JOURNAL OF CHILD PSYCHOTHERAPY VOL. 34 NO.

3 2008 335363

Tripartite therapy with older children: mutuality in the relationship of a parentchild attachment
NANCY BERLIN
New York

Abstract This is the last of a series of three papers exploring the use with older children of tripartite psychotherapy a technique of psychoanalytic psychotherapy of the parentchild relationship with both parent and child in the room together with the therapist. Tripartite psychotherapy merits more attention than it has received. It is a exible, psychoanalytically oriented approach to parentchild relationship problems, particularly useful when the primary attachment has gone awry. A study is presented of a mother and her 12-year-old (adopted) daughter, who are embroiled in a hostile and rejecting relationship. The mutuality in this case illustrates the complexity in attachment relationships, and also how useful tripartite psychotherapy can be in working with attachment issues that often present as problems of the child alone. Keywords Motherchild attachment; parentchild psychotherapy; tripartite psychotherapy; attachment therapy; attachment decits.

Introduction
The vigorous renewal of interest in attachment theory reminds us yet again how profoundly our emotional bonds to our parents inuence us throughout the span of our lives. At its best, this primary relationship protects us from psychopathology and encourages our capacity to enjoy satisfying, loving relationships as adults. An attachment relationship that is not solid, however, has signicant, enduring implications for psychological growth and mental health. Dysfunctional early attachments, particularly in combination with other risk factors, increase the likelihood of psychopathology, poor peer relations, aggression (Greenberg, 1999), anxiety disorders (Cassidy, 1995), gender identity disorder (Coates and Wolfe, 1994) and dissociative disorder (Liotti, 1995, 1999; Schore, 2002, 2005). It is important, therefore, to address problems in the attachment relationship as soon as possible.

Journal of Child Psychotherapy ISSN 0075-417X print/ISSN 1469-9370 online 2008 Association of Child Psychotherapists http://www.tandf.co.uk/journals DOI: 10.1080/00754170802472885

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Attachment theory was ostracised at rst, but has been gradually absorbed into psychoanalytic thinking. The inception of Bowlbys ideas on loss and separation and the fundamental role early motherchild relations had on development (and not only the Oedipus complex and its resolution or sexuality) led him to split from the two major pioneers in child psychoanalysis, Anna Freud and Melanie Klein. When Bowlby formed a research team at the Tavistock Clinic he was joined by James Robertson and Mary Ainsworth whereby the subsequent development of attachment theory unfolded. A brief history of attachment theory and psychoanalysis is presented in Brischs (2002) book on attachment disorders and in Jeremy Holmess chapter (1995) in Attachment Theory: Social, Developmental, and Clinical Perspectives. More extensive reviews can be in found in The Handbook of Attachment, edited by Cassidy and Shaver (1999). The implications of attachment theory for psychoanalysis range from understanding affect regulation and experience and representation within the therapeutic context in which the patient with his model of attachment, interacts with the psychoanalyst and his representational world (Ammaniti, 1999). This is experienced as transference countertransference, where both therapist and patient experience the other based on expectations formed in relation to their primary caregiver. For child therapy, the integration of attachment theory into analytic work has shown that a childs sense of security is greatly inuenced by the responsiveness and attunement experienced in this earliest relationship, which enables the child to learn to modulate affect. It is this emotional connection between parent and child that the tripartite model targets, addressing the intrapsychic meanings for the parent and child of their interactions. The transferencecountertransference experience here is quite complicated; how each the parent, child and therapist experiences the other, based on earlier representations, shifts in varying nuances. Typically, in psychoanalysis, unconscious processes remain central to the understanding of current problems. These processes are brought to light in tripartite therapy as well, but not explored to the extent they would be in individual psychoanalysis. Rather, associations and connections to the past, conscious or unconscious, are highlighted to show the extent to which they contaminate ways the parent and child experience each other and relate to one another in the present.

Tripartite psychotherapy
In the tripartite model of analytically oriented psychotherapy, parent and child come together to sessions with the therapist, who tries to illuminate for them in each others presence their individual fears, anxieties and conicts, and how these mesh within the dyadic relationship. For the parent, transgenerational, unconscious issues interfering in their relationship to their child are acknowledged, to highlight their own part in what is often considered solely the childs problem. Tripartite intervention highlights the complexities of attachment and mutuality, and enables the therapist to work with them directly. In the case presented here, a conicted and onerous motherdaughter relationship was addressed in weekly therapy sessions with both mother and daughter present together, with occasional individual sessions with the mother only, and with father daughter sessions occasionally, over the course of almost three years. The child was a

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12-year-old girl who had been adopted as a baby. She had a strikingly difcult temperament, mild ADD and many of the psychological vulnerabilities (unconscious conicts and fantasies) that go with adoption. The adoptive mother was nding it hard to be warm and sensitive to her daughters needs. Her daughter vehemently pushed her mother away. It might look as if the daughters difculties were confounding her mothers best efforts to be nurturing. But, on a deeper level, clashes like these were probably being complicated by the mothers own issues her intrinsic insensitivities, her own needs and fantasies about motherhood, and in this case, her fears and feelings about the fact of adoption. Likewise, the childs behaviour may look on the surface like an angry but straightforward reaction to the mothers lack of sensitivity. More deeply, however, it is likely that the childs reactions are exacerbated by her own temperament, her weaknesses in affect regulation and her fantasies about the lost birth mother. The process of attachment is complicated; in an adoptive parentchild relationship, it is so complex that it is not always possible to untangle the various individual issues that interfere with the bonding experience. It is possible, however, and it can be very useful, to look at what actually transpires between parent and child, to point out how each contributes to their impasses, and to alter their ways of being together in the interest of a more satisfying relationship for both. Individual child psychotherapy cannot address recalcitrant relationship decits directly. In the 1960s, when child therapy was in its early days, the pre-eminent ego psychology model dictated an individualistic approach to childhood problems. Developmental theory informed child psychoanalysis at that time which focused on how drives and innate capacities nd expression through self- and ego maturation. In this context, the child was considered an individual unto herself, with primary developmental goals of separation, differentiation and autonomy (Blatt and Blass, 1990). Anna Freuds (1965) child-guidance model, which was individualistic, educative and ego-supportive, became the norm for child work. Child and therapist met alone, and parents met with the therapist infrequently for parent guidance. Ego psychology has been the chief shaper of child therapy practice; even with the recent shift to attachment/relational therapies, its inuence continues to prevail (Altman et al., 2002; Brisch, 2002; Hughes, 1997). Interestingly, despite the transition to relational psychotherapy with children, children mostly continue to be seen alone by the therapist. Interpersonal theorists (Sullivan, 1953) and clinicians (Gaines, 1995; Mitchell, 1988) in general conceptualise individual development within a relational matrix. They construe development to be inuenced not for the most part by constitutional temperament or drives, but by interpersonal experiences. The nature of these experiences, including how well they do or do not meet the childs needs, determines how the child organises her internal representations of the caregivers accessibility and responsiveness. This shapes the childs resulting expectations of relationships, beliefs about her own self-worth, and eventually the development of her personality. The primary clinical consideration of the interpersonal and relational therapists who work from this model is the childtherapist relationship process, with interpretive work secondary (Gaines, 1995). Within the childtherapist relationship, in theory, the child has an opportunity to experience herself being seen and treated by someone other than

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her parents. The opportunity to compare these different relationships helps to transform maladaptive internal representations into healthier ones. All of this makes good sense. However, despite their assumption that (with a few exceptions see Katz, 1992, and Youngerman, 1992) psychopathology arises from disturbances in the childs primary relationships, interpersonal child therapists continue to work with children individually, with parents only as adjuncts to the childs treatment. Although Katz (1992) and Youngerman (1992) both included the parents of severely disturbed children more directly in the childrens treatment, the therapeutic work still centred more on the childs individual symptomatology than on unique relationship dynamics. The tripartite model of therapy, however, focuses explicitly on the childs need to reconstruct a new and real relationship with the parent, not with the therapist. Tripartite work involves the parent in all sessions with the child. It diverges from the conventional individual model of intervention in child disorders in its reliance on attachment theory for its conceptual framework, in its attention to the attachment dynamics between parent and child, and in its interpretive attention to those dynamics. I have discussed the history, theory and practice of tripartite psychotherapy in earlier publications (Berlin, 2002, 2005). The purpose of this third paper is to demonstrate in more detail the clinical applications of this treatment approach.

A brief outline of attachment theory

Attachment theory, with its focus on the infancy and toddler periods, has a long history. Based on Bowlbys (1969) formulations from evolutionary biology and his studies of maternal deprivation, it has been expanded by many further studies, ranging from Mahler et al.s (1975) clinical work with severely disturbed dyads to Ainsworth et al.s (1978) experimental explorations of attachment to Sterns (1985) and Beebe and Lachmanns (2002) infant research. The signature premise of attachment theory is that a close, loving relationship between a child and a primary mothering gure is driven by survival needs. Its achievement, therefore, is an important determinant of subsequent developmental gains, such as adaptive behaviours (Humber and Moss, 2005), the development of the reective function (Fonagy et al., 2002), social competency and selfesteem (Cassidy, 1988; Sroufe, 1983), affect regulation (Fonagy et al., 2002), attention, memory and cognition (Main et al., 1985), and the quality of adult relationships (Hazan and Zeifman, 1999). Maunder and Hunter (2008) surveyed recent evidence that the stress of adverse attachment insecurity may impair physical health due to the chronic, prolonged state of physiological hyperarousal with impaired recovery. There is speculation as well that the vicissitudes of the attachment bond may affect neurological development that secure attachment is essential for the development of self-regulatory functions (Schore, 2002). Remarkably, neurobiological consequences of a sustained lack of parental attention are now thought to include symptoms of hyperactivity, learning difculty, impulsivity or distractibility (Ingeborg-Stiefel, 1997). The self-regulating, mutually interacting attachment system ensures survival for the child (Bowlby, 1969), and early attachment experience is believed to be a central and causal factor in how the substrates and skills of emotional regulation develop. An anxious infant in unfamiliar

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situations, in pain, on separation seeks closeness to her mother, and the protection, security and safety that come with it. The infant is always an active partner in this interaction, signalling the kind of help she needs, and how much. The mothers capacity to read her infants cues and respond to them in a sensitive and timely fashion determines both how the infant will feel in the short run, and over the long term the security (or not) of the infants tie to her mother. When the mother responds in a consistently predictable and attuned manner, that infant will probably come to feel pleasure or comfort in her proximity, and a reliable security that her emotional needs will be met. If the mother ignores or disregards the infants displays of distress or bids for connection, or responds to them punitively, the infant will continue to feel distress, anxiety about the relationship itself and an enduring uncertainty about how to ensure the meeting of her emotional needs. An infant like this, left alone with chronic or unpredictable distress states, develops adaptive mechanisms to cope with this insecure bond. Here, we see relationship types that can be avoidant (dismiss the need or importance of closeness), ambivalent (not sure so approaches and retreats), or disorganised (confused, chaotic and tinged with negative affect), to self-regulate and keep anxiety at a minimum. These are less effective and more burdensome, however, than the coping mechanisms that more fortunate children make. Instead of the freedom of secure and reliable attachment that can be safely approached and relinquished as the childs circumstances require, adaptations must be made that take into account the parents needs as well as the childs own. These attachments are less reliable and less secure, and they cost the child something in psychological growth. More specically, a child with a parent who angrily rejects her attempts to attach may respond by becoming avoidant of attachment suppressing her need for closeness to not antagonise her caregiver. A child with a parent whose needs come rst over the childs may develop an ambivalent attachment, uncertain about the parents availability, and adjusting closeness and separations warily to not aggravate the mother. A child whose parents attachment responses are unpredictable or affectively overwhelming may develop what has been called a disorganised attachment, a chaotic and desperate attempt to gure out what will keep the parent available and what will drive her away (Slade, 2000). The neurobiological consequences of stress or chronic anxiety from a dysregulated infant attachment relationship impact upon later mental health. Schore (2002) categorises this type of chronic anxiety as a relational trauma in subtle form, and points out that it has the potential to lead to real structural changes in the part of the brain responsible for emotional self-regulation. Essentially, according to Schore, the continued felt stress triggers heightened reactivity and dissociation, which are imprinted into the developing limbic and autonomic nervous system. These conditions give rise to characteristic deviations in subsequent development of the limbic and arousal systems that process socio-emotional information namely, the area of the right side of the brain dominant for attachment and the regulation of affect and that (we believe) stores the internal working models of the attachment relationship. Any causal link, then, between the quality of the primary attachment relationship and subsequent growth and development, both psychological and neurological, would carry great weight. Empirical research so far has supported the proposed link, requiring that

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we take very seriously anything that may interfere with, or lead to deciencies in, the early motherchild attachment relationship. It is hoped the emerging attachment paradigm will begin to guide early childhood interventions and permeate ways of working clinically with young children, despite the therapists clinical orientation. This model has begun to be integrated into child psychotherapy work in isolated ways, and to include school-age children as well as very young ones (Berlin, 2005; Harel et al., 2006; Humber and Moss, 2005) and adults (George et al., 1985; Hazan and Zeifman, 1999; Hesse, 1999). Key questions have emerged from the massive body of research on early attachment. How does a sensitive mothering environment inuence the sort of attachment tie a child makes with its mother? How do children initiate and inuence responses from their caregivers (Beebe and Stern, 1977; Emde, 1983; Sander, 1980)? How does the naturenurture relationship of the attachment bond create a mutually interacting matrix? In response to these questions, Beebe and Lachmann (2002), extending the earlier infant research of Cohn and Tronick (1988), Sander (1977) and Stern (1985), have compiled an astounding summary of their own work on the mutuality of the attachment relationship. Regulatory patterns are created along with the thoughts and feelings to which they are attached, and come to serve as templates (mental representations of attachment experiences) that guide ongoing and future behaviours (Slade et al., 1999). Put simply, we come to expect from others what we have received from them before. This groundbreaking shift away from a one-way view of parental inuence on child development to a two-way recognition of mutual regulation and interactive patterning has become central to understanding the infants organisation of experience, and to understanding the therapeutic process in child therapy and adult psychoanalysis as well. The importance of attachment between a child and the primary mothering gure,1 most often the mother, is why I depart both from the conventional individual approach to child therapy and from the interpersonal approach where attachment to the therapist is the fulcrum of change. As Wallerstein (2002) said in her eloquent plea advocating timely placement of foster children: Attachment is specic. Attachment gures are not all interchangeable. All children have a propensity to prefer one primary caregiver, usually the mother, early on. Even later on, during middle childhood, the parentchild attachment remains essential to smooth development. School-age children are still not able to deal autonomously with threat and require the parent as a secure base to rely on for needed guidance; that is what attachment is all about. Although they are increasingly developing attachments to other adults and to peers, they continue to require a secure sense of the parents availability (Marvin and Britner, 1999). Furthermore, children bring to their other relationships with peers and adults an organisation of feelings, needs, attitudes, cognitions and behaviours (Sroufe and Fleeson, 1986) that has been formed and transformed in early childhood within the primary attachment relationship. The emergent self crystallises itself around this organisation, and what was dyadic regulation becomes self-regulation: self-regulation based in the attachment relationship and profoundly shaping personality. Attachment to a therapist may be important and useful, but it is not nearly as powerful or benecial as a childs bond to a parent. Given the transformational nature of

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the attachment relationship and its shaping inuence on individual and social development, I prefer to work directly with the motherchild attachment relationship, knowing that a child who can full attachment needs with the mother will then be able to move with ease and security out of the parentchild orbit and into healthy relationships with others. The tripartite model provides a straightforward way to facilitate a secure, safe and comforting emotional tie between mother and child.

Case study
Linda and Michael rst came to me with concerns about their 12-year-old daughter Emma, whom they had adopted at birth. Emma is the only girl and youngest of their three adopted children. They described her as having been strong-minded from the beginning even as an infant, she had been hard to soothe and had resisted swaddling. For years, they said, there had been arguing and bickering over Emmas persistent refusal to follow family rules or engage in daily family routines. She would not clean her room, dress according to her mothers wishes or help during the preparation of dinner. She refused to sit at the table with the family or to visit relatives, and essentially isolated herself in her room or in front of the TV. Emmas refusal to be a part of her family was beyond the normal for any age. She seemed chronically angry with her parents, especially her mother and acted as though she truly did not like them. Both parents felt frustrated, and Linda felt deeply rejected, and resentful at being the main object of Emmas nastiness. Michael shared his wifes feelings, but not to the same degree. He did not harbour the deeper inner resentment that Linda experienced, and he felt sorry their daughter was so unhappy. In my ofce, the two parents conveyed very different impressions. Michael seemed relaxed and comfortable in his own skin. He spoke caringly of Emma, feeling frustrated yet warm towards her. Of course, he spent much less time with Emma and carried less of the brunt, often making it easier to sound empathic. I liked him and felt at ease talking with him. I thought how lucky this child was to have been adopted by such a warm, loving father. I was eager to hear his pleas. Linda felt somewhat rigid, exacting and expressed little warmth or empathy for Emma, but here, I thought to myself, careful to not take sides, she was the one in the line of re most of the time. I felt guilty not liking Linda as much. She truly loved Emma and wanted a better relationship, but she was negative and critical. I thought surely Emmas sense of rejection was valid. Despite the different amounts of time spent with Emma and the different degrees of anger each felt from her, Michael validated Lindas frustration with Emma. What I admired most about Michael was his ability to unite with Linda to help her deal with Emma, and to unite with Emma to help her deal with her mother. Once, having heard the exasperated disapproval with which Linda described her anger with Emma, he wondered out loud whether perhaps Emma sensed what he himself heard in Lindas tone of voice. He complimented Linda for her caring and concern, and said that he, too, felt that Emma was hard to take, but he was also able to wonder whether Emma felt their frustration and in turn felt unwanted, even though he knew they did not mean to convey this. Michael felt that they needed to look at themselves, too, to see what they could do differently, and that was in part why they had consulted me. Michael admitted being on Emmas case too much. He felt he was too

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impatient with her at times, and noting that his wife was on her case too much, he wondered whether Emma felt ganged up on. They were always ordering her around. Linda took in what Michael said. The two of them had, by their description, a close, loving relationship and a sense of security in being able to be honest with each other. I could feel the closeness between them. Now Linda sat quietly next to him, contemplative, and slowly responded, I think youre right . . . Ive never felt close to her, and I always wanted a girl to be close to, the way I wasnt with my mother . . . I feel shes always against me and Ive been so angry. It must come out, how can I hide it? I was so surprised by her response. She was not defensive, and did not feel criticised by Michael. She, too, truly desired to look within and change for the sake of her daughter. I began to like her.

Assessment
After the consultation session with her parents, I met with Emma alone for three sessions. She was strikingly pretty, slender with hazel eyes and light auburn hair. She dressed creatively and appeared to have an eccentric air for fashion. But she sat across from me rigidly, avoiding eye contact. She refused to draw, refused to play cards. She barely moved a muscle. When she did look at me, it was to glare, a look of disgust on her face. I felt a severe sense of disengagement from her and an intense need to draw her out. I turned to questions. I asked about school: did she have friends, how did she choose her unique outt, did she like art, design? Was she close to her siblings, what music did she listen to, any favourite TV shows? Slowly Emma started to look up, and offer a yes or a no to my queries. I told her I had met her parents, and asked if she knew why they had come. Yes, she did know, she said, and began to complain about the family ghting, how controlled she was at home and how forced she felt to do as her mother wished. I told her I knew kids hated feeling overly controlled by their parents, and asked her for some examples. Emma gave some. Her mother expected her to turn the TV off instantaneously, even if there were only ve minutes left in a show; ordered her to tidy up her room the moment she was told to, regardless of what Emma was engaged in at that moment. Sensing her strong resistance to being in my ofce, I wondered out loud if it made her feel like the problem. It did, she agreed, and added angrily, My mother should be here, not me! I can see how angry you are, Emma, I told her. And I believe there must be a reason. I think I should meet with your mother and father so we can learn more how to help you, to help your parents, help you feel less angry. OK, she replied, and this time her manner was softer. My initial sense of Emma remained with me for a long time. Not only did she not feel likeable, she pushed me away and made me feel unliked, except in eeting moments like the one described above. Most often, an air of arrogance surrounded her, and her curt, sarcastic tone of voice felt like a stone being thrown. Her icy glare and angry face made it hard to feel for her. But that rst OK sounded sweet, almost babyish, as though she were wounded and really wanted help. In her pleading look, for the rst time, I could really feel what she was keeping hidden. I then saw Emma and Linda together, to assess how best to intervene. It was an icy meeting. Sitting apart on the couch, mother and daughter avoided eye contact; each

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barely acknowledged that the other was present. Linda began with a litany of complaints about Emma, reading from a notepad. Emma looked furious, but she said nothing, withdrawing deeper into her shell. Linda went on to say that in heated emotional moments at home Emma would declare, You dont want me anyway, Im just a problem. I wish I was adopted by someone else! But here Emma pounced on Linda, with teeth clenched and eyes piercing. No! I didnt say that! she screamed. Lies! How can you say that? You did say that, Emma, Linda insisted. She was bewildered, and apparently entirely unaware how accused Emma felt, how blamed again for being bad. No, no, no! No I didnt! Emma exclaimed, but this time Linda yelled back, interrupting Emma and negating what she had said. Stop interrupting me! I let you talk, let me talk! At that, an abrupt shift occurred; Emma disengaged and looked down, refused to look at her mother, refused to respond to questions, and retreated into her inner world. It was easy to see how Emma and her mother were clashing in this battle. Emma could put on a good outside show with her strong personality, but she harboured a fragile self-esteem on the inside. Even small comments from me or from her mother were taken as direct insults, as if we were conrming her inherent badness. She became enraged when her mother complained to me about the colour of her shirt in such a disapproving tone. Whats the matter with these? Emma said in an exasperated tone. I love this colour! You just dont like anything I wear! Yes, I do said Linda, but, that colour. You dont like anything about me! Why dont you just give me back! I could feel how unaccepting and critical Linda was, and if I felt that, surely Emma did too. I liked the colour of her shirt! But Linda appeared to have no idea why Emma was so angry. She tried to listen to Emma, tried to talk with her. She did want to be close to her. But she did not have a clue about how to go about it. At last she said that she wanted to change so that Emma would not feel so angry with her. What am I doing or saying that gets you so mad at me? Ill listen. And this time Emma softened again and said quietly, looking directly at Linda, Its your tone, your voice, you sound so mean to me. What was going on here? I wondered to myself. First I put together my thoughts about Emma herself. Did she have an especially bristly temperament, or some inherent difculty regulating affect? Was her strong, angry persona a defence to keep her from feeling close to prevent a fear of abandonment, often felt by many adopted children? She was pubertal, typically an age when the full impact of adoption is felt. At the same time, she was at an age when young adolescents need for more autonomy and control becomes acute. Emma did resist spending any time at all with her parents, and she did vehemently defy their ministrations. Then I turned my thoughts to the system Emma was living in. I could feel Lindas anger toward Emma; I could feel and hear her criticalness, her lack of warmth. I even recoiled in response to Linda at times. Surely at least some of Emmas anger and opposition came from a perceived lack of emotional attunement from her mother. But where might this have come from? Was Lindas anger and lack of warmth for Emma a direct consequence of her own upbringing? Or, was her anger related to unresolved feelings about her infertility? Did she have unresolved issues around adopting? What made it so hard for her to be empathic and attuned to her daughter, yet so able to be so with her other children and husband?

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After this session, we all met together once more, to determine how to proceed. Michael and Linda again expressed their disappointment that there had been so few moments of closeness between them and Emma over the years. I noticed out loud that with the three of them here together for the rst time, Emma was sitting cuddled up next to her father, and ignoring her mother completely. Michael allowed Emma to cuddle, occasionally patting her on the leg or putting his arm around her and smoothing her long hair. They both seemed at ease together, comfortable and soothing. Linda sat stify off in her corner of the couch. She made no motion towards Emma, nor did she respond to my comment about Michael and Emmas closeness. To my surprise, however, it was Michael who began the session, complaining how annoyed he had been with Emma at home the past week for not turning lights off, taking too long to get up in the morning, and having to be nagged in the morning to get ready for school. He sounded frustrated and disapproving, and Emma immediately sat upright and became angry. Michael, I said, can you hear how disapproving you sound right now? Can you see how Emma pushed away from you the minute you complained about her? He did not say anything, and I went on. These kinds of behaviours can be annoying to parents, but they are so typical for kids. No wonder Emma looks angry. She doesnt need to be angry, countered Michael, Im just saying I wish shed do as shes told. But now I countered him, in Emmas defence. Thats so dismissive of how she feels, though. You just ignored what she is feeling, how angry she is. For whatever reasons shes angry we at least have to let her know we understand shes angry . . . And, it kind of does make sense to me . . . I think she may feel attacked here, like shes the problem. You tell them!!! Emma interjected, and Michael was quiet again for a moment, looking at her. Well, Ill try harder, hows that? he said. Emma began to cry and buried her head on his chest. He hugged her and smiled at me, again promising to listen better when she expressed her feelings. Michael was able to disengage fairly easily from the power struggles Emma seemed to provoke. Although he and she did not agree on all matters, I said, they seemed to share an easy, owing mutuality; they could listen to each other, respond to each other, smile and touch. Linda, however, had sat through all this alone in her corner of the couch, tense and angry. She watched them, but she budged not one inch closer, offered no word of comfort to Emma. Now she picked up her list of complaints. She doesnt put my brush back, she doesnt say thank you if I drive her somewhere and she always has a nasty tone. She acts like she doesnt want to be in the same room with me. Emma tried to defend herself, but Linda overrode her with more from the list. Finally Emma snapped, How would you like it if I did that to you? She was arrogant and extremely sarcastic to Linda, and Linda countered with bickering, anger and criticism. It was a heartbreaking struggle to observe. After a bit I intervened. You do sound accusatory and rejecting, Linda, with your list of complaints. Anger can be a normal reaction to feeling attacked. Why is it always the mother! I feel so blamed! Linda barked back at me. That is how Emma feels, too, I thought. I said to Linda, This isnt about blame, about whos right or wrong. Its about the way you all respond and react to each other. But this was my

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aha moment, when I could really see the dysfunctional dynamics of the attachment between Emma and her mother. It was fraught with conict and anger, and the hostility and frustration each felt towards the other was glaring. Linda thought Emma was the problem, and vice versa. What was most salient to me was Lindas inability to be sensitively attuned to Emma, and Emmas inability to modulate the rawness of her emotional reactions. The regulatory dynamics of attachment are mutual and interactive, but the parent obviously has greater responsibility and inuence in these exchanges (Beebe and Lachmann, 2002). Neither Linda nor Emma was aware of the part she was playing in their mismatch, but I would not expect Emma to be. I thought that Lindas inability to accept Emma for herself was painfully sensed by Emma. Emmas extreme hostility was probably a reaction to the severity of the disruption in her emotional connection with her mother, which she felt as empathic failures (Kohut, 1972). Infants and children are affected powerfully by such violations of attunement. When they feel conrmed, positive affect and self-worth ensue. When they feel dismissed or ignored, negative affect and feelings of low self-worth take over, as though they are not worth the attention or concern (Kohut, 1972; Slade, 1999). In consequence, in severe mismatches, chronic rage is common, and can become integrated in complex ways into the personality. In Emmas case, her chronic negative affect and low self-esteem shaped the way she organised her defences, and encouraged avoidance and rejection of her mother. In fact, Emma had essentially come to deny the need for attachment. Her relationships were avoidant and strife-ridden within the family, and eeting and supercial outside. Linda and Emma were trapped in an endless struggle in which each insisted on blaming the other. This is a perfect example of the kind of situation where it makes sense to intervene on a relationship level to work in a psychodynamic way with both parties together, not only on how they communicate, but also on ways of being together that can promote a mutually satisfying relationship. When I pointed out how controlling and angry Linda tended to be with Emma, Emma looked at me for the rst time. Michael said that he knew that Emmas anger focused more on Linda than on him, and he acknowledged how upsetting this must be to her. Linda was then able to admit, out loud and in front of Emma, that she truly did wish for a better, closer and more loving relationship with her daughter. We unanimously agreed that I would begin work with Emma and Linda together, to help them forge a more loving bond and a more secure attachment. We also agreed that Emma would come occasionally with her father, as well. In this decision, there was no implication that the fathers role is any less important than the mothers; in this case, however, the problem was clearly most severe between Emma and her mother. Given this clinical presentation of a seriously disordered motherchild relationship and a more secure fatherchild one, focus on the two-way motherchild interaction was the point of entry. I negotiated with Emma and Linda over what day and time would suit each of them best, wishing to give them both the experience of compromise, exibility and listening to each other. This marked the beginning of a two-year journey into reconstructing the motherchild attachment relationship.

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Concurrent vulnerabilities
Attachment quality is not the only factor in development, obviously, but the security of the motherchild attachment is a critical mediator (Fonagy and Target, 1998: 95) in the formation of representations of the self and of the world. Because this actual relationship so deeply affects child development, it takes precedence in tackling the daunting endeavour of disentangling motherchild attachment mechanisms. More and more stressors and situations such as difcult temperament, insecurity in the maternal role, adoption issues, a lack of sustained parental attention, fragile marital relationships, maternal grief or depression, or ADD are increasingly being linked to attachment problems. It is crucial to our clinical understanding that the interaction between the child and environmental risk factors be taken into account (Stams et al., 2002; Ingeborg-Stiefel, 1997). Taken alone, for instance, ADD does not predict disordered attachment. Neither does a difcult temperament, adoption or maternal insensitivity. Taken together, however, concurrent constitutional factors and negative relational factors do predispose to a dysfunctional attachment relationship. Within the tripartite context, it is possible to address directly the characteristics of both parent and child that feed the mutual misattunement and disregard. My rst goal was to reorganise Emmas and Lindas expectations of each other, and the feelings and attitudes that resulted that is, to give them direct, repeated, ongoing experiences that would enable them to transform their internal representations of each other.

Maternal vulnerabilities
The attachment decit between Linda and Emma was the result of an interplay between their personalities and temperaments, their past attachment relationships, real and fantasised, their biological vulnerabilities, and their own issues about adoption. All of these interacted together, nding expression in their perceptions of each other. Regarding Linda, her own maternal sensitivity was the representation of her earlier relationship with her own parents (Slade, 1999; Slade et al., 1999), which in turn affected her perceptions of and fantasies about her child (Hesse, 1999). Her negative attitudes of being rejected and fantasies of having a close motherdaughter relationship, consciously or unconsciously, powerfully affected how she responded to her child, and compromised her ability to respond sensitively to her childs attachment needs. At times, she projected her own unconscious anger toward her mother onto Emma, and feeling bad herself, perceived Emma as bad (Berlin, 2002), further complicating Emmas reaction to her. Linda described an angry, disappointing relationship with her own mother. She had grown up feeling that her mother needed her too much emotionally, and that their relationship was more about her mother than herself. Linda described further how she had yearned for closeness with her mother, but had had to keep her distance, lest she be suffocated. When college bound, her mother strongly encouraged her to not go away to college, and Linda complied, only to regret that years later. Being the youngest, Linda later came to imagine how her mother needed her. She felt guilty, being the last to leave home, leaving her mother alone. Her mother was also very critical, and Linda grew to feel and believe that no matter what she did, it was not good enough. Her mother told

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her not to have children; she did not think Linda would be a good mother. Linda again believed her. Linda therefore yearned dearly for closeness with her own daughter perhaps as her mother yearned for her, and perhaps eliciting a similar response from Emma. Unfortunately, Linda seemed to feel Emmas need for her much as she had felt her mothers, responding with anger and enforcing distance as she had as a child. Finally, Linda lacked the experience of sensitive mothering, which made it difcult for her to be sensitive to Emma. Her mother had no idea how hurtful it was to tell Linda not to have children, that she did not think she could be a good mother!

Child vulnerabilities
Temperament Regarding Emma, an inter-play between her temperament and adoption issues most probably affected her perception of Linda (Chess and Thomas, 1984; Goldsmith and Alansky, 1987). Emma was certainly a difcult child she was tough with negative mood and intense emotional reactions since infancy (Thomas et al., 1968). Her negative perception of her adopted mother compared to her birth mother clearly increased her risk for attachment insecurity (Belsky et al., 1991). But such risk does not exist in isolation from the variables of parenting interactions. Proneness to anger or distress is associated with deance, resistance to parental directives and unmanageability (Kochanska et al., 2005). However, caregiving issues exacerbate the stresses of temperament as much as the other way round. For example, a child with a difcult temperament will have a harder time learning to cooperate with an insensitive mother than a similarly difcult child with responsive and sensitive mothering. Although difcult children adapt more slowly, caregiving behaviours can modify a childs proneness to irritability or resistant behaviour. For example, angry infants with sensitive mothering can become highly cooperative, but with unresponsive mothers they remain strikingly uncooperative (Kochanska et al., 2005). Adoption The risk of disordered attachment in adopted children is imposing. The literature strongly suggests that adoption plays a signicant role in the internal representations of the early attachment relationship (Hughes, 1997; Priel et al., 2000). Thus, the experience of attachment is complicated by circumstances inherent in adoption, such as feelings of loss and abandonment, prior neglect or abuse (Nickman et al., 2005), or the formation of two different sets of parental representations (Priel et al., 2000). Even in adoptive families, however, where the negative effects of a childs difcult temperament on later adjustment are large and pervasive2 (Stams et al., 2002: 815), maternal sensitivity predicts adjustment in middle childhood beyond the effects of infant temperament and gender and parents socio-economic status (Stams et al., 2002: 817). Nonetheless, Emmas issues had to be taken into account as I approached tripartite work with her and her mother. Knowing that in adoptive families the risk of lack of t may be greater due to biological unrelatedness (Brodzinsky, 1987), I paid particular

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attention to how the process of parental attachment to the adoptee interacts with the new risk factors in complicating ways. Linda and Michael had come to terms with their infertility regarding their two adopted sons and they had examined and worked through their own sense of the loss of having their own biological child (Verrier, 1993). I think Linda harboured disappointment and ambivalence toward Emma being a girl who she had wished to heal her earlier disappointing relationship with her mother. Emma naturally sensed this and was reacting to it (Brinich, 1995), thus validating and perpetuating her feeling unwanted (Nickman et al., 2005), and contributing to her sense of self as defective. Problems arise in adopted children, in particular, however, when representations of the adoptive and biological mother are severely dichotomous, when one internal image is really negative and the other image is really good (Fonagy, 1996; Priel et al., 2000). For example, if one in fantasy is imagined as loving and the other in reality is felt as a monster, there is greater risk for acting-out behaviours. Emma tted this picture. The intensity of her anger at, rejection of and deance towards Linda seemed to be a function of a split internal representation. She refused to talk about her birth mother in sessions, but at home she would ask Linda about her. In a heated exchange between the two, Emma lashed out once, You are the meanest mother! You dont even like me! Why dont you just give me back to my birth mother? Shes nicer! I want you, Emma, replied Linda. I do like you! Now, Linda may not have been the warmest or most nurturing mother in the world, but she was surely no monster and she loved Emma and cared about her. Emmas real experience of Linda was far less benevolent than the one she imagined with her birth mother. This invidious comparison most likely compounded the poor t between the two (Stams et al., 2002), which I could see so clearly in this troubled relationship. However, the point of tripartite therapy is that these conicting internal images can be directly identied, and directly claried by pointing out what is reality and what is not, whilst acknowledging the accompanying wish for the missing ideal say the allloving, all-giving birth mother. One day, Emma entered the room fuming, trailing behind Linda and glaring at her. Linda looked extremely annoyed, and said in a huff, Shes mad at me because I wont let her pierce her ears! Why cant I? Everyone pierces their ears! Whats wrong with it? I just dont think you need to do that, thats all! barked Linda. Its always something with you! Whats wrong with it? Emma demanded again, and now I intervened to interrupt the escalating anger. Linda, what are you so against about her getting her ears pierced? It seems to be so important to Emma, but you automatically shut her down . . . and then she gets angrier. Maybe she feels unheard . . . You tell her! Emma yelled. Linda replied to me, not to her. I just dont think she needs to because everyone else does. She doesnt need to. Thats it! she said. So, you care about her being strong enough to be her own person? Youre not forbidding her to get her ears pierced just to be mean. I asked Linda. But what do you think this is like for Emma then? It sounds like she feels youre just being mean and doesnt understand how you really care about her not following the crowd. Linda thought quietly, then said, I dont know . . . Please, Mom! Emma begged softly this time. Please, Mom. I could see that Linda did not feel what this meant to Emma, and also that because Emma was so sensitive and harboured such a negative

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internal image of Linda to begin with, she reacted especially strongly to Lindas lack of sensitivity. We can see in this encounter how concurrent factors such as history, temperament and a lack of maternal sensitive responsiveness (complicated by adoption issues) can coalesce into attachment insecurity (Stams et al., 2002). We will also be able to see how the tripartite technique allows them to be addressed.

Tripartite sessions
My goal with the tripartite approach was to help Linda and Emma reconstruct their internal attachment representations. By modelling empathy, by validating their experiences of feeling unheard and sometimes by offering directives, I had the opportunity to provide an experience of attunement that so far both had missed, and to help them create a new way of being together. The tripartite situation allows the therapist to highlight the importance of listening and of responding sensitively, while exploring each persons individual anxieties, fears, conicts and distortions. With Emma, I utilised the power of defence interpretation in establishing the treatment it was very difcult because she was in the developmental period of early adolescence, beginning the process of reorganisation (Dowling and Naegele, 1995) where sexual feelings and identity strivings are emerging and often difcult to integrate. New defences were developing; also in this phase open hostility towards parents, intellectualisation and acting-out are common. Her normal adolescent narcissism was also intensied she appeared selfabsorbed and detached from her family. Therefore, establishing an initial therapeutic alliance was a challenge during a time when it is developmentally appropriate to be moving away from parents. Emmas rejecting closeness with her parents, however, was beyond the normal realm for her age; it was her defence against the painful disappointment and massive feeling of past abandonment when given up for adoption, and her felt rejection by Linda that kept her at a distance. This protected her, naturally, from affects associated with human attachment (Schecter, 1978). I knew that in order for Emma to benet from tripartite psychotherapy, she had to relinquish gradually her need for detachment as a primary defence, and allow herself to experience the pleasure and the pain of attachment to not only her mother, but to myself as well. This was daunting. She had to protect her sense of self from feeling either rejected or ignored in reality by Linda, and in fantasy by her birth mother. Her pseudoindependence and her arrogant self-sufciency (Schecter, 1978) were clearly interfering with her development toward authentic autonomy, toward a more integrated sense of self. In my work with Emma, the use of myself as a mirroring object, fostering empathic relatedness, while attending to her anxiety of abandonment and loss of love, took precedence. In psychoanalytic therapy, the main goal would have been to re-establish attachment between Emma and myself through the transference. In tripartite therapy, though, with a parent present, the actual transference between Linda and Emma was directly observed. The transference between myself and each of them assumed various congurations, depending on the roles they each assigned me. Simultaneously, I validated Emmas pain and anger toward Linda, and Lindas hurt and anger toward

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Emma to set up a working alliance. Despite Emmas vigorous resistance, her I dont care! attitude, her behaviours spoke otherwise: she came willingly each week, wanted her mother to attend with her, and sat next to her on the couch. I directed interpretations of these behaviours, how torn she was between wanting a close relationship with Linda, yet pulled back at the same time, to Linda so that Emma would not feel attacked with two adults in the room. Transferencecountertransference manifestations were complicated and confusing; they involved different, shifting experiences of four people in the room myself, Emma, Linda and Emmas birth mother. My own countertransference toward Linda and Emma changed dramatically. At times when I felt Linda was insensitive or dismissive towards Emma, I softened and felt bad for Emma, feeling sympathy for her as a hurt child, a child who was so disregarded. I then felt so angry at Linda, for not being able to be the grown-up, to not think of Emma rst, to feel for Emma, to accept Emma. As time progressed and our work deepened, however, Linda softened and became less harsh and much more caring, and in turn, I felt warmly towards her, and gave her much credit for changing to benet her daughter. Then, if Emma retorted in a mean, nasty way to Linda, I felt angry toward Emma, angry she could not welcome the wonderful, positive changes her mother had made in her behalf. Although she continued in her angry posture toward Linda, Emma would try to ally herself with me against Linda. I felt she saw me as an adult authority whom she could appeal to, and hope for sympathy and help. I felt warmly toward Emma during those moments, but did not harbour the earlier anger toward Linda, and was able to respond to each in an authentic, caring tone of voice. As I struggled with my vacillating feeling towards each, eventually they became more balanced, and I believe Linda and Emma felt this, as each became more respectful and empathic towards the other. At rst, Emma began every session with icy stares, angry posture and an adamant silence. I found myself tensing up, sensing Emmas hostility, and feeling she hated me. However, she looked scared after all, her mother was all she had. I reminded myself how young she was, how she was showing me how she felt others experienced her, how she must feel so hated herself. I noticed that despite other available seating, she chose to sit right up next to her mother on the couch. She wanted her mother. Linda always chose the corner of the couch rst, and Emma sat practically on top of her in the middle. Lindas characteristic beginning was a litany of complaints about Emmas behaviour, which she read from the list she had compiled during the week. This angered me, it was so attacking. I felt bad for Emma. One day, however, Emma confronted her mother: How would you like it if I came here with a list about you? They started to bicker. Linda accused Emma of being disrespectful; after all, she was only trying to help. Emma slapped this down too. Nothing I do is right for you! You hate everything I do and you cant stand being around me! Why would I want to be around you when all you do is complain about me? Linda yelled. When Emma yelled back, angrier than she had been when she started, I interrupted to validate and normalise the feelings of each, and to model empathic listening and sensitivity to both. I can see how angry you are, Emma. Im not surprised youre so angry, its horrible to feel so blamed. Emma softened a bit and leaned back into the couch, teary-eyed. Linda, I went on, Its normal for children to feel like they are the problem when their parents bring them to

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therapy. And you did sound a bit accusatory toward Emma just now. Could you hear or feel that tone in your voice? Silence ensued for a moment and then Linda said, Yes, I guess so, but I feel so rejected and she really hurts my feelings and I cant help it. Yes, I responded, the way you felt with your mother. I can see how hurt and angry both of you are. I know how much you want closeness with Emma, you really, really want a close motherdaughter relationship, the kind you feel you missed out on with your mother, and it is hard, Emmas anger pushes you further away. I think you both push each other away with anger . . . it must be frightening for Emma to feel close . . . perhaps shes scared youll give her away, too? And, dont you think anyone would feel blamed if they came here and their mother took out a list of complaints, like they were the bad guy? I dont know, said Linda, huffy again. I felt so rejected by my mother. Nothing was ever good enough for her. Whenever Emma is sarcastic or angry with me she acts like she hates me that Im not loved . . . My mother was always angry with me and controlled me too much. And how did that make you feel? cried Emma. I didnt like it, Linda replied. And Emma retorted, See? Yes, I see, Linda quietly responded, looking directly at Emma, Yes, I see. I could feel this resonate within Linda. She could recognise the familiar feelings of hurt and rejection from her mother, so readily triggered now by Emma. I encouraged Linda to wonder out loud how she could begin to respond to Emma in a different way, to listen and to empathise with her, to try to feel how it felt for Emma. Teary-eyed, Linda looked at Emma again. I feel so hurt, like you dont like me. This time it was Emma who quietly responded, leaning in toward her mother. Yes, I do. You just get so mad at me too much. Much of our work focused on trying to understand Emmas intense anger and her recalcitrant behaviour (I can see how angry you really are. There must be a reason), and on understanding on a deeper level why Linda took this as such a personal assault (You feel so attacked. Have you ever felt this with anyone else in your life?). Occasional individual sessions with Linda explored her own early experiences with her mother, to help her keep those representations from contaminating her attachment relationship with Emma. Linda realised that her powerful feelings of being unheard had been most notably, if not exclusively, aroused by her own mother. (It is hard having a difcult child, I would say. It must feel awful when your daughter is so angry, and makes you feel unheard the way you felt with your mother. What a harsh, hurtful reminder.) At the same time, I normalised some of Emmas behaviour: Although it feels like Emma is doing this to you on purpose, shes not. It seems she is ghting to get close to you, and angry she feels unheard. When children feel emotionally unheard by their parents, they normally show it with anger. My empathy toward Linda, and my efforts to attune to her, were intended not only to full her own unmet needs, but also to show her how to be in relation to her child. Emma was desperately conicted, I pointed out repeatedly to Linda. She wanted a close, warm, loving relationship with her mother. After all, she did come willingly (albeit in a huff) to each session, and sat right next to Linda the whole time. Yet she pushed her away, too, refusing to do things with Linda, being angry and sarcastic. Why might that be? I wondered out loud to Linda. Well, I answered

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almost to convince Linda, its not uncommon for adopted children to worry especially about abandonment. Emma might fear that if she let herself get close to Linda, if she let Linda really get to know her, that Linda might nd out whats wrong with her. Then she might want to get rid of her the way her birth mother had. I asked Linda to think about this, reminding her that being adopted greatly affects how children feel about themselves. Linda rejected my formulation, saying, Well, my other children are adopted and they never had any problems! I dont buy it! Its her . . . something is wrong with her! This annoyed me tremendously. Six months into our work, Emma sat down next to Linda, took her mothers hand and smiled. Without reciprocating, Linda launched into a criticism of Emmas outt. Emma recoiled. That gave me a chance to address for both of them how hard it was for Linda to accept Emma for who she is to love her for their differences as well as their sameness. If I can feel that here in this room, you know that Emma must be feeling it even more. Children are acutely sensitive to how their parents feel about them. If they sense theyre being criticised or even just not being valued for who they are, it scares them, and then they get angry. Over time Linda began to be able to see how negative and rejecting she was with Emma, and how hard it had been to accept Emma as different from herself: Emma was tall, slender and athletic, while Linda was short and heavy. Emma loved music, while it drove Linda crazy. Emma hated sightseeing on vacation, but it was Lindas passion. As Linda became more sensitive to her criticism of Emma for her differences, she began to perceive how deep her wish really was that Emma might have been more like her. It was sad. It was so painful for Linda to realise how she had been with Emma. I sat calmly, silently with them, as they absorbed the sad realisation. At the same time, she began to recognise how desperately she did not want to repeat the relationship she had experienced with her own mother. She consciously made efforts to ease up on Emma, to back off from power struggles, to remain calm, and to respond empathically. She began to feel sad for Emma sad that Emma was not happy, sad that Emma was always angry. I genuinely sensed Lindas sadness and thought surely Emma must also. In turn, Emmas anger began to soften, and she began to ask questions about her biological origins. I dealt openly with the way these two people brought their own personalities into the relationship, and their responsibilities for that. Emma was bristly. Linda was controlling. I made clear that they both had unresolved issues (Lindas unresolved attachment issues with her mother, Emmas adoption) that got in their way with each other. Linda was now recognising her shortcomings Im too critical and demanding, and feel cold with Emma and in individual sessions, she strove to understand them. Why cant I nd things to value in her? . . . Im in her face too much, like my mother was with me. I didnt like it, so I guess I see how Emma must not like it. Linda increasingly looked to me for parental guidance. She said she enjoyed coming, and looked forward to learning about herself, and about parenting in a new way. She even took notes, as though she was taking a part of me home to help her with Emma. She returned eagerly to report how well she had done during the week with Emma, I didnt get defensive! I began to look forward to our sessions, and felt warmly each time I saw her. By this juncture, one and a half years into treatment, real attachment dynamics could be directly addressed. Thirteen-year-old Emma, I pointed out one day, was acting as

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though she did not want a mother and did not need one as though she were perfectly self-reliant. I offered them the hypothesis that I had once discussed privately with Linda. Maybe Emma was nervous about getting close. Maybe she feared being rejected again having felt rejected by her birth mother, feeling she gave her away. This went over like a lead balloon. Emmas severe ambivalence and disappointment in Linda (typically affecting adoptees ability to integrate fully the good and bad aspects of others) affected her own self-image as well. She was unable to accept her own self as good-bad, as imperfect (Tubero, 2002). In turn, this perpetuated her feeling so unwanted. This had an enormous effect on my countertransference. I felt tremendous pressure to not disappoint her, to help her feel wanted. This created a problem for me. I wanted to forge a mutuality between them, between myself and them, but had a strong pull to protect Emma from Lindas initial coldness. Interestingly, I did like Linda, and identied more with her as a mother with a difcult child. Although I felt Emmas underlying sadness and woundedness, I felt angry she could be so rejecting at times, and so hostile. It created a state of quandary. So I tried again. OK, I said. Whatever the reason, I can see that you feel terribly misunderstood here with your mother. And I can see how frustrating it must feel not to feel good enough. No wonder youre angry. This Emma could hear. She looked directly at Linda, made her usual complaint, and then repeated her earlier but still unanswered question. Nothing I do seems good enough for you! Why dont you just give me back? This time Linda softened and edged a little closer to her. I dont want to give you back. I want you. That gave me another chance. I said to Linda, Many adopted children feel abandoned and rejected on some level. Its hard for them to risk getting close to others, especially if they feel their parent is critical and unaccepting to begin with. Linda sat quietly that day, looking down, and Emma maintained her angry, pseudo-independent posture. Yet at home, her parents told me, her behaviour began to change. Emma began to express empathy for her mother, recognising her own rejecting attitude (I know Im mean to you sometimes) and apologising when she was nasty. Her peer relationships began to show that she was developing a more positive internalisation of her mother: Linda overheard Emma say to a friend in exactly her own tones, Dont make a mess. I held occasional sessions with Linda and Michael, to reinforce the mutuality in their relationship. The three of us discussed how temperament, ADD, being adopted, and the t of their parenting styles had all made it harder for Emma to attach with ease. To both parents, I emphasised her strong need to feel accepted, to feel heard, and I suggested they try to look at her through a new lens, one not contaminated by their own earlier attachments to their parents. The nal six months of the tripartite work with Linda and Emma focused on facilitating easy-owing, mutual dialogues maintaining eye contact, verbally expressing feelings directly, empathising with each other. This was complicated stuff. In one session, Emma was being especially sarcastic and hostile. I dont need you! she said ercely. I dont like you and I never will! You just want to x me and never accept me! I dont want anybody! Linda was able to respond empathically. When she looked at Emma and said softly but directly, Its sad . . . sad you feel that way . . . I really want us to be friends and have fun together, Emma broke down crying, saying that she felt confused.

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Emmas transference to me vacillated from the start. Often, she seemed to idealise me, and make bids for help, as someone who could agree with her that her mother was mean and nasty, as one who would side with her and see her mothers faults as she did, that it was her mother who was the problem. At other moments, Emma turned on me, attacked me for not helping, and for not being worth the money. Once, I pointed out Emmas strength in being able to recognise her confusion, and praised her openly for being able, at such a young age, to engage in a conversation like this with her mother. I commented on how well she expressed herself, and on how she really did listen to her mother. Emma turned on both of us in a ash: on Linda rst: I dont need you! . . . I dont like your hair or your clothes or the way you talk! And then on me: And I dont like you! Youre not helping! Still Linda managed to stay with her. Im sorry you feel that way, Emma. Im sorry you feel that, said Linda softly. Now the oodgates opened, and years of pain and sorrow and anger gushed out. Emma sobbed and said again, You always wanted to x me, could never accept me . . . You hate me. Im no good, why did you waste your money buying me? Youd be happier without me! Im nothing, nothing! Now Emmas anger was available in clear focus. The more attuned and empathic her mother became, the more Emma resisted taking her in. She was terried of allowing a warm, understanding maternal gure into her being, yet yearned for it, and pushed it away to prevent loss or abandonment. She attacked me relentlessly too in reaction to any empathic statements accusing me, nding fault. What are you looking at? Youre no help! I hate you . . . youre a waste of money! I remained as calm, empathic and supportive as I could, again modelling for Linda how to be in such a painful, provocative situation. Im really trying to help, Emma, I said gently. Im trying to help your mother understand how bad you feel. Im so sorry you feel so bad, so angry. I think you are a good kid, youre not bad. Now that Linda could increasingly maintain her composure when Emma lashed out at her, Emma seemed to be terried of closeness with a warm, nurturing gure. As Linda became more sensitive and approving, it seemed that Emma was projecting her own negative self-concept onto both her mother and me. Now we focused on helping Emma soften her experience and image of Linda into a more sensitive and approving one, and so to develop over time a more accepting sense of her own self. It was slow going, but now Linda was able to respond to Emmas accusations without anger or disgust, replying, Emma, I want us to have a good relationship, to like and enjoy each other . . . I do like who you are and I dont want to change you. Sometimes Emma did not bite back. At rst she was stunned, surprised that her mother was accepting and understanding, surprised her mother did not reject her for being so angry. But over time the surprise became less, and Emmas expectation of her mother her representation of her came to include the belief that her mother would listen to her with attention and respond with sensitivity, that her mother thought she was worth listening to. Her anger began to abate.

Conclusion
My adaptation of the tripartite model for older children facilitates the reorganisation of relational templates within the context of new experiences (Berlin, 2002, 2005). In the

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therapy situation, past expectations can be replaced with new expectations based on reliable new experiences, and dysfunctional representations transformed into healthier ones. Bowlby (1988) was aware even in his early formulations of attachment theory that early patterns are not set in stone, and are amenable to change in the right environmental circumstances. In particular, and despite resistance to change after childhood and adolescence (Bowlby, 1973), internal representations of attachment relationships are pliable in response to caregiver sensitivity and responsiveness (Bretherton and Munholland, 1999). According to Beebe and Lachmanns (2002) theory of the mutuality of attachment experiences, tripartite therapy provides an ideal facilitating context for restructuring the relationship between mother and child. When an emotionally unavailable, or distant parent can learn in sessions to be consistently and regularly attuned to the child in ways that help the child feel known and heard, an insecure child can reconstruct her internal working model of self and other, revising her sense of self, and perhaps altering her own mode of relating to the parent. The tripartite setting allows repetitive enactments of the basic ways of relating that we know promote a secure attachment sensitive, empathic and responsive parental attunement. This is a more direct way of facilitating change in a dysfunctional parentchild relationship than guiding parents in private sessions on how to be with their child. To me, tripartite work is a signicant and essential alternative way to work with children, to supplement the traditional child psychotherapy model in some cases, and to replace it in others.

Mechanisms of change
Researchers have been able to isolate in almost astonishing detail the relationship mechanisms of attunement and responses that produce secure or insecure attachment. It is precisely those mechanisms that we strive to replicate therapeutically in the tripartite setting to amend a disrupted or decient attachment relationship. One of the most decisive inuences on the security of attachment is the childs qualitative experience with caregivers (George and Solomon, 1999), specically the mothering gures availability and emotional sensitivity. Mothers who are emotionally supportive and responsive, exible, and aware of their childrens needs are more likely to have sound and close emotional ties with their children (Sroufe and Fleeson, 1986). The mothers responses, though, do not lie only in her concrete caregiving behaviour. Maternal caretaking is imbued with meaning and affect. The mothers facial expression, her tone of voice, inection, her body language are all clues as to how she regards her child, clues to which children show great sensitivity, and direct clues the therapist can observe, feel and react to. The way the child interacts with the mother by cooperation, withdrawal, ignoring or opposition becomes part of the dyadic system, and is often the referring behavioural problem. The child is an integral, active partner in this system. She signals whether she needs closeness, distance, or protection, and she learns to associate feelings of pleasure, anxiety, anger or fear with the maternal responses her signalling behaviours evoke. Her temperament, health, sensitivity and biological vulnerabilities all affect her relationship with her mother, just as the mothers affect hers with the child. The parent as a selforganizing, self-regulating unit; the child as a self-organizing, self-regulating unit

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(Beebe and Lachmann, 2002: 25) coalesce within the interactive eld. The members of the dyad bring to it so much of themselves that what appears on the surface as a simple give-and-take relationship is actually an incredibly complex, mutual, reciprocal and interactive dynamic.

Attachment theory and therapy

Attachment theory has nally gained a legitimate place in our conceptualisation of child development, yet the treatment of children has not yet changed accordingly. The tripartite treatment model allows the incorporation of attachment theory into an effective psychoanalytic/psychodynamic model for children of all ages that can address parenting problems, child symptomatology and fundamental attachment issues all at the same time. In particular, the therapist in tripartite therapy can model the reective function (Fonagy and Target, 1998), a fundamental skill that underlies and facilitates the development of secure relationships, and in turn of a positive sense of self, a skill that Bleiberg et al. (1997) believe is the principal focus in child analysis. A mothers awareness of her childs internal life, and her capacity to help the child make sense of her feelings, thoughts and behaviour, may be limited by the insecure attachment to her own mother that now represents her expectations of motherchild relationships and her own lack of experience of being recognised. In the tripartite setting, I can model ways to be attuned and empathic to the child while simultaneously being attuned and empathic with the mother. Openly acknowledging the childs desires, feelings, conicts and fears allows the child to see herself and to feel known, and to help her then make sense of her internal world. It also allows the mother to see how this kind of recognition happens, and what it means both to the child and to herself. Parenting is often contaminated by unconscious, unresolved issues from the past, leading for example, an insecure mother to see her child in limited, distorted ways (Slade, 1999). Helping her to separate out her early attachment experiences from present ones to bring into consciousness inner motivations or conicts gives her the opportunity to perceive the child through a new, more realistic, and more positive lens. Attachment theory highlights the biological basis of attachment behaviours and their importance to survival. These behaviours are expressed across the lifespan in different ways. Relevant to child therapy, reorganisations of the attachment system take place in the context of the developmental issues being negotiated in different phases of maturation (Cicchetti et al., 1990). Ultimately, achieving a balance between dependence and independence, or attachment-individuation (Beebe and Lachmann, 2002: 15) is a life-long developmental issue, which is expressed differently at different ages. For example, very young children cry, cling and have temper tantrums, and it is important to recognise that these are often efforts to evoke parental attention and bring the attachment gure closer. Likewise, when school-age children act out, behaviour that looks like stubbornness or meanness (as Linda thought Emmas did) they may actually be reecting unmet attachment needs. Older children may apparently disregard the relationship, or engage in struggles and argument, but such attempts to control caregiver behaviour again frequently reect an effort to establish a more successful attachment bond.

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In adults, internal working models of attachment based on past experience shape later attachment relationships that satisfy a fundamental felt security, as a giver or a taker. For example, people who have had painful or ineffective attachment experiences as children may learn to avoid attachment relationships later in life, while people who enjoyed secure attachments early later regard such relationships as positive and desirable. People whose experience with attachment has been ambivalent will typically remain so, and as adults will be conicted about closeness with others (Ammaniti, 1999). Emma, for example, was clearly ambivalent about attachment. She wanted to be close, but she was quick to reject intimacy when it was offered, and to dismiss any need for her mother or others. Her dismissals were probably a reection of the unreliability of her closeness experiences with her mother, and perhaps of the fact of her adoption. Linda and Emmas relationship exemplied the insecure type: there was intense friction between them and many missed messages, and they attempted to control each other with prolonged silences, sarcasm and threats, instead of shared, positive affective response. Recent research validates the clinical appropriateness of addressing attachment problems with older children (Cassidy and Marvin, 1992; Main and Cassidy, 1988; Humber and Moss, 2005). Overall, in school-age children, different interactional styles suggest a considerable continuity between early attachment patterns and adult proles. In essence, in older children, secure dyads reected attunement and reciprocity whereas insecure dyads were less attuned, and more angry, annoyed, irritated and critical. What makes attachment relationships develop in one direction versus the other? Genetic predisposition to mental illness, inherent temperament and resilience, chronic illness or disability, physical or sexual abuse, learning disabilities, adoption or foster care, may contribute to or moderate development and attachment. Environments that give rise to attachment decits often contain such risks apart from the actual attachment relationship. It is therefore very difcult to separate which of a childs difculties are the result of poor attachment, and which come from other factors. The best we can do as clinicians is to examine each child in the context of the family, to understand her uniqueness and her risk factors. This is precisely the examination that the tripartite modality facilitates. It is also clear that numerous variables, particularly improved maternal sensitivity, can moderate the impact of a disordered attachment. In the case of Emma and her mother, targeting maternal sensitivity in one and anger and hostility in the other, broke through an attachment impasse. The ambivalent working model of attachment that characterised Emmas affective relating with her mother is frequently seen in adoptive children (Zilberstein, 2006), where a frustrated desire to be close is expressed as anger (Berlin, 2005; Kobak and Sceery, 1988). However, with Emma, her primary problem seemed to be with her mother who was insensitive, and the therapeutic triumph was the work we achieved with Linda in the tripartite context. Within the tripartite setting, both Emmas frustrated desire for closeness with Linda, and her hostility and rejection towards Linda were directly confronted. We let her know we knew how angry she was, how frustrated she was and how conicted she was. Again, one of the most important functions of the attachment relationship is to regulate anxiety. Emmas inability to gain comfort from

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her mother due in large part to Lindas inability to perceive and respond to Emmas needs instead of modulating her anxiety probably heightened it. Not only did she have no reliable source of comfort under stress, but her anxiety about that very situation went unaddressed as well. As Linda adapted a more sensitive way of understanding and relating to Emma, Emma began to anticipate that her needs could and would be met, that she had less need for anxiety on that score, and that when anxiety beset her, her mother would be a reliable source of help. She was able to relax her wariness, and her anger began to soften at home. This was a difcult and arduous case. By the time the family came to treatment, Emmas resistance to letting her mother (or any other adult) in was on its way to being well integrated into her personality, and her rageful response to the narcissistic injury of rejection had taken hold. Feelings were running very high on all fronts, and even the tripartite model had to be handled with extra nesse, lest empathic attunement to the mother feel like rejection to the daughter, and vice versa. I gave particular attention to balancing Emmas age-appropriate developmental strivings toward separation and autonomy with the need to facilitate a capacity for closer connection. I always let her decide when and if she wanted to return, and let her decide if she wanted her mother or father to be present, or if she wanted to come alone. But often the hostility and tension in the room made it hard for us all to stay on course. Emmas anger pushed away not only her mother. Sometimes I too wondered about the viability of this treatment model with a child entering adolescence. But by the time I was wondering out loud whether the more traditional individual child model would not have been more appropriate, Linda refused to give up, and insisted we continue. Emma too refused to be seen alone. She said that she would only come with her mother or father, but her mother was the parent of choice. Later, as we approached our termination date, Emma told her mother at home, I want to work on our relationship now. Over the almost three years that we worked together, things shifted; slowly, gradually, not in great leaps but change they did. There was less ghting; both parents were more patient and more accepting. Linda became less defensive and more empathic. Emma became absorbed in peer relationships, and was less provocative at home. The inherent turbulence of the adolescent years meant that things still got rocky at times. The relationships between them had changed for the better. Emma knew it, and her expectations of her other relationships changed accordingly.
4 Chatsworth Avenue Larchmont NY 10538 USA e-mail: Berlin914@aol.com

Acknowledgements
Dedicated to June Tosca Greenbaum who stimulated the authors commitment to exploring and addressing parentchild relationships.

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Notes
1. In all my papers, I refer to the mother as the primary caregiver. Most infants clearly form attachments to both their mothers and their fathers, and we intuitively believe that father child attachment is just as important. However, paternal attachment is associated with the level of paternal involvement, and although average levels of paternal involvement have increased, even in two-parent families with employed mothers (Lewis and Lamb, 2003), many fathers assume less childcare responsibility than mothers do (Pleck and Masciadrelli, 2004). When fathers are less involved and mothers assume the primary caretaking, infants show a clear preference for the mother (Lamb and Lewis, 2004). At this moment, therefore, the quality of the motherchild attachment has stronger predictive power than the father child attachment does (Lamb and Lewis, 2004; Sroufe and Fleeson, 1986). Clearly, more research that is sensitive to paternal inuences on attachment is indicated. Parental warmth, nurturance and closeness are associated with positive child outcomes with an involved mother or father (Lamb and Tamis-Lemonda, 2004). 2. Being biologically related may help parents adjust to and tolerate a difcult child, thus shared genes may facilitate a better t between parent and child (Stams et al., 2002). In adoptive families, poor ts are more likely to occur (Brodzinsky et al., 1993).

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