This article was downloaded by: [University of Connecticut]On: 09 October 2014, At: 05:46Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

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Merging and Emerging:Separation-IndividuationTheory and the Treatmentof Children with Disorders ofthe Sense of SelfAnni Bergman Ph.D.Published online: 02 Apr 2012.

To cite this article: Anni Bergman Ph.D. (2000) Merging and Emerging:Separation-Individuation Theory and the Treatment of Children with Disorders ofthe Sense of Self, Journal of Infant, Child, and Adolescent Psychotherapy, 1:1,61-75, DOI: 10.1080/15289168.2000.10486334

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MERGING AND EMERGING: SEPARATION-INDIVIDUATION THEORY AND

THE TREATMENT OF CHILDREN WITH DISORDERS OF THE SENSE OF SELF Anni Bergman, Ph.D.

INTRODUCTION I had the good fortune to join both of Margaret Mahler’s research projects at the Masters Children Center at their inception in 1959: one, the observa- tional research on the normal separation-individuation process, the other the research on symbiotic child psychosis, during which the tripartite treatment design was developed under the leadership of Margaret Mahler and Manuel Furer. While the two studies were separate, there was nevertheless a cross- fertilization between them. The painful and distorted developmental processes of psychotic children with exaggerated crises of separation at times helped us to notice the more subtle crises that any child experiences during the first three years of life. In turn, the articulation of the phases of separation- individuation helped to guide the treatment of psychotic children and their mothers, whose navigation of the separation-individuation process was so complicated and so painful. It was easier to bear the pain that these children experienced and endure years of intensive treatment if one could understand the treatment process in relation to developmental processes.

The tripartite treatment design was developed over a number of years and was built on the premise and the observation that psychotic children had never formed a symbiotic bond with their mothers from which the process of separation-individuation, culminating in the achievement of emotional object constancy, could evolve. Therefore, children with psychotic and autistic pathology were treated together with their mothers to facilitate the symbiotic bond between them: at the beginning of treatment, the task of the therapist was to form a bridge between the psychotic child and the mother who felt she could neither understand her child nor be understood by her. The hope was that, by forming a bridge between mother and child, the therapist could help the child to accept the mother’s care and use it so that an affect feed- back system between them could evolve.

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When the separation-individuation research began in 1959, Mahler wanted to build on the work of pioneering researchers such as Spitz, who had observed and very fully described phenomena between mother and infant during the first year of life. At first we began observations of mother-child couples during the second year, but quickly found that the process of separa- tion and individuation was already well on its way. Thus, we began to observe mother-child couples at 6 months. What was not known then, and only began to be discovered when new film technologies became available to infant researchers, was the amazing capacities for discrimination and beginning relatedness during the first 6 months of life. While the burgeoning field of infant research has since shed light on the first 6 months, much of the research has been done in laboratory settings. I feel there is a need for further obser- vational studies in naturalistic settings and have just begun such an observa- tional study in an attempt to understand-from a psychoanalytic point of view-the dynamics of the earliest relationship. The goal of this research has been to study how the baby becomes known to the mother and how the mother gives her knowing back to her infant (Fonagy 1998, Winnicott 1959).

In each mother-baby pair observers have noticed a major shift that occurs between 6-10 weeks. Mahler had originally named the period before this shift the autistic phase, a term she later gave up. My current research group has named the shift the beginning of the emerging dyad. It occurs in the baby, in the mother’s perception of her baby, in her mental representation and fantasy life regarding the baby, and in her feelings about being a mother. We have noticed that, at this shift, the mother talks about having a sense of knowing the baby or a sense that the baby has made himself known to her. Often mothers at this time say that they have fallen in love with the baby.

Prior to the shift at 6 to 10 weeks, we have observed variable amounts of anxiety in the mother about the baby’s survival, about herself as a mother, and about finding reliable ways to comfort, care for, and be attuned to her baby. This anxiety, which seems to occur in all mothers, must be so much greater for the mother whose child is not able to make herself known to the mother or for the mother who is not able to read the child’s signals. The process of being known by the mother who then gives this knowing back to the child is disturbed in psychotic and autistic children, who are so unknowable to their mothers. The primary therapeutic task in the beginning stages of treatment of a psychotic child is to make the child’s seemingly meaningless and bizarre behaviors compre- hensible to the mother, who often feels rejected and helpless.

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Many psychoanalysts have described the unique state of mothering an infant. Winnicott (1956) has called it "primary maternal preoccupation"; Bion writes about the mother's "reverie" (1962); Loewald (1980) describes a level of mentation in which there exists "only one global structure, one fleeting and very perishable mental entity that has neither ego nor object, neither self nor another" (p. 73); Bergman (1985) speaks of the mother's "regression in the service of the baby"; and Stern (1995) has articulated the "motherhood constellation." It may be that the psychotic child blocks the mother's capacity to enter into this special state of motherhood, but it is also true that this state is difficult for some mothers to achieve and tolerate. Whatever the origin of the misattunement, the therapist's task is to facilitate the mother's empathy and the baby's ability to express its needs.

Modell says that " [qor some patients, the therapeutic setting may be their first opportunity to be a child" (Modell 1990, p. 147). In tripartite treatment, the therapeutic setting may be the first opportunity for a child to be an in- fant with an attuned mother and for a mother to be the mother of a know- able infant. The therapist must help the mother enter into her child's world enough so that she is not constantly challenging it, thereby undermining the slow gains of treatment, which often for a long time seem imperceptible.

In the cases I have treated, I have found that mothers of psychotic children have themselves had very disturbed relationships with their own mothers. These mothers are doubly traumatized, first by the deprivations of their rela- tionships to their own mothers and then by the profound frustration and disappointment of not being able to be a good mother. Often these mothers have longed to become mothers because they have hoped to repair the dam- age or loss from their own early experiences. The therapist then has the double task of facilitating the relationship between the mother and the psychotic child and fulfilling some of the mothering functions to the mother.

I will now briefly describe some of the significant transitions in the treat- ment of two psychotic children, Rachel and Rosie.

THE CASE OF RACHEL: FROM "I" TO "I AND You"

BACKGROUND Rachel was 4 years old when she was brought to the Masters Children's Center by her mother. She presented a typical picture of a symbiotic psychotic child. She clung desperately to her mother, seemingly in an attempt to coerce her

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to function only for the purpose of fulfilling her needs. There was no plea- sure in closeness for either Rachel or her mother. Rachel was rigid and panic- stricken. At the slightest frustration she would break into piercing screams. She would not permit her mother any independent existence. For example, she could not tolerate her mother to converse with anyone, either in person or on the telephone.

Rachel showed a mixture of symbiotic and autistic defenses. While she used language, it was never for direct communication, and she did not put words together in a spontaneous way, but instead quoted from books, records, songs, and television commercials. She would also parrot words and phrases that were said to her by people in her environment. Since everything she said was merely an echo of what she heard, the reversal of personal pronouns was a natural consequence. When speaking of herself, she would say; “You get dressed,” “You eat your dinner,” “You go to the park,” and so on. Although she spoke fairly clearly, her voice was lifeless and unmodulated, as were her facial expressions and body movements. Even her frequent shrieks seemed to lack emotional participation. She did, however, use quotations with astonishing accuracy as a way of conveying her feelings. When she was angry with her mother she would quote from fairy tales or folk songs and say, for example, “the poisoned apple” or “she’s dead, of course.”

Rachel was a pretty child, with lovely blue eyes and long, tightly braided hair. She was always clean and neatly dressed; her face was set in a tight, smile-like grimace. He motility was severely restricted: she had a broad tod- dler-like gait, and walked cautiously with small steps, climbing one stair at a time, like a 2-year-old. She would never run and was unable to climb, swing, throw a ball, or use her hands in any kind of manipulative activity. Instead, she was always either bouncing from foot to foot or jumping and waving her arms.

Rachel showed no interest in toys, except as objects to chew on; she liked small objects she could hold in her mouth. When given a doll, she would undress it and then discard it. She spent many hours during the day listening to records or looking at a particular book that caught her fancy. She worked strenuously at shutting out the outside world; when she was unsuccessful, she reacted with anger and fear. If anyone tried to interest her in a new toy, she would ignore it. If she was not permitted to do so, she would knock it down, drop it, or break into loud shrieks. She would not look at a new book or listen to a new record, nor would she wear new clothes. A trip to the shoe

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store was an ordeal for the mother, who could not quiet her screams. Her mother had found only one activity that would interest Rachel: the spelling of words usually had a soothing effect.

Rachel had innumerable fears: of strangeness and strangers, especially of children; of going in cars; of all kinds of household machines, including the mixer, the blender, the vacuum cleaner, and especially the washing machine.

There was a complete breakdown in communication between mother and child: Rachel would climb onto her mother, tear at her body, clamoring, it would seem, for the very closeness and warmth her mother felt she had tried to provide but which was not accepted by Rachel as a baby. The mother was stiff and proper, intellectual, perplexed, trying desperately to make her child behave in a more normal, age-appropriate manner-yet clearly afraid of her own and her child’s feelings and trying to keep the child at a distance, since she was not able to interpret her distorted behaviors as a need for closeness.

Rachel and her mother lived in an isolated world. The parents had sepa- rated when Rachel was ??4 years old, and the mother had since found it impossible to keep up normal social relationships, partly as a result of the child’s difficulties, and partly on account of her own tendency to be overly critical of herself and others.

THERAPEUTIC PROCESS Rachel had many ways of denying her separate existence, some of which were curiously symbolic. For example, one day, on finding a set of plastic letters in the playroom, she looked for the letter I and started to chew on it. Her mother said that at home they had a similar set of letters and that Rachel consistently ate all the Is.

When Rachel first began to show interest in other children, her approach to them showed a dawning awareness of herself as a separate being. For example, Rachel would follow another child around and imitate her without seeming to be quite aware that this other child was her own age and size. When Rachel wanted to reach for something, she went up to the little girl and held up her arms, seemingly in the expectation that the little girl would lift her up-that is, that the child would respond as her mother might. Rachel’s expectations of a little girl were not yet differentiated from her expectations of her mother.

As Rachel started to show more interest in and awareness of her body, I put increased emphasis in therapy on the games that mothers play with their

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much smaller babies: we started to look in the mirror at her eyes, nose, and mouth, touching these parts and naming them. This happened in an atmo- sphere of great intimacy and physical closeness between us. It was climaxed by Rachel's saying for the first time, with great emotional involvement, while looking in the mirror, "I and you!" We then invented games that combined words with pleasurable body feelings, in order to strengthen the emerging sense of I-ness and you-ness. One such game, which Rachel especially liked, was blowing at each other and saying, "I blow on you."

Rachel's growing ability to be in a world in which subjects were differen- tiated from objects was further reflected in her ability to think of objects- including herself-as alone. She asked me to play the song, "The Farmer in the Dell." I had played this song for her many times, but previously she had never been able to sing the last verse, "The cheese stands alone." I had inter- preted Rachel's inability to sing this last verse by telling her that she did not want anyone-not even the cheese-to be alone. On this day, following soon after the day Rachel and I played the "I and you" games, she sang the song first in her usual way and then sang, "The cheese stands alone," looking at me proudly as she sang.

Later in the same session, she had difficulty with a toy that kept break- ing. I talked about how difficult it was for her to have me help her, because if I did help her, instead of magically making things turn out right, we became "I" and "you," which made her feel afraid of being alone. Thereupon she accepted my help and said softly, as if to herself, "I love you." She found the baby doll and started to chant, "Ah, baby, sweet little Rachel." The monu- mental change in Rachel's ability to accept that she could be alone grew out of her trust that I could be in her world with her, after which point tolerating separateness no longer threatened her with total annihilation. With the aware- ness that people are separate, which earlier had been equal to annihilation of the self, she could now experience the need for love and caring. She played with a family of dolls for the first time, causing the mother and the baby doll to sit in the rocking chair together and play at cooking and feeding.

While earlier on it had been characteristic of Rachel that nothing but immediate need satisfaction seemed to make any sense to her, with her increasing relatedness to others came her ability to delay gratification. She developed a sense of time, and especially a concept of the future. She also developed a greater sense of cause and effect and sequencing in general, and with that a greater ability to master anxiety. For instance, she became will-

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ing to accompany her mother to the hitherto much-feared laundry room, and to accept mother’s promise that they would do something nice afterward.

Instead of limiting herself to gestural and indirect demands, Rachel became able to use words to ask for things. On one occasion she struggled to make me understand by gestures and by moving my arms as if they were her own that she wanted me to make a seesaw for her. When I did not comply, she was then able to ask for what she wanted by using words. Interestingly, she said, “Oh, the seesaw,” thus saying what she imagined I would say to her once I understood. Here we see how the process of Rachel’s being able to differentiate between “I” and “you” was gradual.

For a while, Rachel had been playing with a doll family consisting of a father, mother, and one little girl. She had named these dolls respectively Laurie, Lauren, and Laura, and then added another girl doll, who was always passive in the play, who never did anything but just be there. This doll she called Urgie. In playing with the dolls called Lauren, Laurie, and Laura, Rachel seemed to alternate between thinking of herself as Laura, the little girl, and as Lauren, the mother doll. I said to her that it seemed to me as if Laura and Lauren were the same person, to which Rachel answered, “And Laurie too.” Then she played that Laurie was the king, Lauren the queen, and Laura the princess.

For the first time, she then played with a small girl doll to which she had given her own name, Rachel. On that same day, when her mother left the room, she did not respond with her usual jumping, which served both as a discharge of tension and as a way to hide the underlying affect. Instead, she went to the piano and looked forlorn. The mood of sadness over separation from her mother was finally able to emerge; her state of separateness no longer had to be denied. She sat in my lap and said, “Love me.” Then she picked up the doll she had always called Urgie, looked at her thoughtfully, and said, “Urgie, mergie, urgie, mergie.”

Before this, Rachel had given no clues about the Urgie doll’s role in the play, nor about her strange name. Now it seemed as if Urgie might represent Rachel’s urge to merge. The concept itself was not strange to her; we had often talked about her wish to be one with her symbiotic objects. The use of such abstract language, however, seemed quite incredible, although Rachel’s ability to comprehend, use, and at the same time concretize abstract concepts had always been an outstanding characteristic of hers. It seemed quite clear, at any rate, that something of great importance was going on. I said, “So it is

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Urgie-Mergie who makes Laurie-Laura-Lauren all have the same name and be like one person?” Rachel said, “I want to throw it away.” She asked to have the window opened and threw Urgie-Mergie out.

Many important changes followed in the wake of this session, in which Rachel had been able to do to the doll what she herself had been so terrified might happen to her. Earlier, Rachel had thrown blocks and sand; she had also attempted to throw children in school off their chairs or into water. In this session, however, she was able to express in play both the urge to throw away and the fear of being thrown away; and she could furthermore express the idea that there was something within her-Urgie-Mergi-f which she wanted to rid herself. Rachel had now entered the period of verbal commu- nication, symbolic representation, and object constancy. The most important gain of this period was the consistent use of communicative secondary process functional language. She began to use “I” and “you” consistently, and she could now express much more directly how she felt in everyday life situations and in play. She seemed to know and accept the fact that she was separate. She no longer had to deny unpleasant experiences; she gave up the anxious pretense of being always happy. Above all, she seemed to know from then on that the “I” needed to love the “you” and to be loved by the “you.”

RACHEL AS AN ADULT Rachel, now in her late thirties, is living in a stable relationship with another woman. She is working as a librarian, has an active social life, and functions well in the world. She seems well related to her mother, who lives in a different city, but with whom she shares important events of her life.

When I visited her recently, Rachel, who had been adopted, told me about looking for and finding her birth family. This was an important process for her and she maintains contact with her birth family though they live far away. Her birth sister had a baby recently, and Rachel is very excited about this and has visited her.

Rachel is very much aware of her past difficulties, as well as remnants of them in her present way of functioning. Some of her old self-soothing behaviors, such as rocking, are still visible. She has not given up her strong connection to the world of the unconscious and has found healthy ways to live in this world. Not only are her memories of her childhood and her treatment very much alive in her, but she writes poetry, composes music, sings in several choirs, and adheres to religious rituals not part of her upbringing but which

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she discovered as an adult. She has retained strong positive feelings about her early treatment, though she said I might have helped her more with some of her cognitive difficulties, which she now defines as Attention Deficit Dis- order. She also described difficulties she has had with depression, for which she sought psychiatric help. She very much wants her story to be told, would like her real name to be used, and even suggested the title: “Searching for Rebecca: Psychoanalytic Work with Seriously Disturbed Children.

THE CASE OF ROSE: FROM PSYCHOLOGICAL BIRTH TO MOTHERHOOD

BACKGROUND Rosie, an autistic little girl, came for treatment at around the age of 3. Both of Rosie’s parents were artists, and Rosie herself possessed unusual artistic abil- ity. At the age of 3, she was already able to play the piano, imitating pieces that she had heard. When in front of the piano she was completely entranced and could not be interrupted. The piano became Rosie’s exclusive love object, a love object that she could control and that she treated both tenderly and aggressively. Rosie did not speak, made no eye contact, and tended to be wild and unfocused. She did not follow instructions and had to be watched care- fully. Rosie was clearly intelligent: she was able to use materials for building, and she played the piano with amazing facility. While Rosie engaged in solitary play, such as building or water play, she did not engage in symbolic play. She understood what was said to her and communicated thoughts and feelings through the piano, where many of her sessions took place. When not at the piano, Rosie tended to be destructive: writing with crayons on walls and furni- ture, gouging plaster out of the walls, and attacking people physically when she was frustrated and angry. Her mother felt helpless and enraged. An im- portant early communication to Rosie was that her rage would not be responded to with anger in her therapeutic sessions in which her mother took part. During the beginning phase of treatment, the therapeutic task consisted in altering the autistic balance between mother and child. As the therapist, I slowly lured Rosie out of her autistic shell and then attempted to make a bridge between her and her mother. Eventually there were times when Rosie’s attachment to her mother was very specific, and she would be taken care of or comforted only by her. The first phase of the treatment lasted for about four years, during which time she was completely mute and not toilet-trained. Slowly, a close relationship developed between Rosie and me, as well as between Rosie and her mother.

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THERAPEUTIC PROCESS As one would expect, as Rosie came out of her autistic withdrawal, she became increasingly difficult to take care of. She reacted to anxiety by becoming hyperactive and dashing about the room, playground, or building with light- ning speed. She was destructive and intractable, though there began to be moments of tenderness between her and both her mother and myself. Com- munications by way of piano playing were often exquisitely specific and poignant. Often Rosie was ecstatic while at the piano.

Eventually Rosie was sent to summer camp during the summer months when I was not available to support her and her mother in the struggle of her emerging being in the world. While at camp, where she must have felt aban- doned and betrayed, she lost all her love objects: her mother, the piano, and me. At 5 years old, when Rosie returned from her summer camp experience, she had become toilet-trained. On the surface she seemed more serene, but it soon became evident that this serenity was a kind of repetition of the autistic withdrawal with which she had begun treatment. While Rosie seemed more self-sufficient, and had acquired some self-help skills in addition to toilet train- ing, she seemed to have lost her emotional connection. An even more dramatic change was that Rosie no longer played the piano. From then on Rosie never went back to piano playing, and she lost the ability to use the piano as a vehicle both for pleasurable contact and communication. In the therapy sessions, a kind of hopeless mood prevailed for a while. Here we see how imposing the outside world on a child who has not yet emerged from her autistic world causes a breakdown in both worlds, even though some behaviors or skills associated with the outside world might be acquired.

During a session one late afternoon when her mother was not present, Rosie went to the window as it became dark outside. She seemed suddenly very anxious. Both she and I were exhausted from a long session during which she had been completely unwilling to make contact with me, even to the extent that she would not touch any object or toy once I had touched it. Rosie found a pair of scissors and started cutting things and tried to cut her own hair. It was only the next day that I understood her anxiety and realized that the darkness must have reminded her of being away at camp-of being away overnight for many nights. Rosie, who was in a stage where the trauma was continuously lived, felt her parents would never come back to her when she saw it get dark. For Rosie a traumatic event of the past continued to be lived in the present. It seemed that she could not experience relief at the reunion

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with her parents. The trauma of the separation was ongoing until it could be relived and understood in her therapy. Only then could it be further worked through in symbolic play. My interpretation made it possible for her to be in contact with me once again, and the next day Rosie was able to play for the first time since the summer. She reenacted the traumatic experience in play. First she played with little cars in the sandbox and then built a rather elabo- rate highway with blocks. Then she found a piece of black paper and put it on top of the highway; she looked to the window. I thought she was thinking of the darkness, and I reminded her how it had been dark last time, how she had been worried because her mother had not come to pick her up, and how it must have reminded her of the summer when it used to get dark and Mommy did not come. At this point, I felt Rosie was resuming her connection with me. For the first time since the summer, she was reluctant to leave a session.

Following these events and my interpretation of Rosie’s feelings of sadness over the separation during the summer that she had feared would never end, there was a marked change. Rosie was able to look at me, smile at me, and allow me to enter her games. She continued to build highways, built a tunnel, and enjoyed our hands meeting inside the tunnel. To symbolize her despair during the period of separation, she found some scissors and again wanted to cut her own hair and the doll’s. She accepted, however, cutting paper instead, and cut out a tall house with many windows. I interpreted how during the summer, when she had been taken away on a big highway, she had missed her apartment building in the city. She then played in the sandbox. She buried a baby doll in the sand, thereby playing out her feeling and her fear that she would be forgotten at her summer camp at the seashore, as if buried in the sand. Thus Rosie expressed how she had experienced the separation as a kind of death.

Following this symbolic enactment of the traumatic experience of sepa- ration from the love objects she had so shortly before found, Rosie’s play became more symbolic and her communications were less frantic and more organized. In one session when her mother was present, Rosie pretended a doll had a temper tantrum and kicked the door as she herself had done many times during her severe temper tantrums. Then she went outside with the doll-mimicking those times when her mother had asked her to go outside after she had had a tantrum-and threw the doll down the stairs. In this way she conveyed how she had experienced her mother’s anger as a wish to get rid of her. When her mother suggested a reconciliation with her doll, she was

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amenable, thereby expressing that she was willing to make a reconciliation with her mother and me.

As a young adolescent Rosie started to go to a different summer camp for normal children and was able to enjoy it. One summer, however, Rosie’s parents decided to take her along on a summer vacation to a beach. This was a very positive and important experience for Rosie, and when she returned she drew many pictures of serene, beautiful beach scenes with happy children. She made a book about happiness and in it she wrote such things as, “Happi- ness is the sun early in the morning on the beach; happiness is gathering sea- shells; happiness is gazing at the moon at night, near the Ocean in the window of the attic.” She made a particularly beautiful drawing of a little girl, repre- senting herself, looking out the window at the moon. This drawing was especially meaningful because it was a night scene that now included a moon shining on the ocean.

By then, Rosie was beginning to develop a quite extraordinary capacity to observe and know herself with all her vulnerabilities and conflicts. She spent hours drawing and writing and eventually wrote a very interesting auto- biography, weaving together reality and fantasy. It was the story of her life and her treatment, in which she described me as the one who disturbed her images of her ideal self, the one who made her confront the reality of who she was, the one who insisted that she relate, rather than live in her dream world in which she could see herself as beautiful and perfect and admired by everyone. The following is an excerpt from her diary that she read to me:

“We’re almost there now,” said my father to me and Mom. I didn’t turn my head at this point, I just walked between Mom and Dad silently. I felt resentful inside. Just one more block and we’ll be there, I thought drearily. We were always going to Anni Bergman’s house. I had to see her because I was stricken with mental illness. I was practically insane. My parents hated me-o r in my eyes, that was. I was a pain in the neck. I looked down at the dirty, cement sidewalk which was dotted with crushed chew- ing gum and dog crap. Disgusting. Had to watch where you stepped. Well, we got there in five minutes. We went up the grey, painted stairs, up to the gray door of Masters. Dad lifted me up so I could press the doorbell buzzer. Masters was a four-story red brick building. Anni worked there. Anni greeted us warmly as usual, but unfortunately today was one of my bad days. I felt ashamed of my mental illness and of Anni, and especially of myself-period. I loved her but I would never admit that to myself,

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never. I hated her encouragement and lectures about my illness, and I did not like to be pitied. I did not. I resented that strongly. At the moment I stared at Anni in disgust. She wasn’t bad looking, She was slightly chubby, but not fat. She was rather becoming with her short brown hair and had blue eyes that seemed to twinkle at you no matter what mood you were in. I brushed my short, blonde hair from my face impatiently and removed my mental mind out of the building and out of my body into a strange world of my own. I saw myself instead at a beach not unlike Coney Is- land-in fact it was Coney Island. I was playing in the cool, bluish-green waves with other kids of my own age, and I actually talked to them. I was perfect. I had long hair, soft and silky and it was wavy, all the way down to my waist. I also had a rubber seahorse raft which was inflated with air. It was a cool blue with green fins and face. It was perfect too, better than anything in my reality. And I was also wearing a red and white polka-dotted two-piece swimsuit. I was sexy, man. Anni rudely interrupted my train of thought when she said, “Come on, Rosie, let’s go into the playroom.” And here I was once more with my short hair, which I hated, and my mental illness. But one day, I thought, I would have long hair and I would be perfect.

What this excerpt shows about the therapeutic process is both how disturbing my entering into her fantasy world was to her, and also how she was ultimately willing to share and then come out of that world because she recognized that joining me in the outside world was also valuable.

ROSE AS AN ADULT As an adult Rosie lives in a foreign country with a husband, two children, and mother-in-law. She is capable of genuine love and care for her family, especially her children. In a recent letter, she wrote about her daughter:

Mandy has grown into a lovely, bubbly, young girl-woman-she has everything I didn’t have at her age: popularity, boys falling at her feet, nice clothes to wear, and self confidence.. . . I am happy by this; she’s reliving my youth but she doesn’t know it. I don’t tell her. It is enough for me to see my children live happy normal lives. I am at peace with life in spite of my own pain and misery.

Rosie’s connection to her world of primary process is very much alive and, for her, a known necessary condition for being able to live in the other world. Rosie is a very talented painter, and she does her painting while listening to

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reggae music, fantasizing love scenarios between herself and her reggae he- roes. She is in regular contact with her parents and with me, and comes to visit once a year. During that time she continues her analytic work with me. Also for her the retelling and partial reliving of her past remains very impor- tant. As she recently put it in a letter, “You see, Anni, what I have to write about is nothing new, just new versions of the same old songs I sing.”

I am grateful to Rachel and Rosie for having allowed me to share their inner worlds and to accept me as someone who could help them discover and believe that the world of ordinary object relating-with all its difficulties and faults-is worth struggling for.

I was very lucky to have had the opportunity to take part in both the research on the separation-individuation process and the treatment center for psychotic children during that golden age in our country when money was available for psychoanalytic research and treatment. We had the luxury of seeing these very troubled children and their families 4 times weekly in ex- tended treatment sessions, and furthermore we had the opportunity to discuss these cases in seminars and weekly supervisions with Dr. Mahler and a group of exceptional psychoanalysts who were devoted to psychoanalytic treatment of psychotic children. I am deeply convinced that the success I had in treat- ing the two cases I presented was possible because of the treatment setting that provided ample time, not only for doing the treatment, but also for con- tinuous discussion and reflection.

While it may not be possible to duplicate this treatment situation in our time, there are still opportunities to use the insights gained in creative ways. Again, I was fortunate to have the opportunity to do this in the Clinical Psychology Ph.D. program at the City University of New York, where I was given the freedom to create a treatment center for a group of severely dis- turbed and traumatized preschool inner city children. In addition to a thera- peutic classroom, clinical Ph.D. students served as therapists. Treatment sessions were videotaped and discussed in weekly seminars. Many times student-therapists continued to work with these children after the children had to move on from our center, so that some of these children were seen in long-term psychoanalytic therapy.

It saddens me to see how often in our time children who live in a traumatic world in which regulatory processes cannot develop are treated with behavioral methods that ignore the developmental process and the child’s need for the presence of the empathically attuned other. Such children may learn to become

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more compliant with the requirements of society, but I believe that there must be a price to pay and that the price is the development of a sense of self with the capacity for emotional object constancy, which means the capacity for mature object relating.

REFERENCES Bergman, A. (1985). The mother’s experience during the earliest phases of

infant development. In Parental Influences in Health and Disease, ed. Anthony and Pollock, pp. 165-180. Boston: Little Brown & Co.

Bion, W. R. (1962). Learning from Experience. New York: Basic Books. Brazelton, T. B., and Cramer, B. (1990). The Earliest Relationship: Parents,

Infants, and the Drama of Early Attachment. Reading, MA: Addison- Wesley.

Fonagy, P., and Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues 8( 1):87-114.

Loewald, H. (1980). Instinct theory, object relations, and psychic structure formation. Journal of the American Psychoanalytic Association 26:463- 506.

Mahler, M., Pine, F., and Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books.

Modell, A. (1990). Other Times, Other Realities: Toward a Theory of Psychoanlytic Treatment. Cambridge: Harvard University Press.

Stern, D. (1995). The Motherhood Constellation: A Unified View o f Parent- Infant Psychotherapy. New York: Basic Books.

Winnicott, D. W. (1956/1958). Primary maternal preoccupation. In Collected Papers, pp. 300-305. London: Tavistock.

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