use of
timed enactments and self-disclosures to move along the process in what are called
moments of meeting. Herein, together, the patient and psychotherapist cocreate new
and corrective emotional experiences. We note that at times self-disclosures and
enactments occur unknowingly to the psychotherapist and its presence is revealed
by the patient.
Context The child and adolescent psychiatrist went to the waiting room to greet
Michelle (who had requested the appointment) and her mother, at which point
Michelle quickly got up, approached the clinician, and pleasantly stated, “My
mother wants to talk to you without me. I am OK with that; she can take the first half
of the appointment.” Her mother remained seated and silent, implicitly waiting for
the interaction between Michelle and the clinician to provide her the information
she needed about how the interaction was to proceed.
Child and Adolescent Psychiatrist In knowing that both had clearly prepared
for this moment and were asking for something that seemed reasonable, rather
than challenging the patient and her mother, he agreed to accept their request and
learn more about the implicit relational style. He made note about his intersubjec-
tive feeling: “I feel both of you are already attempting to control the interaction,
and it seems something so natural to both. It must be sad not knowing how you
influence others to feel about you and unrealistically expect them to understand
you.” The clinician intersubjectively experienced Michelle as assertive and com-
fortable with the caretaking role she had taken, compared to the passive role her
mother took.
Mother The clinician brought Michelle’s mother to his office and attempted to
engage her by pleasantly sharing the charming attributes of her 3- and 1-year-old
girls, who were in a stroller (a technique common in a contemporary diagnostic
interview, see Chap. 8). She did not address the comments and rather seemed pres-
sured in wanting to let the clinician know the facts about her daughter’s problems or
at least how she saw them. She opened the conversation by stating, “I am so glad to
share my side of the story first, so you can have a good picture.” She felt guilty for
not being available to her daughter during the first 13 years of her life and was now
happy that Michelle was living with her—“She knows that I always cared about her.
I just couldn’t do it until now.” In contrast, in her next comment she did not demon-
strate any real happiness in having Michelle live with her, “The problem is that she
is just like her father; he was very manipulative and vindictive,” and was worried
because she felt her daughter was demonstrating the same tendencies. She believed
that her daughter did not appreciate “that I am in her life now. She should learn that
she needs to open up to me, like most daughters do, so I can help her emotionally.”
She openly stated that she hoped for the clinician to help Michelle learn to open up
with her and to understand that the relationship she had with her girlfriend was
unhealthy and that she should get over it.
Intersubjective: Michelle’s Mother The clinician had a mixed set of intersubjec-

tive experiences. Initially, Michelle’s mother was experienced as likeable and caring
about her daughter’s future in agreeing to seek help for her. Nevertheless, within a
few minutes, the clinician experienced the contradiction of his emotions in the here
and now. Intersubjectively, he thought, “I like her for trying to help her daughter,
although I feel I am speaking with a teenager.” She seemed narrow-minded regard-
ing the complexities about Michelle’s life experiences—growing up without having
her mother available for many years—and was comparing Michelle to her father’s
negative characteristics, even though Michelle excelled in school and asked for
treatment. Further, he was saddened that the two young children in the stroller were
actively seeking for some social referencing during the session, which he provided
in an obvious manner, hoping that their mother would take over, which she did not
during the entirety of the 30-min session. She did not seem to know how to soothe
and reference back to them, clearly having problems in knowing how to be a good
enough mother.
Michelle Upon entering the office, Michelle seemed polite and jovial, and she
pleasantly stated, “Finally I have somebody to talk to. I bet you wonder how I can
live with my mother, who doesn’t know how to be motherly, even to my little sis-
ters.” She added, “I thought it would be helpful for you to meet my mother first.
Most people have a hard time believing me when I say she is not a good mother,
even though she thinks she is. Her not being part of my life until the last 3 years just
confirms that she doesn’t know me.”
She was articulate throughout the session and shared that she now understood
why people feel devastated after breaking up with a loved one. She accused her
girlfriend of being a shallow person for not believing that a long-distance
relationship—several states apart in this case—would work. She added, “We had
two great years; we used a webcam when we slept. It was nice to get up and have
someone that loves you to be there.” She was certain that her emotionally charged
comments pushed her girlfriend away, whom had begun to date an adolescent male.
Intersubjective: Michelle The clinician had a mixed set of intersubjective experi-

ences when talking with Michelle. Although she was a very likable adolescent, he
noted that the experience felt as if he were talking to a young adult woman. He
notices intersubjective feelings of being proud of her for having survived her life
without knowing where her mother was and how brave she was in letting her mother
enter her life in the last 3 years. Nevertheless, although he felt that she seemed resil-
ient and knew about her mother’s limitations, “she doesn’t know how to be moth-
erly,” she also seemed to have compartmentalized her feelings of loneliness. As the
clinician listened, he intersubjectively felt, “Why does this adolescent not talk about
friends? Why is she sharing matters as if we were distant friends catching up?” as in
her narrative there was an absence of any reference to close peers who could have
provided some support to her during her life and much more during the painful
breakup.
Michelle As the session continued, Michelle proved to be exquisitely attentive to

the clinician’s shifts in affect and seemed implicitly able to know what he (and
likely adults in general) needed. For example, at a moment when the clinician was
subjectively feeling at a loss as to what might best help Michelle develop more
adaptive relational patterns, she seemed to recognize this at an implicit level and
said: “I’m sorry I’m giving you so many details about my girlfriend. I just thought
it would make it easier for you to understand why I am so stressed, which you
clearly know my mother doesn’t. She just says it was an unhealthy relationship and
that I should get over it.” In this, the clinician experienced Michelle as a lonely per-
son with resilient skills in self-sufficiency and implicitly knowing how to seek oth-
ers that may be able to understand her dilemmas in life. In doing so, she seemed
unable to be aware that she came across as a person who did not know how to enjoy
being with others in the here and now. This may have explained her preference for
a long-distance, safe relationship, which may have been a representation of an
implicit dismissive internal working model of attachment set in her early life—fail-
ures in affective attunement and social reciprocity by her caregivers.
Intersubjective The clinician’s initial goal, from a contemporary two-person rela-

tional model of psychotherapy, will be to become immersed in shared subjectivi-
ties—from both patient and her mother with the psychotherapist—that are unique
and distinctive to their dyad. This will allow the psychotherapist to intersubjectively
learn how others may feel being with them and to use this as a tool to later cocreate,
in the here and now, more adaptive experiences that can be stored in implicit nonde-
clarative memory for later use. For this to occur, the psychotherapist will need to be
in a frame of mind that will allow him to tolerate the many uncertainties regarding
the origin of Michelle’s difficulties without hypothesizing about how he or she
believes they came about due to unconscious internal conflicts, which is common in
the traditional one-person model. The psychotherapist will allow the patient to
implicitly help him get to know what she is like when interacting with others, after
which he can develop a blueprint that will guide the cocreation of a new organiza-
tion of experiences in the here and now, promoting new and more adaptive ways of
affect regulation and self-cohesion. This is not to say that the psychotherapist will
know in advance which of the patient’s intrapsychic conflicts and past object rela-
tions trigger her maladaptive patterns; rather, he will intersubjectively attend to the
experiences in the here and now (e.g., “I feel you are dismissive of me, and I will
help you know that I am here, present and active. I will let you know how I think
implicitly and nonconsciously I can teach you how to move along the developmen-
tal steps necessary in life”). In doing so, the psychotherapist, over time, will implic-
itly help the patient replace maladaptive relational behaviors that represent the old
familiar—her mother, father, girlfriend, etc.—and nonconsciously move toward a
new relational model cocreated with the psychotherapist.
Context After completing the CDI over the course of three appointments, Michelle
agreed to biweekly psychodynamic psychotherapy in a two-person relational per-
spective, and her mother agreed to meet once a month to support the process. All
parties agree not to pursue the use of medication at that point.
The appointment had been set up for the following week. Michelle’s mother
called the psychotherapist the day before the appointment to ask for help on how to
handle her daughter’s request, via text, to be excused from classes due to a throb-
bing headache. She added that she did not agree with excusing her and shared that
she felt the incident was another example of her daughter’s manipulative behavior.
She ended the conversation by stating that she would like the psychotherapist to
focus on helping her daughter keep her bedroom clean. The psychotherapist inter-
subjectively experienced Michelle’s mother’s telephone call as not actually wanting
any advice. Rather, she seemed to repeat the nonconscious implicit relational know-
ing pattern of “Look how difficult it is to be a mother,” which likely was influenced
by many facets of her own relationship style in her early and adolescent years.
Patient: I already heard that my mom called you yesterday. This should be interest-
ing. Our first appointment and she already gets in the middle. That’s her. You go
first. [Smiling and seeming to feel connected with the psychotherapist, she con-
veys a subjective experience of curiosity and inquiry about what happened.]
Psychotherapist: Your mother called me and left a message that she was worried and
wanted to talk to me before your appointment. As I told you, I usually return calls
from patients and parents to have a better understanding about what may be hap-
pening outside of the sessions. Sometimes parents want to let me know about
medical issues that I may need to be aware of. So I went ahead and called your
mother.
Psychotherapist: [At this point, the psychotherapist feels the connection with the
patient has been lost—a now moment (Chap. 5). She begins to look at the psycho-
therapist with a dismissive attitude. The psychotherapist chooses to stay in the
here and now and smiles.]
Psychotherapist: Your look makes me feel that you disagree with my returning your
mother’s call.
Patient: Go ahead. I am listening. [Indicating she is not ready to share her
opinions.]
Psychotherapist: Your mother shared that you had texted her to help you be excused
from your classes due to a throbbing headache. The second thing she shared
seemed rather silly, that your room wasn’t clean. I thought, with the amount of
things that you do—drive yourself to school, complete your assignments, work
for your grandfather, etc. [Smiling, hoping to reestablish the connection]—that
this was a minor issue unless the Centers for Disease Control agency would deem
it dangerous. [Use of sarcasm about her mother’s request of a clean bedroom]
Patient: Oh my God! I can’t call my mother from school if I am having a throbbing
headache from a mental breakdown. A decent parent would prefer to have contact
with their child. [With a demanding “Take my side” comment]
Psychotherapist: I need your help understanding what you hoped for your mother to
have done when you texted. I liked that you reached out to her when you needed
help due to a headache. [The goal was to cocreate a here-and-now moment of “most
adults think it is important for an adolescent and good student to ask for help.”]
Patient: I needed her support and gave her a chance to be motherly. She usually
doesn’t know how to provide support. When I got back home, she didn’t even ask
how I felt.
Psychotherapist: Walk me through what happened when you got home after school.
It would help me know what you go through.
Patient: I went to my room and tried to take a nap in the dark to get over my head-
ache, which I usually don’t have.
Psychotherapist: It is sad that she did not ask how you felt. It also sounds like your
mother did back off; maybe my advice helped her not be critical of you. [With a
tone of voice indicative of, “Maybe it worked!”]
Patient: I guess, to some extent. [Not wanting to accept the minor change in her
mother]
Intersubjective The psychotherapist’s intersubjective experiences during the first

appointment are of confusion. He does not have enough of an understanding about
the roles Michelle and her mother are accustomed to—the implicit and familiar. He
also has some confusion about whether Michelle is actually reaching out to her
mother hoping for understanding or whether she is implicitly relating to her mother
in a manner familiar to them, confirming her mother’s unavailability and critical
approach. The psychotherapist also notices experiencing Michelle as demanding,
like her mother had described, when Michelle implies, “I want you (the psycho-
therapist) to agree with me and prove you care about me.” The psychotherapist is
aware that he had just began to be immersed in Michelle’s subjectivities and that
further time was needed to intersubjectively know how to best intervene.
Context The psychotherapist experienced intersubjectively a great deal of loneli-

ness in Michelle: not able to connect with her peers and often having to problem
solve without help from others. He also recognized that she had an implicit wish for
input from others about her affective states, although in a pseudo-mature manner,
which prevented her from knowing that others had a different vantage point than
hers that could be helpful.
Patient: My problem is in Latin. The teacher is just an idiot. I have the highest grade
in the class, but it is just too stressful for me with that teacher.
Psychotherapist: Interesting, I thought that Latin was a dying language.
Patient: You’re a doctor; you should know that Latin is very useful. [Smiling and
pleased she has a one up in the interaction, which the psychotherapist experi-
ences as a repetition of her sadly skillful surviving attitude and not an example
of a healthy, playful “I got you” moment.]
Psychotherapist: You’re right; it is interesting how one takes certain things for
granted. Thanks for pointing that out. [Verbally and nonverbally accepts the
correction]
Intersubjective The psychotherapist intersubjectively feels “This is going to be

exhausting. I will have to time the self-disclosures and enactments very carefully, so
as not to become an accomplice of your nonconscious implicit relational invitation
for me to be a critic and confirming my lack of understanding and appreciation of
your struggles. This is clearly a way that you implicitly maintain a constant feeling
that you will be abandoned by others.”
Patient: Latin helps me a great deal with English, particularly sentence structure and
vocabulary in my essays. [Here she seems calm and proud of what she has
accomplished, with a sense of ownership and pride.]
Psychotherapist: Aha, your talent shines. [Laughing and humbly accepts his mis-
take about the Latin language]
Patient: I would like to drop the class, but it won’t look good on my resume. I need
to think about what to do next as I prepare for college.
I hope you notice the fact that I don’t feel I’m good enough for anyone else or for
myself. It makes it very easy to have mental breakdowns when teachers point out
that I’m not applying myself. The teacher said, “You should have had your trans-
lation memorized.” She doesn’t know how stressed I am. She sounds like my
mother; I should do what makes her feel better. She’s a nun and everyone calls
her “Lucifer.” [The psychotherapist begins to laugh.] I’m not kidding. [She also
begins to laugh.] That’s what we have called her for the last 2 years.
Intersubjective The psychotherapist’s intersubjective experiences during this

appointment are twofold. Initially he experiences Michelle’s wish to live as strong,
demonstrated by her banter and challenging of her psychotherapist about the useful-
ness of Latin in her future, being college bound. Further, the psychotherapist experi-
ences a sense of mutuality in which she felt safe in disagreeing without being judged
or criticized, which did not occur with her immediate family. The psychotherapist
stays engaged in the here and now and openly shares his opinion of Latin and
appreciates her correcting him, and he is hopeful that this sets the stage for a new
and more adaptive form of implicit relational patterns of interaction.
Psychotherapist: By the way, did you ever get the results of the AP history test?
Intersubjective The psychotherapist intersubjectively feels that Michelle was

beginning to demonstrate her fragility and that she was tired of self-soothing (e.g.,
“I am not good enough for anyone else but myself”). The psychotherapist notices
being overly worried about the need to be careful and cautious about his comments,
self-disclosures, and enactments. He begins to notice feeling tired and wishing for
an in-the-moment reprieve to assess the reasons for the experience. To this, he non-
consciously makes a comment that provides the reprieve he was looking for,
although this creates a disruption in the flow of the intersubjective experience. He
subjectively shifts from her comments about her fragility and asks about the AP
history test in another class that she was struggling with. Although the question may
have been important at some point, during the back-and-forth of the session, his
timing was not helpful to the patient. In reflecting on his intersubjective feelings, the
psychotherapist recognizes that he had wanted to verbally help Michelle achieve her
academic potential, “talking her out of the feeling of not being good enough.”
During the reprieve he is reminded of his own daughter when she was the patient’s
age, who felt proud applying herself in her AP classes. The psychotherapist’s tired
feelings seem to represent that he was becoming an accomplice to her critical
mother and teachers: “Why don’t you apply yourself? If you do it you will be fine.”
In noticing this, he corrects the disruption.
In a traditional one-person model, the psychotherapist’s disruption may be con-
sidered a form of a projective identification or a countertransference enactment
(Chap. 6). He responded to the patient in a manner that was uncharacteristic to him.
In such cases, the psychotherapist may find that recognizing his or her reactions as
due to transference manifestations from the patient will help him avoid further clini-
cal pitfalls.
Psychotherapist: There I go; I want you to recognize that you can do well in all your
classes, as if you didn’t already know. I must be trying to tell you that you can
overcome the mental breakdowns. I need to pay better attention to how you feel
and see how I can be of best help. [Accepts the temporary role of an accomplice
of others—a critic]
Patient: Yeah, my mental breakdowns freak out my mother and grandparents, and
they just say, “Get over it.” [She seems to accept the apology and feels comfort-
able allowing herself to experience closeness in the here and now.]
Intersubjective The disruption seems to have been repaired by both parties, as at

the implicit level the patient experiences the psychotherapist as accepting her
psychological problems as serious without losing sight to her accomplishments.
The here-and-now interaction occurs in the intersubjective field, and what helps is
not necessarily the verbal dialogue, but rather the nonverbal communications:
subjective shifts in the tone of voice, facial expressions, and body posture by both.
In essence, the psychotherapist conveys, “I made a mistake and let me get back to
feeling what you feel,” and the patient responds, “Yeah, I am glad you are not freak-
ing out.”
In two-person relational psychodynamic psychotherapy, disruptions in sessions
are ubiquitous. They serve as “now moments” when the psychotherapist can reflect
on the reasons for such shifts and recalibrate his or her approach by reviewing what
is subjectively being experienced vis-à-vis the patient’s subjectivity of the psycho-
therapist as it pertains to familiar and maladaptive implicit working models of
relation.
Returning to the Same Session
Patient: [Laughing and returns to the AP test question with more of a sense of play-
ful mutuality with the therapist] Yeah, but I am not saying.
Psychotherapist: Really? [Inquisitive playful attitude]
Patient: OK. I am passing, a B+.
Psychotherapist: I think I know that may not be good enough for you [Smiling and
conveying “I am beginning to know how you think”]
Patient: It’s pretty bad.
Psychotherapist: Getting a B+ on a test after a mental meltdown sounds reasonable
to me. Sounds like your high expectations are similar to your teacher’s. You just
began therapy. Let’s celebrate a B+.
Patient: I guess. I had just broken up and didn’t have time to read any of the mate-
rial. [Feels proud and recognizes her accomplishment]
Psychotherapist: Right. [Acknowledges and with excitement agrees with her
reality]
Patient: It is still pretty bad; I should have known the material. [Is aware about self-
imposed expectations]
Psychotherapist: Without reading it?
Intersubjective The patient and psychotherapist are intersubjectively in sync

again; the disruption seems to have been repaired.
Context The psychotherapist chooses to move along the process by referring back
to the important subject of the patient’s mother, as her support was essential for the
process to continue. The psychotherapist also remained unclear about what had held
their relationship together, albeit fragile, for the last 3 years.
Psychotherapist: If OK with you, I want to get back to what your mother may have
said to you after I spoke with her. [Approaches it tentatively and allows the
patient to disagree if needed]
Patient: She just said, “I spoke to your psychiatrist.”
Psychotherapist: I felt that she really cared when she called. [Which the
psychotherapist feels was genuine. The patient looks annoyed by the thought that
her mother cared and attempts to distance herself from the topic.]
Patient: [With the implicit communication that her mother was not attentive or car-
ing] Oh, she never looks at me or talks to me directly. She doesn’t care.
Psychotherapist: The way I’m thinking about it, I will give your mom a thumbs-up
for calling me and worrying about you, and a thumbs-down for not supporting you
when you arrived home after a mental breakdown with a throbbing headache.
Patient: I don’t think she’s ever worried about me. [Conveying it is unlikely that her
mother could be affectively attuned] You know my history, right? [Jovial and
smiling] She doesn’t care. She probably calls you because she wants you to yell
at me.
Psychotherapist: To yell at you about what? [Jovial]
Patient: She is always telling me “You are disrespectful; you don’t obey me.” Let’s
see, I bring myself to therapy, I take myself to physical therapy, I get to school and
complete my projects, I go to work with my grandfather so I don’t have to ask for
any gas money. She never knows what I’m doing; let’s see who’s disrespectful?
Psychotherapist: Wow! [Implicit agreement with her perceptions]
Patient: [Laughing] She’s nice to you.
Psychotherapist: Not disagreeing with you on that one.
Patient: [Laughs and seems happy] Oh yeah, and on top of that she doesn’t even
thank me for doing my own laundry. My mental problems are real. Are you
going to tell a person who has cancer to get over it? I guess in America some
people don’t believe mental health is real, like my mother.
Psychotherapist: You and I agree on that. [Both laugh] I hope you recognize what a
deep thinker you are and how far you can go with those thoughts, maybe even in
letting others help you.
Patient: [Shakes her head—she doesn’t agree, although she smiles.]
Psychotherapist: I think you underestimate how many people would like to help you
feel better. I am one of them. [Attempting to move along the process and using a
tone of voice and facial expression that nonverbally encourages her to accept
help by others as part of life]
Patient: I don’t believe that one. You have to pretend you care, no offense. [Giggling,
although looking somewhat sad] The things I loved in life were taken away from
me, I can’t play soccer, I don’t have my girlfriend. [Sports injuries prohibit her
from returning to competitive soccer.]
Psychotherapist: Here’s how I think about you in the future. I think that by the time
you are 23 years old, you’re going to be happy in a relationship with an outstand-
ing person like you.
Patient: [She laughs and challenges the therapist.] If I’m around. [Alluding to
suicide]
Psychotherapist: Fair enough, but what about my thoughts about you being as out-
standing in the future as you are now. Will you allow yourself to accept your
accomplishments?
Patient: I don’t see myself capable of accomplishing anything worthwhile [Starts
laughing at the irony of her comments]
Intersubjective The psychotherapist and patient are once again engaged in a lively
interaction even though it involves reflecting on some sad aspects. It also allows the
psychotherapist to intersubjectively make comments and be playful about his views
of the patient’s future. The psychotherapist feels warmth when the patient obliquely
refers to the fact the he cares, although she is playful about the reality that there is
implicit asymmetry as she is a patient and he is paid.
Later in the Session
Psychotherapist: Sorry, I’m just feeling really sad that, at times, I just feel you’re a
lonely teenager and your family doesn’t see that.
Patient: [She agrees and has tears in her eyes.] That would be correct.
Psychotherapist: You had to develop the skill of being self-sufficient in order to
survive the stress of your childhood. [Intended to let her know “I think I know
you” and not in the traditional one-person model in making an interpretation to
promote insight]
Patient: Yes, the few times I felt close, they abandoned me. I remember telling you
on our first appointment that I have abandonment issues. The only person that I
really opened up to was Shelby, and, well, you know how that is now. It was my
fault I lost her.
Psychotherapist: You can feel lonely, but you don’t have to be lonely.
Patient: OK, how? [Smiling and being inquisitive]
Psychotherapist: Coming to therapy is one. [She agrees and seems relieved.] The
other is letting yourself consider being close to someone again.
Patient: No. [Shaking her head]
Psychotherapist: What is the risk?
Patient: You really want to know? [With a smile] Being abandoned again. [Her
facial expression captures the fear. The psychotherapist feels intersubjectively
that overall she is correct.]
Psychotherapist: I think of it this way: If one is hurt when abandoned, it means that
we were connected and attached. You want to eliminate both options.
Patient: Correct, life makes no sense. Why do you think I hate myself?
Psychotherapist: I would like to be one of the many that tries to help you feel bet-
ter. I am happy you come to therapy and allow me to help, but I also feel that at
times I say things, and your facial expression seems to me says, “No thank
you.”
Patient: Yep, that’s about right. Actually, you have kind of done your job a little bit.
Just don’t take too much credit. I still have mental breakdowns. [A moment of
meeting intersubjectively]
Intersubjective There is a moment of meeting in which the patient accepts the

psychotherapist’s impression of her, and she also compliments the psychotherapist
for moving along the process. In a relational model, it is not necessary to make an
effort to verbally discuss what has happened, but rather let the moment of meeting
simmer in both.
Later Session in the Treatment
Patient: My mom hates me. [Pause] She hates me, a teenager that doesn’t clean her
room exactly how she wants it to be cleaned. But I would like to say, “Mom,
thank God you don’t have a teenager who gets drunk every weekend and is preg-
nant at age 16,” like she did. I’ll pull that card to see if she would understand how
difficult it is to be a good student, not do drugs, not drink, not have sex, and not
wanting to kill myself. I shouldn’t have to feel bad about my mother. Thanks,
mom. [Sarcasm]
Psychotherapist: You really have done quite well!
Patient: [Smiling with a sense of futility]
Psychotherapist: It was a heartfelt compliment.
Patient: I know you believe in me, thanks. [Comments made feeling understood and
also safe to experience some degree of sadness]
Intersubjective The psychotherapist intersubjectively feels it is important to be

cautious, so as not to repeat her implicit relational patterns where others have high
expectations and pressure her to achieve, which he recognizes and is also experienc-
ing. He becomes an active participant of her life and not an observer, which in and
of itself would be experienced as a repetition of the feeling of not being likeable or
wanted.
Psychotherapist: I think you should consider a career where you have to listen to
others’ problems.
Patient: I actually am a good listener, but if I had to listen to a teenager like me, I
would smack myself. [Laughs at the irony that the psychotherapist is eager to
listen to her]
Psychotherapist: Because?
Patient: I must be so annoying; I talk about the same things every time I see you.
Don’t tell me you don’t find me annoying for not being able to get over my girl-
friend and always being stressed [Inquisitive and challenging smile]
Psychotherapist: I am not there. I do not find you annoying.
Patient: I’m glad you’re not, but I am there. I sound so annoying. [Points at self.
Maybe that is why I am abandoned.]
Intersubjective The psychotherapist self-discloses that he does not find her annoy-
ing, which helps move along the process and cocreate another moment of meeting.
This comment is considered a countertransference enactment in the traditional one-
person school of thought; it gratifies the patient by answering her question rather
that exploring the unconscious meaning of her comment about whether the psycho-
therapist finds her annoying.
Context The psychotherapist meets with Michelle’s mother on the fourth appoint-
ment of the formal psychotherapy process.
Mother: I know I am not supposed to know what she is talking about, and that’s
OK. I just want to make sure that you know that she is still obsessed with her
ex-girlfriend, and it is not healthy.
Psychotherapist: I agree, although when I see Michelle, I am reminded of the early
relationships we all have when adolescents: obsessed and infatuated. Somehow
feeling the world will come to an end when a loving relationship is over. I am
sure you would agree it is complicated.
Mother: [Smiling] I guess you are right. I met her father and was head over heels
until I realized he was abusive. I just know that Michelle is not realistic.
Psychotherapist: I am sure that you remember what you did as a teenager when your
parents gave you advice about relationships. [Hoping to cocreate a joining expe-
rience in the futility of telling Michelle what to do]
Mother: Yeah, that’s funny; you do the opposite of what they say. I just can’t tell
Michelle to stop trying to talk to her ex-girlfriend; I just feel bad that she gets
hurt. [The psychotherapist has a genuine feeling that she cares for Michelle,
although her approach seems more like a peer.] What should I do?
Psychotherapist: How does this sound to you? You let Michelle know that you are
worried about her, and when she is ready to talk, you will be there for her. You
can model how to help her get over it by not pressuring her to talk about it.
Thoughts?
Mother: I can do that, but I am not sure she can; she is so manipulative.
Intersubjective The psychotherapist experiences Michelle’s mother as wanting to

be caring but is unable to contain her anxiety, as if she wanted matters about mother-
ing her adolescent daughter to be over—a familiar implicit relational knowing from
her life. The psychotherapist chooses to gently model, at an implicit level, how to
help her not repeat what her parents had done when she was a rebellious adoles-
cent—disapproval, distancing, and abandonment. He intersubjectively feels that she
needs concrete tasks outlining how to best parent her daughter.
Psychotherapist: [In a jovial manner and with humor] I of course know how diffi-
cult it must be to parent Michelle. I wonder if you think something like asking
Michelle to sit down and share the pictures of the projects she has completed at
school would work? [The patient had shared pictures with the psychotherapist
and shared she had submitted them for a national award.]
Mother: I like that idea. It’s kind of funny, because I bought her the camera she uses.
I think that would be easier because she has so many projects, and I might not
have time to have her tell me about all of them. I have to take care of the little
ones, you know!
Intersubjective Although Michelle’s mother verbally alludes to wanting to be

available to her daughter, she implicitly wishes for someone else to take over her
role as a mother.
It is important to note that when working from a two-person relational model
of psychotherapy, the goal is not to understand the patient’s or parent’s past object
relations in order to understand the present. As an example, from a traditional
one-person model, Michelle’s mother’s struggles in being a good enough mother
may be understood as a result of her conflicted past object relations: She was
abandoned by her own mother when she was 16 years old; she is raising her
daughter in the manner in which she interjected her own mother’s pathologic
object relations; and she experiences her daughter as a reflection of herself as an
adolescent. Although these hypotheses may be plausible, in the two-person rela-
tional model, attention is placed on the here-and-now experiences from both
mother and psychotherapist as they are contextual and unique to their dyad. In
this case, intersubjectively the psychotherapist believes Michelle seems more
ready and able than her mother to move along her developmental path with the
use of a new emotional experience provided by individual psychotherapy. Whether
the same patterns would have been present if the psychotherapist were a female
or of a different personality style is unknown. Finally, some may suggest that this
case could have benefitted from a joint mother/daughter form of psychotherapy,
which may have been reasonable if the psychotherapist had expertise in such a
model.
Letting Go
Context The psychotherapist noticed that Michelle seemed to implicitly agree

with his perception of her—a bright and talented adolescent.
Patient: [When talking to the psychotherapist about the break up with her girlfriend]
I just realized it wasn’t my fault, it was actually hers.
The first time I broke up with her, it was because I didn’t want to be close to
anybody. You know, for fear of abandonment. The second time I broke up with
her it was because we were constantly fighting, and we would go months without
speaking to each other. No surprise to you, but I love to be in control when some-
body begins to tell me what to do. I guess she didn’t accept me and wanted to
change me. [Smiling] Sounds like my mother, right? [Laughing] At least she was
more caring than my horrible mom.
Intersubjective The process described here is in the early phase of the treatment,
and it is too early for the psychotherapist to consider issues of letting go. Nevertheless,
due to the patient’s history of frequent abandonments by loved ones, it would be
13.5 Summary 329
important for the psychotherapist to openly discuss about any planned time off so as
to not repeat the experience of being abandoned. To this, he may openly share that
during his absence, he will miss the appointments and looks forward to resume them
upon returning. The patient will benefit from some self-disclosure about the reasons
for being away, allowing her to feel an important contributor to the process.
In the two-person relational model of psychotherapy, letting go is generally
considered a time of transition to more adaptive modes of relating with others—and
open to returning for further appointments if needed—rather than an ending or
termination.
With this case, we remind the reader of the many implicit and nonverbal
interactions that occur between patient, family, and psychotherapist, which are
difficult to capture with the use of written language. Nonetheless, we hope to have
provided the reader, at an implicit nonconscious level, a glimpse into the vast
amount of nonverbal communication that transpires in a two-person relational psy-
chotherapeutic process, with ubiquitous disruptions and carefully timed moments of
meeting.
Postscript
After 4 months of twice-a-week two-person relational psychotherapy, Michelle is

improving emotionally and academically and has begun to make friends. Of note,
her mother has declined to attend a parent session stating, “Michelle seems better, I
don’t think I need to come in. I trust you,” and has also declined to have a session
over the phone with the psychotherapist. Sadly, the patient reminds the psychothera-
pist, “She has abandoned you too,” an example of her mother’s implicit relational
knowings.
13.5 Summary
In this chapter, we provide the reader a case example of a 16-year-old adolescent

female who has difficulties negotiating her psychosocial development within the
context of a critical and dismissive mother and the abandonment by her father. This
is hoped to serve as a broad review of the main differences that exist between tradi-
tional one-person and two-person relational psychotherapeutic approaches. We pro-
vide the reader a case conceptualization from a pluralistic traditional one-person
model and follow this with a detailed description of the work that transpired from a
contemporary two-person relational psychotherapeutic approach, with attention
paid to the patient’s and her mother’s temperament, cognitive and affective flexibil-
ity, and internal working models of attachment within the context of the psycho-
therapist’s intersubjective experiences.
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Supervision
14
The meeting of two personalities is like the contact of

two chemical substances: if there is any reaction,
both are transformed.
—Carl Jung
In contemporary psychiatric practice and training, “supervision” consists of regular

meetings between a supervisor—typically a psychiatrist with experience in the sub-
ject—and a supervisee, often a trainee. The meetings between supervisor and super-
visee typically involve matters regarding patient care. To this, they may choose to
review relevant scientific literature, discuss pharmacological approaches, or use
clinical material to formulate diagnostic interventions about a psychotherapy pro-
cess. In regard to the psychotherapy process, the supervisor attends to what has
transpired between the supervisee and his or her patient, with the goal of providing
guidance for how best to proceed in terms of moving along the patient’s psycho-
therapeutic treatment. However, the process of psychotherapy supervision has
evolved considerably over the last 50 years due to the introduction of the concepts
from two-person relational psychology and based on the findings from neurobiol-
ogy and developmental psychology as discussed in Chap. 3. Thus far, these con-
cepts have been studied and disseminated mainly by psychologists and social
workers; it is our hope that with this book, we can bring the concepts of relational
two-person psychology, including psychotherapy supervision, to the attention of
young child and adolescent psychiatrists and psychotherapists.
In this chapter, we begin our discussion of the supervisory process with a brief
review of the traditional one-person model as it relates to supervision, followed by
a review of the supervisor’s use of a relational two-person psychology model and
the supervisee’s experience. Accordingly, we hope to provide an in-depth under-
standing of the different ways in which contemporary theoretical concepts can influ-
ence the process for both the supervisor and the supervisee. To create a “good

DOI 10.1007/978-3-642-40520-4_14
332 14 Supervision
supervisor–supervisee fit,” it is important for supervisors to be well versed in the

supervisory model and to tailor their teaching styles to the learning style of the
supervisee and not vice versa (Carol 2010). Finally, this chapter provides a guide for
the supervisee on what to expect from supervisors who utilize a contemporary rela-
tional approach.
It is our hope that child and adolescent psychiatrists or clinicians who have
trained in an academic institution where psychodynamic and relational concepts are
part and parcel of the understanding and treatment of their young patients will make
use of this book as they begin their journey toward becoming a well-versed
supervisor.
14.1 Historical Background of Psychotherapy and Core

Psychotherapy Competencies
The Accreditation Council for Graduate Medical Education (ACGME) has devel-
oped a series of core competencies that need to be acquired by child and adolescent
psychiatry trainees. These include six general competencies (patient care, medical
knowledge, practice-based learning and improvement, interpersonal and communi-
cation skills, professionalism, and systems-based practice) (Andrews and Burruss
2004). In 2001, the Residency Review Committee (RRC) officially mandated psy-
chotherapy training for psychiatry trainees, which included competency in five core
modalities of psychotherapy: (1) supportive psychotherapy, (2) psychodynamic
psychotherapy, (3) cognitive behavioral therapy (CBT), (4) brief psychotherapies,
and (5) combined medication management and psychotherapy. Additionally, expo-
sure to family therapy, couples therapy, group therapy, and other evidence-based
psychotherapies was also introduced as a requirement (Tucker et al. 2009).
Nonetheless, it was recognized that finding trained faculty to teach all five psycho-
therapy competencies was difficult. By 2007, it was clear that interest in psycho-
therapy had declined and the RRC made updates to the core psychotherapy
competencies, which included reducing their required training to only three areas:
psychodynamic therapy, CBT, and supportive therapy. Meanwhile, the training in
family and group psychotherapy remained in the form of exposure only (Tucker
et al. 2009) which is unfortunate in many ways. Of note, it limits the number of
newly minted child and adolescent psychiatrists who are well versed in family and
group therapies, which is an important, complex, and daunting task when working
with children and adolescents, which benefits from training. In addition, it requires
trainees to devote more time to pharmacological interventions, and it encourages
referrals for psychotherapy to psychologists and social workers who have limited
collaboration with the busy trainee due to the time constraints of training.
Of interest, the American Psychiatric Association (APA) committee on psycho-
therapy developed the Y model for the use in teaching the three competencies
required by the RRC (Plakun et al. 2009, see Fig. 14.1). The model is efficient,
integrated, and evidence based, and it avoids pitting one form of psychotherapy
against another. According to Plakun, “The place where psychotherapy education
14.1 Historical Background of Psychotherapy and Core Psychotherapy Competencies 333
Fig. 14.1 Eric Plakun’s Cognitive- Psychodynamic

Y model of psychotherapy behavioral
(Adapted from Plakun et al.
(2009))
Diagnostic formulation
Defined boundaries
Therapeutic alliance
Empathic listening
Common factors
begins in residency is conceived of as composed of the shared elements of psycho-

therapy across schools. Located among the shared elements are the current brief,
supportive, and combined medication and psychotherapy competencies” (Plakun
2006). In the Y model, the stem consists of the core processes that are identified as
being common to all forms of psychotherapy: empathic listening; identifying dys-
functional patterns; developing a formulation; and attending to issues of boundaries,
confidentiality, crisis management, and involvement of significant others. The Y
model assumes that psychotherapy unfolds within the context of a therapeutic alli-
ance (Plakun et al. 2009). The two branches of the Y model involve teaching spe-
cific aspects of CBT and psychodynamic therapy. Unfortunately, there are
experienced cognitive and behavioral psychotherapists that openly reject psychody-
namic psychotherapy for not being evidence based, which leads trainees to have
confusing and unsettling experiences about the benefits in all forms of
psychotherapy.
Psychotherapy Supervision as a Core Competency
The American Board of Psychiatry and Neurology (ABPN)—in association with

the Accreditation Council for Graduate Medical Education (ACGME) and the
American Academy of Child and Adolescent Psychiatry (AACAP)—recognizes
psychotherapy supervision as a core competency in the treatment of children and
adolescents. This provides the acquiring of clinical skills in major treatment modali-
ties, which include brief and long-term individual therapy, family therapy, group
therapy, crisis intervention, supportive therapy, psychodynamic psychotherapy,
cognitive behavioral therapy, and pharmacotherapy. As Mellman and Beresin
(2003) state, “[Psychotherapy supervision’s] eminence in psychotherapy education
seems well established and well assured.” Watkins and Scaturo (2013) add,
“Psychotherapy supervision has long been and remains a critical means by which
the culture of psychotherapy is taught and perpetuated.” However, as Cardoso
Zoppe et al. (2009) state, “There is still tension between biological and psychoso-
cial tendencies,” and they go on to highlight that current teaching methods for
334 14 Supervision
trainees routinely lack integration regarding the many elements of what is helpful to
patients, due to the fact that the supervisors are influenced by the setting in which
the patient is seen, and their school of thought. Every trainee and every supervisor
have a theory of cure that guides his or her approach. It is important for the supervi-
sor and supervisee to understand what theory the supervisor is working from in
order to be able to talk openly about its role in the current state of psychotherapy.
Therefore, it is important to support and educate our supervisees about the value of
an integrated approach in a world of Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5, APA 2013). Most supervisees are eager to learn
about psychodynamic and relational theories if we demonstrate excitement in
applying and teaching these dynamic concepts throughout their training. As Reiss
and Fishel (2000) state, “Psychotherapy supervisors now represent only the residual
backbone of psychotherapy programs. The importance of what these supervisors
teach and how they teach it has never been greater as the time devoted to teaching
the art of psychotherapy diminishes, and the trainee has fewer settings in which to
learn the principles of psychodynamic psychotherapy.”
Although the process of supervision continues to be embraced by many, it is also
important to note that many outstanding psychiatrists and other clinicians have
declined to supervise trainees in psychotherapy. In this regard, many have limited
their supervision to pharmacological aspects of treatment. This trend parallels a
larger trend over the past decade in which psychiatrists have reduced the time spent
practicing psychotherapy (Mojtabai and Olfson 2008). We hope that our efforts
serve to contribute to the enthusiasm of teaching the art of psychotherapy and
supervision.
14.2 Becoming a Supervisor
The process of becoming a psychotherapy supervisor is an important developmental

step for child and adolescent psychiatrists and psychotherapists. Moreover, this pro-
cess is seen as an integral part in shaping future clinicians. As Berger and colleagues
(1990) note, “The supervisory relationship is the main way that trainees develop their
identity as psychotherapists.” A supervisors’ development of knowledge and skill is
critical to their role as a mentor (Angus and Kagan 2007). Following the completion
of his or her training, a newly minted child and adolescent psychiatrist may be asked
to become a supervisor in psychopharmacology, consultation liaison, or psychother-
apy. Some training programs may require recent graduates to take a course on super-
vision before they begin to supervise, while others may utilize ongoing supervisor
conferences, and still others have no prerequisites. Needless to say, this important
process in the formation of our future clinicians has not been standardized.
In a recent discussion by the lead author with medical students and child and
adolescent psychiatry trainees, they noted that they had little exposure to psychody-
namic psychotherapy and that they were not aware of child psychiatrists who con-
tinued to practice such a form of treatment.
14.2 Becoming a Supervisor 335
Supervision: From a Traditional One-Person to a Relational

Two-Person Model
The process of psychodynamic supervision has evolved considerably, from a foun-

dation rooted in Freud’s structural and drive theories and Klein’s object relations
theories to a more contemporary understanding informed by temperament,
attachment, developmental psychology, neuroscience, and relational theories.
Supervision in a Traditional One-Person Model
Any discussion of psychotherapy supervision, particularly with regard to traditional

psychodynamic tenets, requires a brief foray into the role of psychodynamic think-
ing within training programs. Traditional one-person psychodynamic psychother-
apy has been taught in psychiatry training programs since the 1940s and is based on
five fundamental assumptions: (1) a central importance of the unconscious in men-
tal functioning, (2) the symbolic meaning of behaviors, (3) the existence of internal-
ized unconscious conflicts, (4) the idea that symptoms have meaning, and (5) the
belief that transference-based thoughts and behaviors are critical to understand and
help the patient change by overcoming the developmental interference on the emo-
tional growth process (Delgado et al. 2012). The traditional one-person supervisor
runs the risk of being seen as an omniscient observer whose function is to enlighten
the supervisee (Yerushalmi 1999).
Critiques of the Traditional One-Person Approach to Supervision
As discussed in Chap. 6, we have colleagues who continue to supervise trainees

using the traditional one-person model. They perpetuate the archaeological inquiry
of a child or adolescent patient’s unconscious inner life through the use of play,
transference issues, and the interpretation of dreams. This form of inquiry allows
the clinician to clairvoyantly know the patient better than the patient himself. Also,
traditional one-person model supervisors give importance to oedipal conflicts in
elementary school age children and the loosening of the regressive parental ties in
adolescents. Orange et al. (1997) state that this view represents a rather Cartesian
approach in the understanding of our patients. This does not take into account the
many important aspects of the patient’s and their family’s temperament and innate
working models of attachment—nature—nor the important contribution from their
environment, nurture, in forming their personality.
It is unfortunate that supervisees learning about psychodynamic psychotherapy
are generally not exposed to a relational two-person model, and if so, it is usually in
the form of a minimal amount of lectures with the implication that it is not relevant
or important for the child and adolescent psychiatry trainee to learn. It has become
a problem in which those who adhere to the traditional one-person model often
336 14 Supervision
criticize the relational two-person model without a thorough understanding of it.

Further adding to this problem is that in some training programs, trainees are
expected to complete the Psychodynamic Psychotherapy Competency Test (PPCT),
a 2-hour multiple-choice exam that is administered once a year during their training
and is based on traditional one-person model concepts (Mullen et al. 2004). In doing
so, training programs imply what is correct and thus limit the trainee’s ability to
learn about the importance of developmental research in regard to psychotherapy
and have the freedom in deciding which model is best for their patients.
14.3 The Two-Person Relational Model and Its Relevance

to Supervision
Over the last 30 years, with the emergence of a two-person relational psychology,
there has been a significant shift in the understanding and treatment of a person’s
psychological problems—from intrapsychic and object relations conflicts to prob-
lems of internal working models of attachment, affective attunement, and implicit
relational knowing. This shift has led to treatment interventions that focus on the
bidirectional here-and-now subjectivities continually modified by the reality of both
persons, known as intersubjectivity. Supervision in psychotherapy is inherently bidi-
rectional; the supervisor must be open to teach the supervisee as well as learn from
the supervisee. In a relational two-person model of psychotherapy, the terms “cocre-
ate” and “intersubjectivity” are sine qua non to the theory and technique. They reflect
the active participation by both patient and psychotherapist in the encounter, with
continuous and novel changes created from each other’s nonconscious subjective
experiences (Fig. 14.2). We offer Kierkegaard’s quote as a reminder of our task in
two-person relational psychotherapy supervision: “Instruction begins when you, the
teacher, learn from the learner, put yourself in his place so that you may understand
what he understands and in the way he understands it” (Kierkegaard 1998).
Undoubtedly, the notion of a two-person, relationally based psychodynamic
model of psychotherapy was not well received by supervisors of the traditional one-
person psychoanalytic model, as it challenged the legitimacy of its tenets.
As stated by Friedman (2010), “Many classically trained psychoanalysts may in
their actual practice incorporate changes that have been advanced by relational psy-
choanalysis, [although] their basic stance remains unchanged.” As Frawley-O’Dea
(2003) aptly states, “The relational supervisor holds that it is crucial to live out
mindfully with the supervisee and eventually to make explicit with him relational
patterns set in play within their relationship.” The relational two-person model has
gradually become a concept that most psychodynamic psychotherapists must con-
tend with, as it has served as an umbrella for several forms of psychotherapies that
endorse implicit or explicitly well-timed self-disclosures and enactments (e.g.,
mindfulness, dialectic, cognitive, patient centered).
However, training programs have struggled with a lack of experienced faculty
who are qualified and able to teach the complex and specialized courses needed to
learn, embrace, and apply the relational two-person model. As such, for a trainee to
14.3 The Two-Person Relational Model and Its Relevance to Supervision 337
Two-Person Relational Supervision
Child + Family Supervisee Supervisor
- Case conceptualization
Meaning making - Share prior supervisory experiences - Safety and spontaneity
Social referencing - Conveygoals hoped to achieve - Help move along the process
Temperament - Describe patient as a real person - How to time enactments
IF IF
Cognition - Share intersubjective experiences and self-disclosures
Cognitive ﬂexibility - Bring doubts and concerns - Review video and audio recordings
- Comfortable sharing diﬃcult moments - Assign readings
-Working with parents or caregivers

experiences
Co-created moments
Repairs
of meeting
Fig. 14.2 Schematic representation of the intersubjectivity during a supervisor and supervisee
encounter. Learning occurs in the intersubjective field (IF), the overlap of subjective experiences.
Bold arrows in the IF represent here-and-now moments of meeting
begin to master relational psychodynamic psychotherapy, the two-person model

must be incorporated early in adult psychiatry training and continued in child and
adolescent psychiatric training, and the trainee must be continually open to observa-
tion and discussion about the applicability of the theories to practical day-to-day
patient care, whether it be on the inpatient unit, in the outpatient clinic, or on the
consultation service. Additionally, regarding the art of two-person relational psy-
chodynamic psychotherapy, the abilities to observe and share details about
patients—to follow ongoing “threads” of subjectivities and make inferences of
implicit relational patterns—are often passed down by experienced faculty orally
and subjectively through their work. The importance of this form of teaching cannot
be emphasized enough; it is not only teaching the “art” but also providing the men-
torship needed for the next generation of colleagues.
Reiss and Fishel (2000), in reviewing the literature on supervision, observe that
“without adequate preparation, supervisors run the risk of boundary violations,
breaching ethical codes of conduct, destructive reenactments, restrictive practice
styles that limit the growth of their supervisees, inadequate coverage of the basic
tenets of psychodynamic practice, and occupational ‘burnout.’” In this regard, we
have known colleagues who were not well versed in relational psychodynamic
tenets and declined to help the supervisee further learn these concepts. They often
would state: “Relational is just a new word for what we already have a theory for. It
is not that complicated; you just need to be empathic with your patient.” This could
not be further from the truth. Supervision in a two-person relational model is not
338 14 Supervision
only gratifying, it can also be difficult in helping supervisees overcome their anxiet-
ies when asked to become active and present in the psychotherapeutic process. The
complexities of supervising psychodynamic psychotherapy are eloquently described
by a colleague in a clinical case presentation on supervision:
In the beginning of a supervision, I try not to give any directions as to what the supervisee
should or should not do—bring notes or not, stick with presenting one patient or not. I am
curious about how the supervisee will organize him or herself in relation to the task of
learning. Once I’ve understood the ways in which they do this, for better or for worse, I may
suggest modifications. For the obsessional supervisee hiding behind her notes, I may sug-
gest she not bring them, explaining that I would like to hear how she filters the information
from her patient through her own psyche rather than rely on a per verbatim report. For a
vaguer and more loosely organized supervisee, I may suggest he bring notes to better under-
stand the interactions.
14.4 The Two-Person Relational Supervisor
At the outset of supervision, the supervisor should show his or her vitality and curi-
osity about the supervisee’s previous educational and supervisory experiences: How
does the trainee feel that his or her training is going? What have been their previous
supervisory experiences (including the good and bad)? What does the supervisee
consider his or her strengths and weaknesses as a psychotherapist? What would he
or she most like to learn from the supervision? The answers to these questions will
orient the supervisor with regard to his or her approach to the supervisee.
The foundation of any good supervision, from a relational perspective, will
include a review of the patient’s biological, psychological, and social history—as
well as consideration of the internal working models of attachment used when relat-
ing to the psychotherapist—and a determination whether the supervision is for cri-
sis intervention, relational psychotherapy, family process work, cognitive behavioral
therapy, etc. Moreover, flexibility and the ability to allow intersubjectivity to influ-
ence the supervisory dyad are of paramount importance, as described by Kernberg
(2010): “I have found it very helpful to vary the intensity and rhythm of my contri-
butions to the supervisory process, ranging from periods in which I might very
actively try to convey information and influence the therapeutic process, to those in
which I might sit back and position myself on the receiving end as I listen to what
is going on with the patient, and to what new contributions the therapist may make.”
Goals for the Relational Supervisor
• The supervisor should be well versed in the theories that he or she is asked to
supervise.
• The supervisor must openly disclose his or her goals and objectives and should
also disclose areas of limitation.
14.5 Case Conceptualization in Two-Person Relational Supervision 339
• The supervisor should encourage the supervisee to share his or her expectations
of the supervision process.
• The supervisor should carefully ascertain the level the trainee is at with regard to
his or her development as a psychotherapist.
• The supervisor must establish an atmosphere of safety for the supervisee to feel
comfortable to present case material, as well as raise issues that he or she would
like to further learn.
• The supervisor—if at all possible—should openly encourage the use of video
and audio recordings by the supervisee.
• The supervisor should review theories that fit the patient’s needs and should be
willing to explain differences between relational models (self-disclosure and
enactments) and traditional models (boundaries) and cognitive therapies.
• The supervisor should highlight legal and ethical issues when appropriate.
• The supervisor should suggest readings that are pertinent to the cases that are
being supervised.
• The supervisor should encourage and facilitate the supervisee’s work with the
patient’s parents or caregivers.
• The supervisor should provide and request feedback about the supervisory pro-
cess every 2–3 months.
Limitations to a Two-Person Relational Supervisory Approach
Some relational supervisors often continue to teach with concepts remnant of the
traditional one-person psychology, a tendency that may be attributable to limited
exposure to and reading of contemporary relational literature. This generally inter-
feres with the trainee’s ability to develop a solid foundation of each theory.
14.5 Case Conceptualization in Two-Person Relational

Supervision
Case conceptualization is of central importance in any psychotherapeutic work,

regardless of modality. In relational supervision, it represents a careful scaffolding
of the patient’s innate and environmental strengths and weaknesses with regard to
the development of their personality. Neufeldt (2007) notes that the case conceptu-
alization is a crucial component of psychotherapy supervision: “Without a sound
case conceptual framework, supervision can become rather haphazard.”
The relational supervisor will remind the supervisee that uncertainty is ubiqui-
tous to relational psychotherapy. That is, in case conceptualization it is more about
determining what the patient needs in order to develop more adaptive patterns of
interaction rather than necessarily needing to inquire as to what created these pat-
terns. In using intersubjective experiences, the supervisee can help cocreate new
emotional experiences for both the patient and his or her parents or caregivers.
340 14 Supervision
It is common for the supervisee to initially conceptualize their psychotherapy

patients in a traditional one-person model. In such instances, the supervisee may
make broad statements such as “The patient is attention seeking and is splitting his
parents as all good or all bad” or “The parents are intrusive, hostile, distant, and
unable to mentalize the patient’s state of mind.” In essence, this type of case concep-
tualization represents a traditional one-person approach, as the supervisee firmly
believes that he or she knows the patient through the hypothesis developed in
observing a child’s play or listening to their verbal narrative, which is considered to
represent the truth.
The Supervisee Who Remains Loyal to a Traditional One-Person Model

Jamie, a 10-year-old girl, comes for the treatment of her shyness and anxiety.
Her mother shares that Jamie performs well academically, although she has
problems in getting ready to go to school and avoids interacting with her peers
at school. In contrast, she is very jovial, happy, and talkative when with her
parents, older siblings, and cousins. Jamie’s parents are healthy and very
social and are baffled by their daughter’s anxiety. The female supervisee
shares with her relational supervisor that her case conceptualization of Jamie
considers her as “having problems with preadolescent issues. Her shyness and
anxiety are a defense due to her fear in speaking up, as she assumes that her
parents will be disappointed in her if she expresses her anger. She shared that
her parents have high academic expectations on her.” Further, the supervisee
believes that the parents come across as demanding and high achievers and
that Jamie is likely correct in her perception of them.
In supervision, the relational supervisor helps the supervisee develop a case con-
ceptualization from a relational perspective by using the same material.
1. The supervisor shares that he was struck that the patient was very verbal and not
shy with the supervisee. The supervisor shares that by her description of the
interactions, he subjectively felt that the supervisee was at ease and enjoying the
process. He uses this to encourage the supervisee to notice that her patient
seemed comfortable relating with her, although the supervisor subjectively felt
the supervisee was describing an interaction akin to that of with a friendly adult.
This allows the supervisee to reflect that the patient’s internal relational model
when interacting with her was suggestive of an implicit comfort of dialogue with
adults and not peers. The supervisor follows this with a discussion about the fact
that the supervisee’s interaction with the child seemed to be more likely to be
found with an older age child. The supervisee subjectively recognizes this and
states: “That’s right. I noticed that I was experiencing her like a little adult. I
wasn’t sure if she was comfortable playing, so we just talked.” This provides the
supervisor an opportunity to review the importance for the supervisee to gently,
and over time, provide Jamie a new emotional experience in the form of playful-
ness that she seemed to implicitly lack.
14.5 Case Conceptualization in Two-Person Relational Supervision 341
2. Later the supervisor wonders about what subjective experience the supervisee
had of Jamie’s parents. This was to encourage the supervisee to use her intersub-
jective experience of the parents as a tool of whether they in fact were demand-
ing and had high expectations of their child. The supervisee smiles and states
that, to the contrary, she had found the parents as very loving and accommodat-
ing toward Jamie: “They make sure she has plenty of time to get ready for school,
and they go with her and let her know that they hope she can also have fun with
her peers at school. They are very warm and caring but definitely not playful.”
This allows the supervisee to appreciate how she had cocreated with Jamie a
negative perception of her parents, when in fact they were caring, and the reasons
for their limited playfulness with Jamie remained unclear. This also allows for a
discussion about the cultural aspects that may have been contributing to the
implicit importance placed on education over play in the family.
3. The supervisor asks, in light of the new case conceptualization, what the super-
visee subjectively feels would be helpful for Jamie. He adds that he subjectively
had felt that the supervisee had not been her playful self with Jamie and won-
dered if she would consider letting her patient know in the here and now how she
felt. She openly states, “I like her parents, and I think they will understand the
importance of play, if I am sensitive to their cultural norms.” The supervisor
reminds that only the supervisee’s subjective experience of Jamie and her par-
ents, in vivo, will let her know if the approach “feels right to all involved.”
By contrast, a supervisee who is experienced in a relational two-person approach

can focus on how he or she feels subjectively with their patient in order to discern
the temperament and internal working models of attachment being used in the here
and now. He or she can then formulate a case conceptualization that helps cocreate
new, more adaptive experiences.
The Supervisee Who Works in a Two-Person Relational Model

Jake, a 12-year-old boy, stated that his parents were mean and always fighting.
The female supervisee’s intersubjective experience of Jake was that he was
not genuine and believed that he seemed to be exaggerating his complaints, as
she had met the parents and found them to be likeable and caring toward Jake.
In the here-and-now moments with Jake, the supervisee experienced him as
treating her “as if I am a person he just met in the street. No real affective con-
nection with me.” The supervisee shared that it took effort to be able to play
and talk with Jake at his level. She used her intersubjective experience as a
guide about his likely developmental and emotional delays. She felt this was
further confirmed when she told Jake that she would be meeting with his par-
ents the next session, and he became upset and angrily said, “You’re going to
take my parents’ side.” She recognized that intersubjectively he felt that he
was in trouble when she mentioned meeting with his parents. This likely
implicitly reminded him of the many times his parents were called after his
342 14 Supervision
negative interactions with others, due to his misinterpretation of information

from his cognitive deficits. She replied with a melodic, jovial, and calm voice,
saying, “Jake, I want to take your side and help you feel better so you don’t
always think that you are in trouble.” He responded by thanking her for help-
ing him not be in trouble, “Nobody likes me.”
The supervisee shares that intersubjectively she feels that the patient’s parents—
like her—“don’t know what else to do to help him.” She considers helping the par-
ents begin to communicate actively with teachers and develop a behavioral plan to
avoid his meltdowns. She adds that his parents are exhausted and frustrated that,
cognitively, “the poor boy, he just doesn’t get it.” The relational supervisor helps the
supervisee appreciate that her efforts in keeping the psychotherapy process in the
here and now and at Jake’s developmental and emotional level have begun to pro-
vide elements of a new and corrective emotional experience—“He seems to begin
to think together with you about what it feels to him being in trouble.” Moreover, in
applying information about temperament, cognition, and internal working models
of attachment, the supervisee has begun to consider that she will (1) obtain a thor-
ough developmental history about his temperamental attributes, as she experiences
him to have a feisty/difficult style and subjectively feels that his cognitive limita-
tions impede what relational psychodynamic psychotherapy could provide; (2) dis-
cuss with his parents Jake’s potential cognitive weaknesses, which may explain his
distortions of others’ intentions; and (3) discuss the need for formal cognitive test-
ing to develop realistic behavioral, academic, and psychotherapeutic interventions.
Additionally, Delgado (2008) states: “Although young residents and therapists have
many theoretical choices regarding how they understand a case, or how they inter-
vene, one important fact to remember is that our comments are only helpful if they
make sense to the child. Once a child feels understood, she will guide us about what
language to use and with which issues they need help.”
Finally, it is critical for supervisors to have, without defensiveness, their own
case conceptualizations of their supervisee’s patients. In short, this facilitates a two-
way exchange of subjectivities in vivo. Such an approach will implicitly allow the
supervisee to experience the curiosity and spontaneity that he or she will ultimately
incorporate into his eventual role as a supervisor.
14.6 The Supervisee in Two-Person Relational Supervision
Child and adolescent psychiatry trainees begin psychotherapy supervision during

the course of their general psychiatry residency, and in many ways their experience
in supervision is not only affected by their own theoretical background and prior
clinical experience with patients but also, importantly, by their previous supervisory
experiences (Berger and Buchholz 1993). By the time they begin supervision in
14.6 The Supervisee in Two-Person Relational Supervision 343
their child and adolescent psychiatry training program, they have had nearly 3 years
of supervision experience with other supervisors.
In relational psychotherapy supervision of child and adolescent psychiatry train-
ees, we commonly hear their anxiety when they are not sure what, or how much, is
appropriate to self-disclose during the process with the child or adolescent. Common
statements are “I don’t want to interfere with what the child thinks is important” or
“I am worried that they won’t like me if I say something wrong.” Needless to say,
we have all gone through this phase of anxiety when beginning a psychotherapy
process with children. In the relational two-person model, anxiety can be put to
good use by educating the child or adolescent psychiatry trainee that they are not
alone—the patient also struggles with the anxiety in being with them (Maroda 2010).
Relational supervisors generally suggest that when the supervisee plans to openly
share their impressions of the patient’s play or narrative, they would benefit from
stating, “Let’s think together,” which allows for a new emotional experience and
sets the stage for implicitly learning to ask for help from others. In essence, it is
cocreating, in the here and now, a more adaptive way of managing the complexities
of their life. It may be difficult for supervisees to understand that the patient’s
improvement occurs at an implicit level and may occur in the absence of verbal
feedback from the patient during sessions. In the relational model of supervision, it
“strives to free those in training to use their minds and voices to challenge as well
as to learn from those who have gone before them” (Frawley-O’Dea 2003).
Using Intersubjectivity in Two-Person Relational Supervision
As we have discussed, intersubjectivity is a critical aspect of two-person relational

psychotherapy, and it plays an equally important role in supervision. Supervisees’
case formulations combine subjective and objective knowledge of their patients
(Yerushalmi 1999).
Intersubjectivity with a Supervisor, a Supervisee, and His Patient

A 10-year-old boy was treated in relational psychotherapy by a child psychia-
try trainee to master his anxiety and fearfulness. The trainee, in supervision,
shared that he saw the child as having an ambivalent/anxious attachment style
because when he encouraged the boy to reflect about his worries, “he would
shut down.” The supervisor, of a relational two-person school, had the inter-
subjective experience during the supervisory hour that the trainee in present-
ing the case material seemed anxious. He seemed to be playing out the child’s
apparent ambivalent/anxious attachment style. The supervisor had the subjec-
tive experience that the trainee seemed to have cocreated a mutually anxious
experience with the patient. The supervisor felt that what may best help both
the patient and the trainee would be to demonstrate in vivo how to use inter-
subjectivity to access internal working models of attachment in both the
344 14 Supervision
trainee and the patient. In doing so, it would provide the blueprint for new
emotional experiences. The supervisor, with sensitivity to the trainee’s anxi-
ety, shared that he thought that joining them in a session to observe and partici-
pate in order to teach about intersubjectivity live could benefit the process. The
trainee noticeably became anxious and fearful about why the supervisor may
want to join the session. The supervisor shared, “I would like to demonstrate
how to use relational concepts in psychotherapy, and you and your patient can
be my consultants about whether it is helpful or not.” To this the trainee recog-
nized the atmosphere of mutual curiosity created by the supervisor and stated
that he needed help in “getting better in play therapy” and appreciated the
supervisor’s willingness to join and be open to feedback from his and his
patient’s comments. In short, both trainee and supervisor cocreated a moment
of meeting (Chap. 5) to move along the supervisory and psychotherapy pro-
cesses. They agreed that the supervisor would join in the next session.
In the next session, the trainee introduced the supervisor to the patient
openly, saying, “He is going to help us help you feel better.” The three pro-
ceeded to play the board game Chutes and Ladders, typical for children from
3 to 7 years old. The supervisor noticed intersubjectively that both the child
and the trainee were playing in the same superficial and nonplayful manner
the trainee had described in supervision. The supervisor also experienced
intersubjectively both being anxious while playing; it seemed that the trainee
was comfortable being with the patient but avoided sharing his here-and-now
experiences, fearing it would make the patient more anxious. When it was the
supervisor’s turn to move, and in reflecting on 10-year-old developmental
milestones, he noticed that the child was quite bright but lacked the confi-
dence in enjoying play, demonstrating independence, or challenging rules. He
then proceeded to move and pass the child’s and the trainee’s pieces, knocking
them over and saying in a cheerful although somewhat sarcastic manner,
“Excuse me, I am just lucky to pass you two, and I thought, ‘Hmm, it just
seems fun to knock you both over.’” Surprisingly, both the child and trainee
looked at each other for a few seconds and began to laugh and make fun of the
supervisor’s move. In this moment of meeting, the child engaged in social
referencing and looked at the trainee for implicit permission to retaliate
toward the supervisor’s piece as he was next to move. The trainee got the
implicit request from his patient for permission to act like a 10-year-old, and
with clear affective attunement to the child’s emotional state said, “Yeah, let’s
go get him.” They continued laughing and enjoyed knocking over their pieces,
and the child demonstrated his eagerness to play. It had become more impor-
tant to for the trainee to be genuine with the patient, play and laugh together
rather than to anxiously play by the rules base on the trainee’s anxiety.
From this vignette, we can see three important elements, characteristic of rela-
tional two-person psychology, as they relate to the supervision process:
1. The trainee had focused his efforts on establishing a therapeutic rapport with the
child with caution rather than on outwardly introducing his intersubjectivity
because he had conceptualized the case with a traditional one-person model. In
other words, he felt there was a need to find the “buried treasure” in the past that
held the key to what led to the child’s anxieties.
2. The initial description by the trainee that the child had an ambivalent/anxious
attachment style was not only what he observed but also what he contributed to
the child’s reciprocity. As seen in the play between the child and trainee, when
they joined forces and decided to team up against the supervisor in the session,
it could be said that their observed attachment styles were safe and secure and
with mutuality. Therefore, it is important to know that when working with chil-
dren and adolescents, observed attachment styles are influenced by our personal
proclivities. If the trainee would have been overconfident—using an intellectual
approach to the problem and applying cognitive behavioral principles to concep-
tualize the case—he may have been able to take an active role in directing the
child as to what the child should do to feel better. We can only speculate what
path the child may have taken to interact with the trainee’s intellectual approach.
For example, he might have withdrawn due to the intensity of affect in the room
and appeared to be of an avoidant/dismissive observed attachment style. In stat-
ing that a child has observed behavior typical of a secure, ambivalent/anxious,
avoidant/dismissive, or disorganized attachment style, this is only partially cor-
rect. We recommend that when referring to the attachment styles of patients, they
should be noted as such: “The observed attachment style of the patient with me
is [specific style]. I notice that this style changes to [alternative style] when he or
she notices that I am [sad, angry, or tired] or when the patient is with [different
person].” This allows noticing the important shifts in relational patterns that may
provide clues about the internal working models of attachment and intersubjec-
tivity of the patient that seem maladaptive.
3. The relevance of the interaction between the trainee and supervisor in this case
is not reflective of a standardized cookie-cutter approach to supervision. It is a
relationship in which both parties are influenced by the patient, although in dif-
ferent manners. The trainee brought into the supervisory hour the patient that he
remembered subjectively, which clearly is not the full picture. Unlike in the case
of the 10-year-old boy, not all supervisors are willing to demonstrate how they
work in front of their trainees knowing that they will be scrutinized. Likewise, in
good relational supervision, the fear of how the trainee may feel if their work is
intruded upon should be discussed openly, as this can only occur if there is a
mutual sense of collegiality and safety cocreated during the process.
346 14 Supervision
Lying in Supervision: A Two-Person Relational Approach
Lying by supervisees is not a new concept. Supervisees lie to their supervisors for
many reasons. Among psychotherapy supervisors, some think that “lying” may be
too strong a word, and rather it is best to think of the supervisee as leaving things
out until they feel safe enough and knowledgeable enough in the supervisory rela-
tionship to know it is safe to share their thoughts and actions (Jacobs et al. 1995).
We know that many of our young colleagues fear being judged and that there is a
high likelihood they at times have edited out material—or simply lied—to their
supervisors. Gabbard writes about lying to his supervisors during his psychoana-
lytic training (2009). Hantoot (2000) eloquently states: “Lying in psychotherapy
supervision represents a failure on the part of the trainee to manage his or her
impulses and affects in more adaptive ways. Such a failure may reflect limitations
in a particular trainee’s capacity to manage affects, as well as being a result of inad-
equate external supports. The ability of the supervisor to provide an adequate hold-
ing environment in the face of the regressive pressures of training is a key factor in
avoiding the pitfalls associated with misrepresenting case material.”
It is known that when the supervisees edit the material taken for supervision, it is
likely due to their knowledge of the supervisor’s preferred school of thought and a
fear of being criticized for their actions if they are not consistent with the supervisor’s
theoretical preference. Thus, at times, they learn how to present case material that
may be praised rather than present material they are struggling with. This is similar
to when patients implicitly learn what their psychotherapist is more likely to attend
to when a traditional one-person model is used, be it dreams, conflicts, or transfer-
ence issues. That is, the supervisee and the patient alike learn what is valued by the
person that has been given the task of helping them understand the human mind. The
supervisee may learn that process notes please the supervisor, just as the patient
learns that dreams please the psychotherapist. They use this knowledge to share what
they have implicitly learned is important to the other person, in order to please.
The supervisee who is immersed in relational two-person psychology, when
supervised by a traditional one-person supervisor, may be subject to criticism. This
could include comments such as “Your approach is too supportive and will not lead
to insight and change”; “It is not psychodynamic—the patient knows too much
about you”; “I am not sure I am comfortable with your approach”; and so on. It is
our hope that as supervisors, we must come to grips with our limitations, and when
it becomes difficult for the supervisee to feel they are in an atmosphere of safety to
explore traditional or contemporary concepts, an open discussion is needed to come
to an agreement of how to proceed and help feel they do not have to leave things out.
If that is not possible, ultimately a transfer to a supervisor with more expertise may
be the best option.
Spontaneity in Supervision
An important element of the supervisory relationship is trust and the supervisor’s

ability to tolerate spontaneity from the supervisee, both in their work with patients
and in supervision. The authors have found that in supervising colleagues and train-
ees, when the possibility of helping the child by observing them at their home, at
their school, or in other places is introduced, their anxiety increases and they make
comments like “Won’t the child feel bad if I show up at their home or school?”
“Isn’t that breaking a boundary?” and “Will the child be able to trust me if they
think I am taking sides with the parents or teachers?” These comments are more
about the anxiety of the psychotherapist than about what is best for the child
(Table 14.1).
Table 14.1 Common questions posed by supervisees in two-person relational psychotherapy

supervision
How long will it take me to understand my patients like my supervisors?
Do I have to self-disclose every time the patient asks me a personal question?
How will I know if the patient is getting better if it is not about insight?
How do I tolerate the feelings generated: frustration, anger, sadness, and the love by my
patient? Do I call these feelings countertransference?
The Supervisee’s Dilemma in Sharing with His Supervisor That He Has Gone to
His Patient’s Home
A child and adolescent psychiatry trainee had begun individual psychotherapy
with a 15-year-old adolescent who had a 2-year history of depression. The
patient was the third of five children born to an upper middle class, religious
family who lived in the suburbs of a Midwestern city. After 6 months of weekly
relational psychotherapy, the patient was improving, and the trainee felt less
worried about him, as he seemed to have more adaptive working models of
attachment, evidenced by his ability to relate better to his parents and peers.
The trainee had intersubjectively found the patient to be increasingly likeable
and more able to implicitly make use of the new emotional experiences pro-
vided by the trainee. However, toward the 8th month of the psychotherapy
process, the patient called to cancel his appointments in two consecutive
weeks. The trainee struggled to understand the reasons for the cancelations
and subjectively struggled with his worry about the patient, as well as his
sense of frustration with the patient’s unusual behavior. The patient would call
and leave a message for the trainee: “Doctor, it’s Harry. I don’t have anything
to talk about today; I’m not coming.” On the third week, about 20 min. prior
to the session, Harry’s mother called to cancel his weekly appointment. The
trainee was confused by the call, as typically Harry had been the one to call.
He became worried, as the subjective experience was reminiscent of earlier
psychotherapy appointments when Harry’s chronic depression and sense of
loneliness were at their peak. The trainee, wondering about medical reasons to
explain the cancelations, asks Harry’s mother if Harry had been feeling
OK. She said that he was healthy but had recently begun isolating and they—
his parents—were tired of trying to figure him out. She added that they were
348 14 Supervision
surprised that he had requested his appointments to be canceled, and they were
planning on making their own appointment to discuss their concerns. The
trainee subjectively felt that something was uncharacteristic of Harry and his
parents, and he also felt that waiting would risk matters worsening. It hap-
pened that Harry’s appointment was the trainee’s last one for the day, and he
subjectively felt that it would be helpful for him to go to their home and see
Harry. He asked Harry’s mother if the session could occur at the family’s
home. She agreed and was pleased with such an offer.
As the trainee drove to the patient’s house, he wondered, “How am I going
to explain this one to my supervisor?” He thought, “If he were to criticize me,
I’ll tell him that what I did was no different than what the family therapists of
the 1980s would have done.” The trainee drove to Harry’s home, where he
found Harry crying in his room after fighting with his parents about his isolat-
ing to his room. The trainee saw that the room was adorned with awards won
by his older brother. The patient stated: “Thanks for coming. My depression
came back and I am disappointing my parents and you. I will never be as good
as my brother.”
Upon returning to his office, the trainee worried that the supervisor would
not “get what it was like to be in the room with my patient when he was
depressed and feeling lonely.” However, the supervisor proved supportive of
the trainee’s efforts to help the patient, and both were able to review the pros
and cons of what had happened. What ensued resulted in the patient being
able to work with the trainee in understanding the course of his chronic
depression, and he agreed to take medication to help manage his symptoms
with the help of his parents
This example highlights the many complexities that can emerge for the super-
visee, and the supervisor needs to be able to tolerate spontaneity of action.
14.7 The Use of Video Recordings in Supervision
We wish to emphasize that with the technological advances that make it simple to
video record our work, we are easily able to share our work with our trainees. This
provides them a model and encourages them to share their work with their supervi-
sors and in their didactic classes.
We have been complimented for sharing our work, as it shows that we are not
wizards that somehow always know what to say and do in sessions. It is helpful to
demonstrate how, in certain moments, we became an accomplice to the patient’s
maladaptive patterns of interaction. In a basic example, we nonconsciously became
the critical or exasperated parent, as was evident by the material being shared. Of
course, it is also helpful to share what we do well, as this is the best form of
teaching.
14.7 The Use of Video Recordings in Supervision 349
Additionally, when supervisees share their work in the form of video recordings,
they may ask, “What would you have said?” This provides the supervisor a valuable
tool, as he or she is able to see and hear the intersubjectivities present during the
moment that led to the question. This allows a better appreciation of the subjectivi-
ties—tone of voice, facial expressions, and body postures—between patient and
supervisee during the process.
The supervisor’s role is to facilitate the student’s discovery of ways of observing
and forming intuitions from the clinical situation without the early encumbrance of
theory (Goldberg 1998). We are not suggesting that supervision is a parallel process
to psychotherapy, but rather a parallel process to mentoring and perhaps parenting.
We need to be willing to compliment, support, and encourage our supervisees, as
well as remind them of the arduous task of learning over time. In an atmosphere of
mutual learning and without having the expectation that the material is always
understood by the supervisee, supervision is open for sharing hypotheses and
reviewing what the patient can teach us over time. We openly share our mistakes
and our excitement when we get things right, without displays of erudition, clever-
ness, or superiority.
The Well-Intentioned Supervisee

A senior trainee shared with excitement a video recording of a 6-year-old boy
he had been seeing in traditional psychodynamic psychotherapy for 6 months.
In the video recording, the child was seen drawing and coloring strong char-
acters and then giving the drawings to the trainee. The trainee’s previous
supervisor had thought that the psychotherapy process was going well; he
believed that the child’s drawings of strong characters were the representa-
tions of his abusive and unpredictable father. He suggested that the child
needed to draw the strong characters to defend against his unconscious anger
at his critical father. When the trainee changed to a relational supervisor, sev-
eral aspects in the video recording were discussed within the context of con-
temporary diagnostic formulation. The child’s drawings were very simple,
and the child did not provide any stories about the strong characters; rather, he
would just name them and move on in a disorganized manner. Developmentally,
milestones typical of 6-year-olds include being able to describe experiences,
talk about thoughts and feelings, and think about their place in time and life,
which the child had not achieved. With sensitivity, the supervisor noted that
the trainee also seemed superficial in speaking about the child, as if he had
little to say about the play observed in the video recording. The supervisor
asked the trainee if he had felt engaged with the child’s subjectivity. The
trainee paused and said: “I noticed that I am always the one that has to develop
the stories to help the child not be so concrete, and I become tired and bored
playing the same thing over and over. My other supervisor thought things
were going well and that the child would eventually ‘gain insight’ through the
play.” This led the relational supervisor to help the trainee review
350 14 Supervision
developmental milestones based on age, which the child was clearly behind.
Formal cognitive testing was obtained and revealed that the child had border-
line intelligence, which explained his concrete play. This information allowed
for a shift in the approach by the trainee, which included providing more sup-
port and educational guidance for the mother, requesting from social services
that visitations with his father be supervised and actively working with the
child’s school to help develop realistic expectations and accommodations.
This vignette highlights the need for supervisors to help supervisees allow for
their subjectivities to be used in a helpful manner. That is, the implicit relational
mutuality between the supervisee and supervisor allows having a moment of meet-
ing, which serves to catalyze and move the supervision along (BCPSG 2010).
Before we leave this example, we note that we are aware that the traditional one-
person supervisor may wonder if this is an example of a trainee simply complying
with the new supervisors’ suggestions. The relational supervisor experiences the
well-respected trainee in the video recording as feeling tired and bored during the
child’s play and wonders in the here and now if his impressions are accurate. The
supervisor opens the intersubjective field in that he asks for consultation from the
trainee about his thoughts regarding his experience of his own work in the video
recording. Had the supervisor experienced the trainee intersubjectively in disagree-
ment, he or she would have proceeded to engage the trainee in an open discussion
about the differences in understanding the child’s play.
A note of caution: Some supervisors are not comfortable sharing video record-
ings of their work, and this may lead some trainees to assume that the supervisor is
not actively practicing psychotherapy. In this case, we risk that supervision may not
be valued or the supervisor may be seen as out of touch. This is of particular concern
since the contemporary relational two-person model is a relatively new form of
understanding and helping our patients (Chap. 3). As such, we would ask that super-
visors consider having a set of personal video recordings to share that are generally
well received by supervisees.
It is beyond the scope of our book to review the many rules regarding video
recording consents (reviewed in Chap. 9), and we refer the reader to their depart-
ment or medical state policies for details on video recording for education, length of
time valid for a consent, etc.
14.8 Concluding Thoughts on Two-Person Relational

Psychotherapy Supervision
Indeed, the practice of supervision is an exciting endeavor, a sentiment captured by

Kernberg (2010): “For the supervisor, seeing the supervisee’s growing indepen-
dence in doing good work, supported by his or her capacity to convey new informa-
tion and to provide new leads to the supervisor, is a gratifying experience of knowing
References 351
one has contributed to the supervisee’s autonomous growth.” Thus, “Good supervi-
sion becomes an extremely interesting learning process for both participants. The
supervisor’s self-reflective function may be shared with the supervisee to an increas-
ing degree over time, so that the supervisor’s speculations, uncertainties, and pos-
sible alternative formulations regarding the patient can be made available in more
direct and open ways, facilitating the supervisee’s identification with the supervi-
sor’s self-reflective attitude. Transmission of this attitude, in turn, broadens and
deepens the supervisor’s pleasure in the supervisory process” (Kernberg 2010).
Wachtel (2012) aptly states, “One of the most important things I try to teach my
students is that they should notice inconsistencies on the patient’s part but should be
wary of pointing them out as such, lest they seem more like district attorneys than
therapists.”
Therefore, the process of supervision is central to psychotherapy training and
serves a number of important functions. Moreover, there are key responsibilities for
supervisors engaging in the supervision of relational psychotherapy. In this regard,
supervisors are tasked with codeveloping a case conceptualization of the supervis-
ee’s patient and also establishing an atmosphere of safety for the supervisee to pres-
ent case material and issues that he or she would like to learn more about. Moreover,
the supervisor working with a supervisee who is engaged in relational psychother-
apy will need to help the supervisee to understand differences between the two-
person relational model and traditional one-person models (e.g., the differences of
self-disclosures, enactments, and boundaries). We note that at times self-disclosures
and enactments occur unknowingly from the psychotherapist and their presence is
revealed by the patient in the form of a moment of meeting or of a disruption to the
process.
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Appendix
Appendix A: Developmental Milestones
Developmental milestones: 2- to 3-year -old toddlers
Developmental domain Proficient Concerning
Social/emotional At 2 years old, plays mainly beside Poor affection for friends
other children, does not like
sharing, and may grab and push Aggressive forms of play
At 3 years old, shows affection for Poor self-regulation while playing

friends without prompting, takes
turns in games, shows concern for Does not know how to make use of
a crying friend, and has a wide toys or enjoy play
range of emotions
Little interest in taking turns in games
Language/communication At 2 years old, average vocabulary Limited amount of words used

should be 50–300 words
Use of offensive words, likely heard
By 3 years old, should have a from adults
vocabulary of 1,000 words and be
able to carry a conversation using Loud use of infantile voice
two- to three-word sentences using
plurals and pronouns
Cognition At 2 years old, completes phrases Play is simple or disorganized

of two to three words and
communicates needs (hunger, Poor ability to play make-believe and
thirst, pain, etc.) speaks of negative view of others
At 3 years old, plays make-believe Concrete play without story line

with dolls, animals, and people,
completes puzzles with three or
four pieces

DOI 10.1007/978-3-642-40520-4
354 Appendix
Behavior/motor At 2 years old, begins to run and Impulsive with poor self-regulation
kicks a ball, builds a tower of six to
seven cubes Repetitive behaviors or actions
At 3 years old, runs easily and Often aggressive actions

climbs well, has control of bowel
and bladder during the day
Parental “milestones” Creates a stimulating and colorful Unpredictable routines

environment
Abrupt and inconsistent discipline
Reads to the child
Poor recollection of feeding and sleep
Displays consistent and predictable schedules
discipline and routines
Unaware of child’s distress during
Attunes to child’s needs even conflict between parents
during episodes of angry feelings
Bothered by child’s needs and yells at
child rather than attunes
Adapted from: Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities,
Centers for Disease Control and Prevention; Shelvov SP, Hannemann RE, Trubo R (2004) The American
Academy of Pediatrics: complete and authoritative guide for caring for your baby and young child.
Bantam Books, New York, NY
Appendix 355
Developmental milestones: 4- to 6-year -old children
Social/emotional Enjoys exploring and is curious Restricted range of emotions

about toys and games
Ignores other children
Increasing creativity with make-
believe play Argues with persons outside of the
family
Wants to please and agrees to
rules, although may change rules Shows extreme behavior, usually
often aggressive or sad
Increasingly cooperates and plays Limited repertoire of games and

with other children over playing activities
alone
No interest in make-believe or
Likes to sing, dance, and act interactive games
By 5 years old, can tell the

difference between pretend and
real and is aware of gender
May be very demanding at times,

and very compliant at other times
Language/communication Sings a song or recites poem from Speaks unclearly and is difficult to
memory understand
Tells stories with full sentences Cannot retell a favorite story or video
Can say first and last name Frequent errors with pronouns
Increasingly uses future tense Unable to comment on daily activities or

experiences
Uses basic rules of grammar
Limited and repetitive vocabulary
By 5 years old, recites the
alphabet and counts to 10 Poor use of grammar, especially plurals
and past tense
By 6 years old, average
expressive vocabulary should be Imitates words of others and uses out
2,500 words, and receptive of context
vocabulary should be 20,000
words
356 Appendix
Cognition By 6 years old, identifies many Has trouble scribbling

colors and numbers
Resists dressing self and toilet training
Can draw a person and geometric
shapes with increasing Difficulty staying focused on a single
complexity activity for more than three minutes
Can count 10 or more things Difficulty distinguishing between pretend

and real
Developing idea of “same” and Cannot follow three-part commands

“different ”
Speaks in infantile manner
Remembers parts of stories and
tells you what may happen next in No depth to their stories or play
a story
Developing an understanding of
time
Knows about things used every

day, like money and food
Can draw a circle or triangle
Behavior/motor Can print some letters or Unable to jump in place

numbers
Unable to brush teeth, wash and dry
Stands on one foot for 10 s hands, or get undressed without help
or longer
Draws pictures in very simple form
Hops and eventually skips
Restlessness, over-activity, and abrupt
Uses a fork and spoon and behavior/motor
sometimes can use a knife to
spread
Can use the toilet on his or her

own
Swings and climbs
Can dress independently; may

need help with laces and buttons
Parental “milestones” Reads stories and attunes to the Frequently involves children in conflict
child’s reactions to the story line between parents
Is consistent, repeats instructions Consistently displays affect in harsh

with tone of voice and gestures manner
reflecting care and firmness
Inconsistent and abrupt discipline
Is warm and affectionate when
child expresses angry feelings Frequently shouts when the child needs
attention
Has predictable routine in
parenting and playful activities Unrealistic expectations of the child
Use of corporal punishment
Appendix 357
Developmental milestones: 7- to 9-year -old children
Social/emotional Fears of monsters, kidnappers, and Intense sadness or despair

large animals
Only smiles or laughs at the expense
Play includes use of fantasy and of making fun of peer or adult
imagination. May have imaginary
friends Problems making and keeping friends,
demanding of their loyalty
Develops a sense of humor,
expresses simple jokes and Displays anger, aggression, or temper
rhymes tantrums
Initially desires to play with parents, Demands privileges of older siblings

but gradually shifts toward friends
Does not fear being alone in public
Can play in organized sports and places
follows rules
Develops a greater sense of

empathy with same-sex peers, but
still mostly self-focused
Language/communication Can describe with some detail a May steal or lie with a poor
favorite activity, video, or book understanding of the consequences
Uses correct grammar and Poor comprehension of age-

sentence structure most of the appropriate books and videos
time
Self-injurious behavior such as head
Recognizes and reads simple banging, scratching, or biting when
words angry
Able to thank others for help Frequently uses foul language
Cognition Develops the skills to process more Learning becomes increasingly

abstract concepts and complex difficulty; avoids doing homework
ideas
Frequent disruptive behavior at school
Is able to focus on the past and
future as well as the present Continues to communicate with simple
sentences
Can draw a figure with a head,
body, arms, and legs Does not pick up on humor
Identifies right and left easily Difficulty with changes in routine or

transitions
Speaks in infantile manner
Seems younger than age

358 Appendix
Behavior/motor Usually has good balance and Frequently falls during simple
enjoys running, jumping, skipping, activities
and other forms of physical play
Inability to hold and use writing
Able to hold a pencil and clearly instruments
write letters
Repetitive behavior/motors such as
Can copy triangles and diamonds hand flapping or rocking
Can ride a bicycle and tie shoes Frequent physical pains such as
stomachaches, headaches, or
Increasing height and weight vomiting
Frequent aggressive behaviors toward

siblings and peers
Parental “milestones” Is involved in child’s extracurricular Often asks the child to take sides
activities between parents when in conflict
Delegates age-appropriate Frequent complaints of other persons

responsibilities within the home in the presence of the child
Works to reduce changes in child’s Usually is harsh; inconsistent

life, shields children from parental discipline may include corporal
conflict punishment
Always expresses anger verbally by

yelling
Relies on child to listen to adult

problems or loneliness
Appendix 359
Developmental milestones: 10- to 12-year-old adolescents
Social/emotional Close friendships to same-sex Doesn’t smile or laugh, prefers to argue

peers or demand
Becomes critical of adults Problems making and keeping friends
Has intense interest in belonging Angry and aggressive comments or

to a team and enjoys organized behaviors, temper tantrums
competitive games
Dislike of organized games
Anger is common, resents being
told what to do, and rebels at
routines. Reacts emotionally
rather than logically
Experiences many fears and

worries about physical changes
and appearance
Language/communication Begins to be interested in world Does not see the consequences of

and community events stealing or lying
Has strong urge to conform to Prefers to view age-inappropriate books

peer-group morals and videos, which can include violence
and sex
Good abstract reasoning, with Self-injurious behavior such as head
meaningful conversations with banging, scratching, or biting when
peers stressed
Use of foul language
Cognition Challenges adult knowledge Frequent negative behavior at school
Increased ability to use logic Declining grades with increased

difficulty
May have interest in earning
money Difficulty with small changes in routine or
transitions
Has interest in having privacy
Avoids schoolwork, and it does not bring
pleasure
Behavior/motor Rapid growth if in puberty and is Impulsivity is common

increasingly aware of body
changes (e.g., voice, body odor) Aggression is aimed at hurting others
Girls begin to show secondary Bullies other children who are not as
sex characteristics strong
Increased coordination and Frequent use of physical aggression

strength
360 Appendix
Enjoys sports and video games Begins to resort to self-harming activities

with peers, both organized or in when angry or unhappy
community
Shift in sleep patterns
Parental “milestones” Is able to anticipate and discuss Undermines other parent

pubertal changes
Gives the child adultified role in caring
Is understanding and supportive for younger siblings
Helps child set the rules and Unable to perceive academic or social
decide own responsibilities struggles in child
Gives child opportunity to make Makes fun of child if child makes

decisions mistakes
Provides for organized activities Increases use of negative comments

in sports or clubs and blames the child often
Appendix 361
Developmental milestones: 13- to 15-year -old adolescents
Social/emotional Withdraws from parents, who are Irritability, mood swings

invariably called “too old”
Expects to fail and blames parents
Needs less family companionship
Bullies other children
Worries about grades, appearance,
and popularity Blames parents for unhappiness
Identifies with peer group Enjoys teasing others
Ambivalent about sexual Engage in self-defeating, aggressive,

relationships antisocial, or impulsive behavior; may
withdraw or isolate
Body image and dieting patterns
begin to have prominence Does not respect others’ property
Age-specific moodiness Body image avoids mainstream

peers’ image
Language/communication Enjoys reading or being involved in Unable to enjoy being with peers
school projects unless involved in negative
behaviors
Thrives on arguments and
discussions by using logical thinking Argues with adults using foul
language
Cognition Increasingly able to memorize Concrete thinking
Thinks logically and hypothetically Behaves as if societal rules do not

about concepts apply
362 Appendix
Engages in introspection and Difficulties at school lead to disruptive

probing into own thinking behavior
Has realistic plans for the future Use of nicotine, alcohol, and drugs
Behavior/motor Experiences sudden and rapid Aggression is aimed at hurting

increases in height, weight, and others
strength with the onset of
adolescence No inhibitions of sexual or substance
abuse activity
Enjoys competitive sports and video
games, both organized or in Bullies other children who are not as
community strong
Participates in outdoor chores with Frequent use of physical aggression

parents
Parental “milestones” Decision making is done as a Undermines other parent

parental unit, even when divorced
Unable to perceive struggles in
Assists in navigating through peers
pubertal changes
Makes fun of other’s mistakes with
Models emotional and behavioral foul language
regulation during arguments
Engages in unilateral authoritarian
Engages in consistent support and parenting with limited collaboration
limit setting
Overly identifies with adolescent, has
Models by engaging in altruistic poor limit setting, and is too
activities permissive
Allows the adolescent to have an

adult role when needed for selfish
reasons
Appendix 363
Developmental milestones: 16- to 19-year -old adolescents
Concerning
Similar to deficits in 13- to 15-year-
olds, although in more extreme
Developmental domain Proficient form
Social/emotional Usually has many friends and a Irritability, mood swings

few in whom they confide
Bullies peers and adults
May be strongly invested in a
single romantic relationship; may Blames parents for any mishap
begin to become sexually active
Begins to speak of physical actions
Worries about failure toward others, self-harm, and suicide
if demands to be liked or loved are
Has conflicting feelings about not met
dependence/independence
Difficulties trusting
Age-specific moodiness
Language/Communication Able to fluidly shift between different Enjoys being with peers only if they
contexts, including ages and peer use the same foul language
groups
Involved in negative behaviors with
Able to use more complex more planning
communication to express ideas,
including nonverbal and abstract Argues and threatens adults and uses
ideas foul language without concern for
hurting others
Establishment of ethical and moral
values Unable to form or maintain
satisfactory relationships with peers
Cognition Beginning to integrate knowledge Concrete thinking is common

leading to decisions about future
Critical of parents and believes
Makes steps toward intimacy societal rules do not apply
Conscious choices about which Difficulties at school lead to disruptive

adults to trust. behavior
Respects honesty and Use of nicotine, alcohol, and illegal

straightforwardness from adults drugs
Behavior/motor Has essentially completed physical Aggression is aimed at hurting others

maturation; physical features are
shaped and defined No inhibitions of sexual activity
Probability of acting on sexual Takes pleasure in bullying peers

desires increases
Frequent use of physical aggression
May become sexually active or
experiment with drugs
Parental “milestones” Discusses appropriate clothing in Unable to understand or dismisses

context of changes in physical the adolescent’s struggles
maturity
Makes fun of adolescent if adolescent
Is available to talk and to listen.
makes mistakes
Avoids ridicule of inconsistent
behaviors
364 Appendix
Demands respect in angry and hostile

manner
Provides accurate information on
consequences of sexual activity Unaware of adolescent’s
whereabouts
Gives limited supervision roles in
household of siblings Failure to be aware of adolescent’s
developmental needs
Engages in promoting college or
other adult roles Expects adolescent to be overly
involved in parent role of younger
siblings, although demands respect at
other times
Appendix 365
Appendix B: Contemporary Diagnostic Interview

Case Formulation Tool
Contemporary Diagnostic Interview Case Formulation Tool
Patient Name: ____________________________________ Age: ______ Sex: Male Female

Difficulties in Developmental Milestones for Stated Age:
Social/Emotional Gross/Fine Motor Cognition Parental availability Language/Communication
Contemporary Diagnostic Interview

Temperament Cognition Cognitive Flexibility Int. Working Model of Attachment
Easy/Flexible Above Average High Secure

Slow-to-Warm-up Average Adequate Anxious/ambivalent
Mixed Below Average Limited* Dismissive*/avoidant
Difficult/Feisty* Intellectual Impaired* Disorganized*
Disability*
Specific LD*
Non-Verbal LD*
* consider neurodevelopmental deficits, injury or psychological trauma: formal cognitive testing needed
DSM-5 Psychiatric Diagnosis based on Descriptive Criteria

Intellectual Disability Brief Psychotic Disorder
Language Disorder Schizoaffective Disorder
Social Communication Disorder Schizophrenia
Autism Spectrum Disorder Substance/Medication-Induced Psychotic Disorder
Delusional disorder
Attention-Deficit/Hyperactivity Disorder
Major Depressive Disorder
Bipolar I Disorder Substance/Medication-Induced Depressive Disorder
Bipolar II Disorder Unspecified Depressive Disorder
Cyclothymic Disorder Adjustment Disorder
Substance/Med-Induced Bipolar Disorder
Unspecified Bipolar and Related Disorder Cannabis Use Disorder
Disruptive Mood Dysregulation Disorder (DMDD) Alcohol Use Disorder
Obsessive-Compulsive Disorder Intermittent Explosive Disorder (IED)

Oppositional Defiant Disorder
Conduct Disorder
Separation Anxiety Disorder
Social Anxiety Disorder (Social Phobia) Posttraumatic Stress Disorder (PTSD)
Panic Disorder Acute Stress Disorder
Agoraphobia Reactive Attachment Disorder
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder Anorexia Nervosa Bulimia Nervosa
Unspecified Anxiety Disorder Unspecified Eating Disorder
Symptoms of ______ although does not meet full DSM-5 criteria.

Pertinent Environmental Factors (parents, peers, school environment, trauma):
Sample Formulation:
The patient is a __ year old [race and gender] presenting with [description of functional impairment]. The clinical interview
suggests that the patient has [describe level of cognition] and also [has or does not have] a learning disability.
Additionally, there is a [high/adequate/limited/impaired] cognitive flexibility. The patient’s early childhood environment is
remarkable in that [describe]. Temperament, since infancy, is consistent with [easy/feisty/slow-to-warm-up/difficult/odd]
style. Internal working models of attachment (IWMA) are observed to be [description]. In terms of formal psychiatric
disorders, the patient [does or does not] meets DSM-5 criteria for [list DSM-5 diagnoses].
Index
A Avoidant/dismissive attachment, 73, 231

Abandonment, 232, 315 Axline, V., 280
Abuse, 142
Adaptability, 220
Adler-Tapia, R., 38, 291 B
Adolescence, 132, 134, 220, 228, 229, 239, 311 Barnett, D., 267
Adoption, 64 Barrett, T.F., 133
Adult Attachment Interview (AAI), 74 Bartlett, A.B., 172
Affect attunement, 66 Basal cell carcinoma, 295
Affective attunement, 24, 64, 83, 116, 123, BCPSG. See Boston Change Process Study
186, 193, 203, 230, 234, 267, 273, 318 Group (BCPSG)
Ainsworth, M.D.S., 73 Beebe, B., 57
Alexander, F., 102 Beeghly, M., 265, 266, 274, 276
Altman, N., 40, 50, 169 Behavioral, 243–245
Ambivalent/anxious attachment, 231 inhibitions, 75
Amerongen, M., 170 Bereavement, 222
Amodal, 81, 95 Beresin, E., 333
Amygdala, 187, 190, 194–196, 200, 201, 203 Berger, S.S., 334
Andrews, L.B., 332 Berman, E., 42
Anterior cingulate cortex, 188, 194, 196, Bettelheim, B., 176
200, 203 Bidirectional, 55, 57, 237, 238, 243
Anthony, E.J., 47, 49 Biederman, J., 87
Anxiety, 54, 220, 229 Bion, W., 27
Anxious attachment, 73, 104 Biopsychosocial, 64, 207, 210
Aron, L., 117, 163 Bleiberg, E., 30, 31, 85
Aserinsky, E., 159 Blos, P., 29, 132, 170
Ashliman, D., 178 Borderline, 138, 232
Association for play therapy, 281 personality, 29
Asymmetry, 51 Bornstein, B., 23, 115
Atmosphere of safety, 242 Boston Change Process Study Group
Attachment theory, 37, 70, 72, 73, 190, 207 (BCPSG), 52, 66, 98, 100, 137, 156
Attention deficit hyperactivity disorder Boundary(ies), 163, 164, 170
(ADHD), 172, 189, 295 crossings, 164
Atwood, G.F., 152 violations, 164
Auchincloss, E.L., 154, 158, 280 Bowen, M., 133
Autism, 189, 199, 200, 202 Bowl, S., 225
Autistic spectrum disorders, 243, 244 Bowlby, J., 25, 29, 73, 75, 219
Autobiographic, 5 Brenner, C., 121, 152, 158

DOI 10.1007/978-3-642-40520-4
368 Index
Bretherton, I., 265 Craighero, L., 82

Bromberg, P., 9 Craniosynostosis, 268
Brooks, R., 82 Creativity, 243
Buirski, P., 152 Culture, 187
Curiosity, 214, 243
Curtis, R., 151
C
Cabaniss, D.L., 164
Call, 294 D
Capacity to be alone, 27, 28 Damasio, A.R., 81
Cardoso Zoppe, E.H., 333 Default mode network, 193, 196–198, 201
Caregiver-infant relationships, 4 Defense mechanisms, 57, 135, 283, 315
Cartesian, 335 Delgado, S.V., 26, 73, 91, 118, 128, 131,
Case 134, 141, 168, 173, 210, 254, 275,
conceptualization, 339 279, 297, 311, 335, 342
formulations, 235 Depressive position, 26, 27, 137, 146
Chess, S., 75, 219 Developmental disabilities, 210, 243
Child Developmental infant research, 70
and adolescent psychotherapy, 1 Developmental interference, 16, 34
psychoanalysis, 15, 17, 20, 22–24 Developmental lines, 23
Child-centered family treatment, 32 Developmental milestones, 280, 294
Cicchetti, D., 266, 267 Developmental psychology, 47, 63, 219
Closeness, 215, 234 Developmental research(ers), 63
Co-construct, 58 DeYoung, P.A., 152, 172
Co-construction, 40 Diagnosis, 208
Co-create, 40 Diagnostic formulation, 209–211, 241, 242
Co-created experience, 7 Dialectical behavioral therapy, 174
Cognition, 222, 224, 240 Dickstein, S., 85
Cognitive abilities, 222 Diener, M.J., 84
Cognitive–affective schemas, 229 Disclose, 242
Cognitive behavior therapy, 174, 254, 332 Disorganized attachment, 84, 90, 108
Cognitive flexibility, 21, 31, 227–229, 231, 237 Disruptive mood dysregulation disorder, 221
Cognitive functioning, 218 Dodd, B., 81
Cognitive testing, 223, 245 Dreams, 157, 159, 160
Cohen, D.J., 24 Drell, M.J., 22
Collateral information, 238 Drives, 73, 123, 124
The Complete Fairy Tales of the Brothers DSM-5, 172, 207, 208, 234, 239, 334
Grimm, 178 Dyslexia, 245
Computed tomography, 268
Confidentially, 257, 258
Consent E
of video recording, 259 Early adolescence, 293
to treat, 251 Ego, 16–18, 23–27, 30, 34, 65, 124, 127,
Contemporary diagnostic interview, 12, 103, 135, 146
211, 213, 269, 280, 294, 312 defenses, 16, 24
Contextual, 46, 47, 53, 73 Einstein, A., 145, 175
Conversational approach, 234 Electrocardiogram, 212
Corrective emotional experiences, 1, 33, 51, Electronic devices, 259
58, 92, 102, 122, 145, 149, 194, 273, Ellenberg, H., 150
307, 316, 328, 342 Emde, R., 64, 81, 85, 95, 130, 138, 175, 271
Couch, A.S., 24, 27, 174 Emotional availability, 84, 103, 266, 276
Countertransference, 142, 161, 162 Emotion regulation, 227
enactment, 99, 322, 326 Empathy, 189, 195, 200
Cozolino, L., 79 Enactment, 5, 39, 165, 166, 274
Index 369
Erikson, E., 24, 25, 127, 293 Gifted student, 245

Esophagogastroduodenoscopy (EGD), 268 Gill, M.M., 154, 163, 296
Ethnicity, 187 Gilmore, K., 79
Evenly suspended attention, 152 Goodness of fit, 75, 214, 219, 227, 251
Executive function, 227 Gottlieb, G., 274
External attributes, 236 Granic, I., 279
Greenberg, J., 16, 45
Greenson, R.R., 151
F Grimm brothers, 176, 178
Failure to thrive, 64, 268 Group therapy, 174
Fairy tales, 175, 176, 178
Family, 135
therapy, 174 H
tree, 229 Haglund, P., 152
Fantasy, 144 Halpern, C.T., 274
Farber, B.A., 165 Hans, L., 17, 19–21
Farley, F., 311 Hansel and Gretel, 176–178
Ferenczi, S., 42, 147 Hantoot, M.S., 346
Ferro, A., 27, 166 Harlow, S., 71
Finnish Psychiatry group, 176 Harmon, R.J., 271
First-time mothers, 67 Hartman, H., 25
Fishel, A.K., 334 HIPAA, 257, 258
Flashman, A.J., 23 Hippocampus, 189, 196, 201, 203
Fliess, 129 Hobson, J.A., 159
fMRI. See Functional magnetic resonance Hoffman, I., 15, 40, 121, 163
imaging (fMRI) Holmes, J., 38, 44
Fonagy, P., 70 Honig, A.S., 159
Fosha, D., 102 Hospitalism, 64
Fosshage, J., 33, 59, 116 Hug-Hellmuth, Hermine von, 22, 27
Fraiberg, S., 168, 272, 315
Frame of mind, 215
Frankel, J., 150 I
Free associations, 121, 158 Iacoboni, M., 82, 138
Freud, A., 17, 22–25, 27, 132, 135, 153, 272, 274 Id, 18, 124, 125
Freud, S., 17–21, 24, 26, 42, 54, 119, 121, Idealizing, 31
123, 129, 135, 153, 158, 176, 185 Identification with an aggressor, 147
Freud’s method, 16 Implicit relational knowing, 37, 55, 67, 93,
Friedman, H.J, 336 97, 117, 122, 123, 140, 147,
Fromm, E., 176 153, 215, 327
Functional connectivity, 187, 189, 201 Implicit relational patterns, 212
Functional magnetic resonance imaging Implicit relational schemas, 166
(fMRI), 190, 194, 199, 201, 202 Individualized education plan, 224
Furman, R., 296 Infant development, 55, 63
Fuzzy intentions, 100 Infantile neurosis, 20
Insecure-ambivalent/anxious attachment, 89
Insecure-avoidant/dismissive attachment, 90
G Insecure-disorganized attachment, 90
Gabbard, G.O., 47, 157, 172 Insight, 148
Gaines, R., 40 Insula, 188, 190
Gene x environment interactions, 191 Intellectual disabilities, 244
Genogram, 298 Internal working models, 21, 25, 31, 88
Genome-wide association studies, 199 of attachment, 37, 88, 115, 138, 150, 166,
Gerber, A.J, 39, 87 210, 215, 241, 243, 273, 338
Giedd, J.N., 311 of social relationships, 73
370 Index
Interpersonal neurobiology, 71 Little Red Riding Hood, 176, 177

Interpersonal psychotherapy Lying, 346
for adolescents, 174 Lynn, D.J., 151
Interpersonal theory, 45 Lyons-Ruth, K., 93, 97
Interpretation, 26, 153, 156, 300
Intersubjective, 216
experience, 56, 58, 66, 221, 227 M
field, 51, 53, 81, 87, 92, 96, 98–100, MacLean, G., 22
103–107, 109 Magnetic resonance imaging (MRI), 268
Intersubjectivity, 4, 31, 37, 38, 40, 69, 93–95, Mahler, M.S., 28–29
101, 118, 130, 134, 149, 154, Main, 74
173, 213, 217, 218, 251, 285, Maroda, K.J., 165
312, 336, 338 Mayes, L.C., 24
Interview process, 235 McCarley, R., 159
Intrapsychic, 16, 18, 24, 27, 28, 53, 116, 135 McDevitt, T., 293
phenomena, 117 Meaning making, 5, 68, 81, 82, 120, 123,
Introjection, 137, 142 273, 286
Medication, 245
management, 332
J Meersand, P., 79
Jacobs, D., 176, 338, 346 Mellman, L.A., 333
Jaffe, J, 82 Meltzoff, A., 69, 82
Johnson, J.S., 88 Menes, J.B., 296
Joining and holding, 235 Mentalization, 70, 101, 243
Jung, C., 22, 129 Metaphor, 244
Middle school, 293–309
Mindsight, 71
K Mini International Neuropsychiatric Interview
Kagan, J., 75, 87 for Children and Adolescents, 207
Kandel, E.R., 130 Mirroring, 31
Kaplan, M., 173 Mirror neurons, 82
Kernberg, P.F., 29, 30, 338 Mirror neuron system, 193, 198, 199
Kierkegaard, S., 336 Mishna, F., 170
Klein, M., 22, 26–27, 31, 137, 283 Mitchell, S., 45, 46
Kleitman, N, 159 Molenberghs, P., 83
Kohut, H., 31 Moment of meaning, 145
Krimendahl, E., 280 Moment of meeting, 51, 97–99, 239, 286,
K-SADS-PL, 207 299, 301, 308, 325
Montagu, A., 44
Mood, 219, 220
L Motherese, 103, 104, 106, 169, 273
Lachmann, F., 57 Mother’s Day, 224
Language, 186, 199 Mourning, 297
Laplanche, J., 156 Munholland, K.A., 265
Latency, 131, 280 Mutuality, 42, 52, 64, 238
Learning
disorders, 222, 243
weaknesses, 222, 223 N
Lester, E.P., 157 Nealis, A.L., 159
Levenkron, H., 49 Negative maladaptive behaviors, 240
Lewis, A., 16 Nelson, C.A., 266
Like me, 214 Neufeldt, M.L., 339
Like them, 214, 235 Neuroimaging, 185, 188, 190, 195, 196,
Limbic system, 194, 196 199, 201, 202
Index 371
Neuroplasticity, 187, 192, 193 Pharmacological, 246

Neuroscience, 63, 211 Pine, F., 16, 34
Neurotic symptoms, 119 Plakun, E., 332
Neutrality, 150, 161, 249, 315 Plasticity, 192
New York Longitudinal Study, 87 Plastow, M., 22
Nonconscious, 7, 25, 31, 37, 66, 83, 89, 116, Pontalis, J-B, 156
120, 122, 126, 136, 149, 166, 174, 186, Posttraumatic stress disorder, 200
213, 235, 299, 312, 321, 336 Preadolescence, 293
Noncritical, 240 Prefrontal cortex, 187, 189, 190, 195, 197,
Nondeclarative, 307 198, 201–203
memory, 8, 58, 94, 98, 116, 117, 119, Prepuberty, 293
120, 124, 125, 130, 138, 147, Present moment, 96
176, 212, 214, 234, 276, 288, 316 Primate, 198
memory systems, 37, 93 Projection, 28, 31, 138, 142, 143
Normal disruptions, 231 Projective identification, 29, 31, 138, 142,
Novick, J., 168 143, 162, 322
Novick, K.K., 168 Prosody, 49
Now moments, 96, 97 Pruning, 193
Nurture, 187 Psychiatric evaluation, 213
Psychic determinism, 53, 121
Psychoanalysis, 101
O Psychoanalytic pluralism, 16, 34
Object relations, 16, 17, 26–32, 118, 137, Psychodynamic, 243
138, 146, 328 psychotherapy, 49, 60, 332, 335
theory, 129 self, 218
O’Brien, J., 173 Psychodynamic Psychotherapy Competency
Obsessional neurosis, 283 Te (PPCT), 336
Oedipal, 127 Psychosexual
Oedipus complex, 18, 20, 27, 128, 129 developmental stages, 18, 24
Offer, D., 134 phases, 17
Offer, J.L., 134 stages, 127
One-person psychology, 116, 118 Psychotherapy, 39, 101, 244
Oral, 127 Puberty, 280
Orange, 156, 335
Orbitofrontal cortex, 201
Ormrod, J., 293 R
Ornstein, A., 31–33 Rachman, A.W., 42
Oxytocin, 200 Rank, O., 42
Rapid eye movement, 159
Rapport, 215
P Rapprochement, 28
Paranoid position, 26, 27, 137 Real relationship, 96
Parapraxes, 158, 161 Reflective functioning, 193, 203
Parietal cortex, 197, 199 Regulatory theory, 70
Passivity, 231 Reiss, H., 334
Patterson, G.R., 279 Relational, 50, 57, 101, 118
Pearson, R.M., 149, 151, 158, 160, 162, 168, Relationalists, 47
267 Relational schemas, 136
Pediatric cardiology, 211 Relational two-person psychology, 345
Perlman, F., 150 Release of information, 258
Personal attributes, 239 Renik, O., 167
Personality, 135, 232 Residency Review Committee (RRC), 332
disorders, 101 Resistance, 16, 154, 155
Petrucelli, J., 276 Resnick, J., 159
372 Index
Resnik, J., 16 Sroufe, L.A., 67, 266

Revonsuo, A., 160 Stekel, W., 21, 22, 43
Reyna, V.F., 311 Stern, D., 65, 81, 100, 156
Rhesus monkeys, 71 Still-face, 68
Rizzolatti, G., 82 experiment, 82
Rodman, F.R., 6 Stockholm syndrome, 147
Roffman, J.L., 87 Stolorow, R.D., 33, 152
Ross, J.M., 174 Strange situation, 89, 90
Rubin, J.B., 151 Strawn, J.R., 73, 91, 254, 297
Rustin, J., 58, 273 Structural model, 18
Rycroft, C., 44 Subjective experience, 236
Subjectivity, 234
Sullivan, S., 45
S Superego, 18, 25, 27, 125
Safran, J.D., 84 functions, 157
Salomonsson, B., 272 Supervisee, 331, 334, 338, 341, 346
Samberg, E., 154, 158, 280 Supervision, 12, 331, 334–336, 338, 343, 347
Sameroff, A.J., 79 Supervisor, 331, 334, 338, 350, 351
Sander, L., 274 Supportive psychotherapy, 332
Sandor, L., 178 Surrogate mothers, 72
Scaffolding, 68 Suttie, I., 44
Scaturo, D.J., 309, 333 Symptoms, 208
Schaefer, C.E., 281 Syntax, 224
Schafer, R., 29
Schore, A., 70, 91
Second phase of separation–individuation, 29 T
Secure attachment, 73, 89, 230 Tamis-LeMonda, C.S., 266
Sekaer, C., 58, 273 Telepsychiatry, 260
Self-defeating behavior, 216 Temperament, 74, 75, 86, 115, 187, 193,
Self-disclosures, 5, 58, 164, 166, 274, 289, 198, 200, 210, 218–221
301, 326 styles, 220
Self-esteem, 226 Termination, 291, 307, 329
Self-object, 315 Terr, L.C., 29
Self-regulation, 68, 189, 218, 233, 241, Theory of ego development, 25
245, 266 Theory of Mind, 69, 202
Self-regulatory schemas, 138 Third party payers, 255
Separation–individuation, 28, 29, 65, 98 Thomas, A., 74, 75, 219
Sequencing, 241 Three wishes scenario, 229
Setting the frame, 12, 249–263 Time-outs, 233
Siegel, D., 71 Toilet training, 191
Slips of the tongue, 158 Topographic model, 17, 18
Sloppiness, 100, 308 Traditional one-person, 115, 119
Soavi, G.C., 283 model, 55, 57, 59
Social cognition, 200, 202, 227 psychology, 1, 15–34, 293
Social customs, 187 Transference, 16, 17, 22, 24, 27, 31, 32, 34,
Social reciprocity, 231, 318 142, 153, 154, 300, 315
Social referencing, 64, 85, 123, 193, 203 Transitional object, 28, 32, 139, 140
Sociocultural theory, 74 Transitional phenomena, 139
Something more, 156 Trauma-focused cognitive behavioral
Songer, D., 26 therapy, 174
Spezzano, C., 39 Trevarthen, C., 69, 81
Spitz, R., 63 Tronick, E., 68, 82, 177, 265, 274, 276
Splitting, 29, 31, 138, 143, 146, 147 Tucker, P.M., 332
Spontaneity, 346 Tutter, A., 172
Index 373
Twinship, 31 W
Two-person psychology, 37–60, 101, Wachtel, P.L., 15, 46, 55, 92, 127, 148
117, 118 Wallin, D., 154, 155
Two-person relational model, 21, 25, 31, 152 Wasserman, M.D., 59
Two-person relational psychology, 1, 15, Watkins, C.E., 333
20–21, 24–26, 31, 33, 34, 38, 44–46, Wee-widdler, 19
54, 80, 116, 118, 120, 122–125, 130, We-go, 65
136, 154, 155, 159, 165, 207, 235, We-ness, 65
269, 272, 279, 331 Westen, D., 47
Two-person relational psychotherapy, 51, 63, Winer, R., 154
145, 164 Winnicott, D.W., 6, 26–29, 139, 141
Typical conversation, 236 Wittels, F., 21, 22, 43
Worked through, 16
Working memory, 227
U Working with parents, 252, 274, 290, 302, 327
Unconscious(ly), 15–18, 22, 27, 29, 32, 34,
59, 83, 119, 142, 162, 308
drives, 54 Y
Yanoff, J.A., 17, 168
Y model, 333
V
Vaillant, G.E., 151
Video recordings, 349 Z
Visual–spatial abilities, 226 Zipes, J., 178
Vitality, 213 Ziv-Beiman, S., 165, 166
Vygotsky, L., 74 Zone of proximal development, 74

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Contemporary

ISBN 978-3-642-40519-8 ISBN 978-3-642-40520-4 (eBook)

Library of Congress Control Number: 2014956865

© Springer-Verlag Berlin Heidelberg 2015

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

To Elliott Nicole and Rachel Marie

To Carolyn, Noah, and Harrison

Psychodynamic psychotherapy with children and adolescents is undergoing a tran-

Topeka, KS, USA Kirby Pope, MD

relational psychotherapeutic interventions within the context of accrued knowledge

The Authors’ Journeys

My training included learning the value of using information obtained through

Cincinnati Psychoanalytic Institute as a training and supervising adult and child

I completed my residency training in general psychiatry at the University of

In my final year of medical school at the University of Massachusetts, I still could

Children’s Hospital Medical Center. Unlike conventional child psychiatry training,

Cincinnati, OH, USA Sergio V. Delgado, MD

Peter Blos (1904–1997) The Second Individuation

Daniel Stern (1934–2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

5.9 Corrective Emotional Experience . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Ego in Two-Person Relational Psychology . . . . . . . . . . . . . . . . . . . 125

6.17 Fantasy in Traditional One-Person Psychology

6.27 Boundaries and Self-Disclosure in Traditional One-Person

7.5 Genetics and Two-Person Relational Psychotherapy . . . . . . . . . . . 199

8.9 Putting It All Together: The Four Pillars of a

9.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

12 Two-Person Relational Psychotherapy: Middle School

14.2 Becoming a Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Sergio V. Delgado, MD Dr. Delgado is Professor of Psychiatry, Pediatrics, and

Currently, Dr. Strawn is an Assistant Professor of Psychiatry and Pediatrics at the

Ernest V. Pedapati, MD Dr. Pedapati is an Assistant Professor of Psychiatry at the

© Springer-Verlag Berlin Heidelberg 2015 1

Table 1.1 Evolution of traditional one-person and two-person relational psychologies

Anna Freud-Ego Psychology

Heinz Kohut-Self Psychology

Peter Fonagy Mentalization

Cognitive Psychology Affective Attunement, Corrective Emotional Experience

Cognitive Behavioral Therapy

Murray Bowen Frank Lachmann David Wallin Richard Briggs

Stella Chess BCPSG*

using specialized tools, a careful reconstruction of the original site is accomplished

1.1 Making the Case for Two-Person Relational

The book’s subtitle—“Integrating Intersubjectivity and Neuroscience”—was care-

Introduction to Two-Person Relational Psychology

Two-person relational psychology, unlike its forerunners in the traditional one-person

1.2 Context and Key Concepts in Two-Person

There is no doubt that psychological forces lead patients to tenaciously hold

relational schemas, financial hardships, etc.). The psychotherapist seeks to

A Brief Glimpse into a Two-Person Relational Approach

in fantasy?” These hypotheses ostensibly exclude the nonconscious subjective

1.3 Limitations of Two-Person Relational Psychology

difficulties in children with attention-deficit/hyperactivity disorder in regard to their

1.4 How to Use This Book

© Springer-Verlag Berlin Heidelberg 2015 15

2.1 Traditional One-Person Psychology

Child and adolescent psychoanalysis and psychodynamic psychotherapy were

2.2 Historical Background of Traditional One-Person Model

Child and adolescent psychoanalysis and psychodynamic psychotherapy developed

2.3 Freud and Classic Psychoanalytic Theories

Sigmund Freud (1856–1939): Drive Theory

Table 2.1 Sigmund Freud’s psychosexual stages

(Freud 1924). According to Freud, pleasurable heterosexual intercourse was the