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(2002). Journal of Infant, Child & Adolescent Psychotherapy, 2:61-89Organizing Principles of Interaction from Infant Research and the

Lifespan Prediction of Attachment: Application to Adult TreatmentBeatrice Beebe, Ph.D. and Frank Lachmann, Ph.D.

In this paper we apply organizing principles of interaction documented in face-to-face interactions in infancy to both the implicit and explicit dimensions of therapeuticinteraction in psychoanalysis. In our previous work we approached interaction with adyadic systems model of communication (Beebe and Lachmann 2002, Beebe et al.1992). In this view all communication is coconstructed by both partners, although notnecessarily in symmetrical ways. We used the dyadic systems model to defineorganizing principles of interaction for psychoanalysis. The most general of theseorganizing principles entails the integration of self- and interactive regulation, whichare simultaneous, complementary, and optimally in dynamic balance. We furtherdifferentiated “three principles of salience”: ongoing regulation, disruption andrepair, and heightened affective moments, each of which refines our understanding ofthe nature of self- and interactive regulation (Beebe and Lachmann 1994). In thispaper we extend the concept of organizing principles of interaction in psychoanalysisto vocal rhythm coordination, facial mirroring, and distress regulation. The conceptof organizing principles can further specify the details of how interactions areregulated.

Infant research has shown that vocal rhythm coordination, facial mirroring, anddistress regulation in the early months of life predict infant attachment at one year.These three patterns organize the nonverbal, implicit—————————————

We note as a caveat that we are limiting the concept of nonverbal communicationin psychoanalysis to the repetitive, rapid action sequences that are largely out ofawareness. Symbolic nonverbal gestures, such as a raised hand held flat and open,which is an explicit communication of “stop,” are excluded from our discussion.We wish to acknowledge the contributions of Stephen Knoblauch, Judith Rustin,Dorienne Sorter, Barbara Kane, Lin Reicher, Sara Markese, Lauren Cooper,Michael Ritter, Emily Brodie, and Marina Tasopholous.

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dimension of relatedness. We propose that they operate across the lifespan, mediatingall affiliative-attachment-intimacy systems, including mother and infant, adult lovers,and patient-analyst. We bring two types of evidence to bear on this proposal. In thefirst, the three patterns of interaction (vocal rhythm coordination, facial mirroring,and distress regulation) have been shown to varying degrees to organizeaffiliation/intimacy in infancy, childhood, adolescence, and adulthood. In the second,attachment itself has been shown to predict development from infancy to elementaryschool to adolescence to adulthood. Because the three patterns of interaction predictone-year infant attachment, and one-year attachment predicts adult attachment, weinfer that these three patterns continue to mediate the co-construction of attachmentacross the lifespan. Integrating both explicit and implicit modes of communication,we illustrate how these three patterns organize the patient-analyst relationship in onetreatment case.

Dyadic Systems ViewWe approach interaction with a dyadic systems model of communication. In this

view all communication is co-constructed by both partners, although not necessarilyin symmetrical ways. Interactive exchanges are a product of the integration of self-and interactive regulation. Interactive regulation is organized through bi-directional“influences,” or “co-construction.” Since this term is so easily misunderstood, wereiterate that neither causality nor mutuality is implied; rather bi-directionalcoordination refers to the probability that one person's behavioral stream can bepredicted from that of the other, and vice versa. Positive as well as aversiveinteractions can be bi-directionally coordinated. This concept of bi-directionalcoordination defines one use of the term “co-construction,” that is, all interactions areco-constructed by both people.

In translating the bi-directional model for psychoanalysis, it is important toarticulate both the patient's experience of being influenced by the analyst, as well asinfluencing the analyst; and the analyst's experience of being influenced by the patient,as well as influencing the patient. Of these four vectors of experience (two for eachpartner), often one or two are privileged by patient and analyst. Self-regulation isalso a critical aspect of the systems model. Interactive exchanges are a product of theintegration of self- and interactive regulation.

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Sander (1977, 1985, 1995) has argued for a systems model integrating self- andinteractive regulation (see also Gianino and Tronick 1988, Tronick 1989). Hedescribes the infant as bringing primary endogenous activity that must be coordinatedwith the partner. Included in this primary activity is an intrinsic motivation to orderinformation, detect regularity, generate and act on expectancies. Sander proposes thatthe way self-regulation is organized, in relation to the dyad, sets the stage for thesense of self as agent. A subjectivity of “one's own” is continuously being organized,including access to, articulation of, and regard for one's inner states. But the innerprocess is enhanced or limited by the ongoing interaction, and vice versa. Thus innerprocess is organized by both self- and interactive regulation. The individual can befully described only in relation to the dyad. That self- and interactive regulationalways impact on each other defines our second use of “co-construction,” theco-construction of inner and relational processes (see Beebe and Lachmann 1998).

The co-construction view advanced here potentially alters our usual understandingof the analyst's subjectivity (see Beebe and Lachmann 2002). Instead of seeing theanalyst's subjectivity as potentially constraining, biasing, distorting, or facilitating theprocess, using the co-construction model we view each partner's subjectiveexperience as an emergent process, continuously affected by the interaction as well asby the person's own self-regulation.

Implicit Relational PatternsForms of attachment and intimacy are organized in infancy and carried forward in

development through implicit relational patterns, as well as through explicit symbolicnarratives. Moment-to-moment shifts in face, voice, orientation, and rhythm providean essential means of sensing the partner. Mother and infant as well as two adultpartners, such as lovers, or analyst and patient, develop repetitive patterns ofregulating face and voice in “rhythms of dialogue” (see Jaffe and Feldstein 1970,Jaffe et al. 2001), generally out of awareness. The sequence of one's own actions inrelation to those of the partner, and an associated self-regulatory range and style,come to be expected. Even four-month-old infants detect regularity in spatiotemporalevents, in both the self and the environment, and they develop expectancies based onthese events, which implies some future-oriented

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mental process (Haith, Hazan, and Goodman 1988). We use patterns of expectationto define presymbolic representations in infancy (see Beebe and Lachmann 1994),which is one way of conceptualizing the initial organization of implicit proceduralprocessing.

Whereas explicit memory refers to symbolically organized intentional recall forinformation and events, implicit memory includes procedural and emotional memorythat is outside of awareness. Procedural memory refers to action sequences that areencoded nonsymbolically as patterns of expectation and influence the organizationalprocesses that guide behavior (Grigsby and Hartlaub 1994, Squire and Cohen1985). These action sequences are initially “intentional,” in the sense of goal-directed, both for the infant as well as the adult (Mueller and Overton 1998). Onlyafter they become automatic with repeated practice are they “nonconscious” or out ofawareness. They can again become the focus of awareness if these action sequencesdo not proceed as expected.

Lyons-Ruth (1999) has defined implicit relational knowing as “… rule basedrepresentations of how to proceed, of how to do things … with others … such asknowing how to joke around, express affection, or get attention … as much affectiveand interactive … as cognitive … (it) begins to be represented long before theavailability of language and continues to operate implicitly throughout life” (p. 284).Another example of implicit “knowing how to proceed” can be illustrated byattention regulation patterns, such as who initiates looking, whether or not thepartners mutually gaze at each other, how long it is comfortable to hold a mutual gaze,who looks away first, and how reactive either partner is to the other's looking away.In general, it is at the implicit procedural level, on a moment-to-moment basis, thatpowerful interactive “emotion schemes” (Bucci 1997) of face, gaze, vocalization,and orientation are organized, shifts in degrees of tracking and coordinating with thepartner are played out (see Jaffe et al. 2001), and disruption and repair arenegotiated (see Beebe and Lachmann 1994, Tronick 1989).

Lyons-Ruth (1998, 1999) notes that implicit relational knowing operates out ofawareness and outside of verbal consciousness. The organization of meaning isimplicit in the action sequences of the relational dialogue and does not requirereflective thought or verbalization to be known. She defines development, anddevelopment in psychoanalysis, as increasing differentiation and integration ofimplicit relational procedures, which occur

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parallel to a similar process in the explicit realm. As Lyons-Ruth argues and as weillustrate below in the case presentation, implicit relational procedures are extremelysensitive to the quality of participation by the partner.

In psychoanalytic treatment the expectancies that regulate intimate relating can bereorganized in the implicit domain without necessarily reaching conscious awareness(see Beebe and Lachmann 2002). Lyons-Ruth notes that only a small area of thepatient's implicit relational knowing will ever become the subject of verbal narrativeor transference interpretation. By implication, the implicit mode is the far morepervasive and potentially more powerfully organizing than the explicit. The idea thattherapeutic action can occur at the implicit level without verbalization is an importantchange for a theory of therapeutic action. This position is forcefully argued byGrigsby and Hartlaub (1994), Clyman (1991), Emde and colleagues (1991), Bucci(1997), Schore (1994, 1996), Stern, Sander, Nahum, Harrison, Bruschweiler-Stem, and Tronick, (1998), Pally (1998), and Lyons-Ruth (1998), among others.Clyman has proposed that implicit procedural processing provides a measure ofcontinuity from childhood to adulthood and organizes transference expectations.

These two levels, the implicit action sequence and the explicit symbolizednarration, must be integrated for a fuller understanding of therapeutic action inpsychoanalysis (see Beebe and Lachmann 2002). These two levels potentiallyaffect each other. The struggle to symbolize the implicit action level can be seen asone of the major goals of psychoanalysis (Bucci 1985, 1997). The nature of thesymbolization can then potentially affect the implicit action level. However,therapeutic action proceeds in both these modes, whether or not they are integrated.

The distinction between explicit and implicit processing provides a newframework within which to integrate verbal and nonverbal communication inpsychoanalysis. Patterns of expectation provide one definition of implicit proceduralknowledge, which is a potent mode of therapeutic action. Therapeutic action canoccur in an implicit form of processing without necessarily translating thecommunication into an explicit verbal mode.

Despite the importance of implicit relational knowing in potential continuitiesacross the life span, we do not hold that early patterns necessarily become long-termentrenched procedural memories that govern interaction in adult dyadic life (seeHarris 1997). Instead we espouse a transformational view, along the lines of Sander(1977, 1995) and Sameroff (1983), that early

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patterns set a trajectory that can nevertheless transform. Only in pathology is there arelative loss of this transformational process.

The implicit organizing principles that we illustrate in this paper are vocal rhythmcoordination, facial mirroring, and distress regulation. These principles are derivedfrom research on mother-infant face-to-face interaction. We chose them because allthree patterns have been used to predict 12-month infant attachment. Therefore thesethree patterns can be considered to be nonverbal modes of the transmission ofattachment quality in infancy. We also chose them because all three patterns havebeen shown, to varying degrees, to organize affiliation/intimacy patterns inchildhood, adolescence, and adulthood. We thus propose that these three patterns aremodes of transmission of attachment and affiliation across the lifespan. This argumentis strengthened by recent research showing that attachment patterns assessed at oneyear predict development in elementary school, adolescence, and adulthood.Extending this argument, we propose that vocal rhythm coordination, facial mirroring,and distress regulation also carry qualities of attachment, affiliation, and intimacy inpsychoanalysis, constituting organizing principles of implicit relational knowing.

Lifespan Prediction of Attachment from Infancy to AdulthoodAttachment theory provides a unique framework for conceptualizing a lifespan

model of the organization and representation of affiliative/intimate interactions. Thisframework includes both implicit action patterns and explicit representation patterns.Bowlby (1969, 1980) and Ainsworth and colleagues (1978) proposed that infants,children, and adults construct mental models (representations) of self and others outof interactions with primary partners, and that these mental models provide continuityof relationship styles. The working hypothesis is that the same characteristics ofdyadic communication that influence the course of infant and childhood attachment(such as responsivity, predictability, support, safety) are also among the determinantsof adult representations of attachment security (see Hazan and Shaver 1987).Attachment researchers share the assumption that mental models of relationships areopen to revision. However, they differ in emphasizing personal continuity versusdyadic transaction and transformation; they differ in the degree to which these mentalmodels are seen as co-constructed, transformational processes, organized as afunction not only of the individual, but of the relationship pattern.

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We view infant as well as adult attachments as transformational or “emergent”dyadic processes, co-constructed by both partners. A systems model offers a theoryof change based on transformation of patterns: systems that function together arechanged by their mutual activity; that is, they generate emergent properties (seeSameroff 1983). Thus adult attachments are not fully predictable from infancy,childhood, or adolescence. Our mental models (representations) of our attachmentsdo not persist as rigid prototypes, but transform, as Freud originally suggested (seeBergmann 1987). We conceptualize this transformation as a bi-directional,reciprocal process between partners. Relatively enduring mental models ofaffiliation/intimacy/attachment are potentially in a continuous dyadic process oftransformation and reconstruction. Rather than conceptualizing continuity as aself-contained process within a person, we view the dyadic process as the route topredictability in development: continuity in development can be detected throughrelationship patterns, which include both self- and interactive regulation processes(Sameroff and Chandler 1976, Sroufe and Fleeson 1986, Zeanah et al. 1989).

In the past decade, several studies have documented that the mother's attachmentstatus during her pregnancy, assessed by the Adult Attachment Interview (AAI),predicts the infant's attachment security at one year (Benoit and Parker 1994,Fonagy et al. 1991, Ward and Carlson 1995). The AAI is an extensive interview-based instrument that evaluates adult security of attachment based on the coherence ofthe picture that the individual presents of his or her history (George et al. 1996).

Three remarkable recent studies have shown that infant attachment at one year canin turn predict childhood, adolescent, and adult outcomes. Waters and colleagues(2000) predicted attachment at age 21 from infant attachment at one year. Sroufe andcolleagues (2002) predicted elementary school adjustment, and peerrelationships/intimacy in middle childhood and adolescence from one-yearattachment. Grossman and colleagues (2002) predicted romantic attachmentrepresentation at 22 years from infancy, childhood, and adolescent attachment-relatedmeasures.

Waters and colleagues (2000) evaluated 60 infants for attachment security at oneyear in the Ainsworth Strange Situation test. Of these, 50 were evaluated again at age21 for attachment security (AAI). Seventy-eight percent of the individuals retainedtheir secure or insecure status (72 percent using 3 groups: secure, insecure-avoidant,and insecure-resistant). Among

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secures, infants whose mothers reported one or more traumatic events (loss of aparent, parental divorce, life-threatening illness of child or parent, parentalpsychiatric disorder) were 4 times as likely to change to an insecure attachmentclassification than infants whose mothers reported none. This study demonstrates bothcontinuity of attachment classification under more relatively optimal developmentalcircumstances, as well as the transformational nature of attachment formation,particularly less optimal transformations, under conditions of developmental stress.

Sroufe's group (Collins and Sroufe 2002, Sroufe et al. 2002) followed 175children from infancy to young adulthood. They propose that the intimacy of romanticrelationships is based upon experiences that support the development of intimacy innonromantic relationships (in a transactional, transformational process). The qualityof peer experiences in preschool, elementary school, and adolescence was predictedby the Ainsworth infant attachment classifications. The preschool and elementaryschool measures were based on teacher ratings; adolescent measures were peercompetence and capacity for relationship vulnerability, based on ratings from campcounselors, and friendship intimacy, based on analysis of an interview transcript.Ten- to eleven-year-olds who were classified as secure in infancy were more likelyto form a friendship than children classified as insecure in infancy, and those with asecure history were more likely to have friends with a similar secure history. In anintensive analysis of a subset of adolescents (N = 41), those who formed couples hada history of secure attachment in infancy. A prediction to romantic attachment at age21 is forthcoming from this group.

Currently the strongest empirical longitudinal support for continuities ofattachment styles from infancy to adult mental models of romantic attachment comesfrom the work of Grossman and colleagues (2002). Their study followed 49families, with many measures of maternal/paternal sensitivity, parent-child play,child and mother attachment, and child discourse quality, across infancy, 12 and 18months, and 2, 3, 6, and 10 years. At age 16, adolescents were assessed, byprojective stories, for flexibility of response to social rejection by a “romantic”partner. At age 22, the young adults were assessed with the Owens and colleagues(1995) measure of security of current romantic model. Although there were numerousfindings, here we focus only on the prediction of 22-year-old romantic attachmentrepresentation.

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The two strongest predictors of adult romantic attachment model at age 22 in theGrossman and colleagues study were (1) a composite measure of maternal sensitivityfrom infancy to 16 years, and (2) the 16-year-old's flexibility of response to romanticrejection, assessed by projective stories. In the Grossman and colleagues measure, asensitive mother is attentive to her child's communications, interprets them“correctly,” responds “appropriately,” acknowledges her child's feelings, helps herchild know his/her own motives and put them into words, and explains her ownmotives. In addition, the Grossman and colleagues study found that the child'sattachment status at age 6 predicted 22-year-old romantic attachment representation.And infant attachment status at 12 and 18 months predicted 6-year-old attachmentstatus. This latter finding suggests that infant attachment affects 22-year-old romanticattachment in a transformational way, via its link to 6-year-old attachment.Interestingly, the father's sensitive and gentle challenging play, which supported thetoddler's exploratory play at 2 and 3 years, also predicted the 22-year-old's romanticattachment representation. This study is the first to provide a definitive empiricalsupport of the hypothesis that childhood- and infant-attachment patterns are indeedrelevant to the eventual romantic love model of the young adult. The Grossman andcolleagues study emphasizes the concept of maternal sensitivity as the “mechanism”or key operative variable explaining these continuities across the lifespan.

The predictions of Waters and colleagues (2000), Sroufe and colleagues(2002), and Grossman and colleagues (2002) describe transformational trajectories,in which attachment patterns may remain stable, or predictably transform, as afunction of particular contexts such as trauma.

How Affiliation/Intimacy/Attachment is Transmitted across theLifespan: Three Proposed Organizing Principles of Interaction

We focus on three patterns of interaction between mother and infant at 4 months,which have been shown to predict infant attachment at one year, thus organizing thenonverbal implicit dimension of relatedness in infancy. The three patterns are vocalrhythm coordination, facial mirroring, and distress regulation. As we will describebelow, these three patterns continue to mediate affiliation/intimacy/attachmentthroughout life. And as we have shown above, attachment at one year predicts atransformational trajectory to young adulthood. We thus propose that vocal rhythmcoordination, facial

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mirroring, and distress regulation are key organizing principles of implicit relationalknowing, carrying qualities of attachment and intimacy across the lifespan.

Vocal Rhythm Coordination as a Lifespan Organizing Principle ofInteractions

Research on vocal rhythm coordination illustrates the co-construction ofattachment and intimacy patterns across the life span. In social interactions, rhythmitself provides ongoing information necessary to predict and coordinate with one'spartner, so that each can anticipate how the other will proceed (see Jaffe et al. 2001,Warner 1992). We experience some interaction rhythms, perhaps those with whichwe resonate, as “good vibes,” whereas others are experienced as disturbing. Becausea partner's rhythm is assessed in reference to one's own, Byers (1976) suggests thatwe continuously assess an interpersonal rhythmic relationship, a form ofcoordination. Research on vocal rhythm refines our understanding of how partnersproceed moment by moment, how each knows when it is their turn to speak, howeasily the turn is exchanged, how tightly each partner tracks the other's vocal rhythm,and rules for interruption and joining.

Bi-directional coordination in the timing of vocal exchanges, during which eachpartner “tracks” (correlates with) the durations of vocalizations and pauses of theother, have been demonstrated for adults as well as mothers and infants (Beebe et al.2000, Capella 1981, 1991, Crown 1991, Feldstein and Welkowitz 1978, Jaffe andFeldstein 1970, Jaffe et al. 2001, Warner et al. 1987). When speakers coordinaterhythmic patterns such as vocalizing and pausing, they are in fact exchangingimportant information regarding the perceived warmth, similarity, and empathy oftheir interaction. Adult research has continued to show that matching and coordinationof the timing of communicative behaviors facilitate interpersonal attraction, empathy,and social relatedness (see Crown 1991).

A study by Jaffe and colleagues (2001) documents a continuum of 4-monthmother-infant vocal rhythm coordination, ranging from high to low, which predictedone-year attachment outcomes. Midrange coordination predicted secure attachmentwhereas scores outside the midrange predicted insecure attachment. Highcoordination was conceptualized as interactive vigilance, low coordination as anaspect of withdrawal or inhibition. Interactive vigilance

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and interactive inhibition further articulate forms of interactive regulation that can beused in adult treatment. Although currently no longitudinal lifespan data on vocalrhythm coordination exist, we speculate that vocal rhythm coordination is onenonverbal mode of transmission of intimacy and attachment styles across the lifespan.

The coordination of timing patterns is like the music on which verbal content islater superimposed (see Beebe and McCrorie 2003, Beebe et al. 2000, Jaffe et al.2001). Just as important as the words is the way that we talk and coordinate ourrhythms of sounds and silence, which carry dynamic, emotional meanings (seeDissanyake 1996). From infancy onward we coordinate (to varying degrees) with apartner as to when to vocalize, when to pause, and for how long; whose turn it is,when to join in simultaneously, and how to exchange turns. Through expectancies welearn to anticipate the partner's pattern in relation to our own. In so doing we arelearning nonverbal ways of “being with” the other (see Stern, 1977, 1985). In fact,Dissanyake (1996) argues that the mother-infant dialogue creates a fundamentalemotional narrative out of which adult music, language, and poetry can grow.McCrorie (2001) elaborates this argument for poetry with the Jaffe and colleagues(2001) data on vocal rhythm coordination.

Building on these midrange coordination findings, a “balance model” wasgenerated, positing a midrange optimum in both self- and interactive regulation(Beebe and Jaffe 1999, Beebe and McCrorie 2003). In the mid-range, interactivecoordination is present but neither insufficient nor obligatory, and self-regulation ispreserved but not excessive. Optimal social communication and development ishypothesized to occur with flexibility to move between self- and interactiveregulation, yielding relatively optimal levels of attention, affect, and arousal. Foreach partner, operating outside the midrange may index an attempt to cope with adisturbance in the interaction. An excessive monitoring of the partner, at the expenseof self-regulation, defines one pole of imbalance, “interactive vigilance.”Preoccupation with self-regulation, at the expense of interactive sensitivity, definesthe other pole of imbalance, “withdrawal” or “inhibition.”

We thus suggest that timing and rhythm coordination is one key means throughwhich security of attachment is co-constructed: lovers, mothers and infants, analystsand patients all create different bi-directional patterns of vocal rhythm coordination,moment by moment (see Beebe and McCrorie 2003).

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a These different patterns will contribute to different emotional climates and differentattachment security, and they will potentially trigger unconscious fantasies.

A number of other studies allow us to suggest that vocal rhythm coordination is alifespan organizing principle, present in childhood, adolescence, and adulthood.Vocal rhythm patterns in childhood are associated with affiliation patterns (Feldsteinand Field 2001, Welkowitz et al. 1976). Vocal rhythm patterns in adolescencediscriminate autistic vs. normal subjects (Feldstein et al. 1982). In adult speakers,rhythmic coordination alone, without any verbal content, conveys emotionalinformation regarding perceived warmth, similarity, and empathy (Feldstein andWelkowitz 1978, Jaffe and Feldstein 1970, Warner 1988, Welkowitz and Kuc1973). Vocal rhythm patterns in adulthood discriminate dating couples andfriendships (Crown 1991). Vocal rhythm patterns in analyst-patient dyads areassociated with treatment outcomes (Holtz 2003).

Facial Mirroring as a Lifespan Organizing Principle of InteractionsThe capacity to enter into split-second, highly coordinated vocal exchanges in

infancy is paralleled by a similar capacity to coordinate split-second facialexchanges. This capacity is highly adaptive in evolution. Even monkeys participate insplit-second facial exchanges with each other (Chevalnier-Skolnikoff 1976). Theterm facial mirroring originated in psychoanalysis. Winnicott (1965) suggested thatthe precursor of the mirror is the mother's face: when the infant looks at his mother,he sees himself. Using second-by-second microanalyses of videotape and film,research has documented that facial mirroring in mother-infant face-to-face exchangesis very fast, usually split-second. In general each partner affects the other's face, frommoment to moment (Beebe and Gerstman 1980, Beebe and Stern 1977, Cohn andBeebe 1990, Cohn and Tronick 1988, Kronen 1982).

In infancy, maternal facial expression response to infant facial expression, fromsecond to second, predicts one-year infant attachment outcomes and distressregulation in toddlers (Malatesta et al. 1989). Mothers who show a lower, or more“midrange,” degree of facial coordination have secure infants at one year, whereasmothers with high coordination have insecure-avoidant infants at one year. Motherswith disturbances in facial empathy (such as a positive face in response to an infantdistress face) have toddlers who show facial constriction of distress, “holding it in.”

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In the “visual cliff” experiment (Klinnert et al. 1986), one-year-old infants use themother's face to guide their evaluation of danger. Under a glass table sits a “visualcliff,” so it seems that the child might fall. Across the table at the other end is anattractive toy. The child begins to cross, then looks back to the mother. If she displaysa fear face, the child will not cross. If she smiles, the child crosses easily.

Facial mirroring and the coordination of facial exchanges is as relevant to adultsas it is to mothers and infants. It can thus can be seen as a lifespan organizingprinciple of interactions. Eibl-Eibesfeldt (1970) filmed lovers flirting on parkbenches. Because his camera was rigged, seeming to film in a different direction, thelovers were entirely unaware of being filmed. His microanalysis of the film revealedsplit-second responsivity of face, gaze, and head orientation between the lovers.

In studying adults, Ekman and colleagues (1983) found that a particular facialexpression is associated with a particular pattern of physiological arousal. Bymatching the expression of the partner, the onlooker produces a similar physiologicalstate in himself. Thus, in a process of facial mirroring, each is participating in thesubjective state of the other. Furthermore, an internal process (physiological arousal)and a relational process (matching) are inextricably coordinated and are organizedconcurrently.

Facial mirroring occurs largely out of awareness. Dimberg and colleagues(2000) exposed adult subjects to 30 milliseconds of happy, angry, and neutral targetfaces through a masking technique, so that the subjects could not consciously perceivethe face. Simultaneously, subjects were monitored for facial activity by miniatureelectrodes. Despite the fact that the subjects could not consciously perceive the faces,they displayed distinct facial muscle reactions that corresponded to the happy andangry target faces. Thus, positive and negative facial responses can be evoked out ofawareness. In this sense important aspects of face-to-face communication occurs in anonconscious, procedural mode.

Facial mirroring is important in adult treatment. In Heller and Haynal's (1997)remarkable study, “A Doctor's Face: Mirror of His Patient's Suicidal Projects,” onepsychiatrist interviewed patients who had attempted suicide, with one video cameraon each person's face. The psychiatrist's own predictions of which patients wouldreattempt suicide, written immediately after the interview, correctly identified only29 percent of the patients who later made a second attempt. However, amicroanalysis of the facial responsivity

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between the doctor and the patient correctly identified 81 percent of the patients wholater made a second attempt. And it was the doctor's face that was more powerfulthan the patient's face in this prediction. With his patients who would later makeanother attempt, the doctor frowned more, showed more head and eye orientation,more overall facial activation, and increased speech. This study is an excellentexample of implicit relational knowing, operating outside of awareness and outsideof verbal consciousness. The doctor “knew” something in the implicit mode that hecould not access in the explicit mode.

Distress Regulation as a Lifespan Organizing Principle of InteractionsIn Ainsworth's (Ainsworth et al. 1978) seminal work on attachment, distress

regulation in the mother-infant dyad was seen as central. Ainsworth showed thatmaternal unresponsiveness to infant crying differentiated insecure as opposed tosecure attachment. A number of studies have suggested that securely attached infantsexhibit more fuss cry than insecure, suggesting that more frequent crying patterns maybe a reflection of the competence of the infants in communicating distress to thecaregiver (see Bradshaw et al. 1987, Del Carmen et al. 1993; Isabella and Belsky1991, Kiser et al. 1986). Distress regulation in infancy predicts one-year infantattachment. Del Carmen and colleagues (1993) found that mother calm/soothe inresponse to infant fuss/cry at 3 months predicted 12-month secure infant attachment.

Distress regulation is a central aspect of mother-infant interaction (see Beebe2002). The critical issue in the management of infant distress is the capacity that bothinfant and parent bring to soothe and dampen as opposed to escalate infant distress.Temperament of both partners plays an important role. Korner and Grobstein (1977)and Brazelton (1994), among others, have described variations in the neonate'sability to regulate state. By the time infants are assessed in the face-to-face situation,typically 3-6 months, neonatal fluctuations in the management of an alert state havereceded with maturation of the nervous system, and the infant's temperament hasbecome inextricably intertwined with interactive patterns in the dyad. Nevertheless,there are substantial differences in the ability of infants to manage moments ofheightened distress. Some infants become increasingly distressed and the filming hasto be interrupted. Other infants are more “resilient,” able to pull back from adistressed state, calm down, and continue

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to engage and signal the caregiver (see Tronick 1989). These differing patterns arestrongly affected by the nature of the mother's management of distress.

An extreme form of “mutually escalating overarousal,” where each partnerresponded to the other's distress with a reciprocal escalation, each “topping” theother, until the infant vomited, was described by Beebe (2000). When evaluated inthe Ainsworth attachment test at one year, this infant was classified as “disorganized”attachment. In this form of attachment, the infant displays simultaneous approach-avoidance patterns.

Infant capacity for self-comfort, an important form of self-regulation, is seen infingering clothes, skin, an object (strap of the seat), mother's hand, or putting a fingerinto the mouth. Tronick (1989) has shown that infants of depressed mothers arepreoccupied with self-comforting behaviors, attempting to manage distress more orless “on their own.” More self-touch occurs in infants classified as avoidant vs.secure attachment (Koulomzin et al. 2002).

The parent's partial “matching” or “joining” of the infant's vocal distress, with“woe face”; and associated vocal “woe” contours (vocal empathy), but without thefull volume or intensity, is often effective in helping the infant to dampen arousal.Matching the rhythm (but not the volume) of the crying, and then gradually slowingdown, facilitates infant distress regulation (Beebe 2000, Beebe 2003, Gergeley andWatson 1997, Stern 1985). When the infant is in a very dampened state, such asstilling, or loss of tonus with limp posture, partially joining this state, staying ratherstill, waiting, and gently responding to any slight change of posture or headorientation with a gentle matching, can help the infant re-engage (see Cohen andBeebe 2003).

Maternal difficulty in “partnering” infant distress may result from denial of infantdistress, for example, as the infant cries, mother says, “We like this, don't we,” ormother shows positive faces in response to infant distress (see Malatesta et al.1989, Lyons-Ruth 1998). Or difficulty in partnering distress may be associated withthe mother's idealized fantasy that she will be able to protect her infant from alldistress. In the treatment of mother-infant pairs, Beebe (2003) assesses the mother'sapproach to her infant's distress, observing her ability to empathize with the distress,with “woe” face and voice, or by gently matching the infant's distress rhythms to calmthe infant down, or by entering the dampened state.

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Distress regulation in toddlers and middle childhood is associated with attachmentpatterns (Cassidy and Kobak 1988, Marvin et al. 2002). As infants, insecureavoidant children avoid the mother in the reunion of the Strange Situation. Cassidyand Kobak interpret this avoidance as a form of masking of negative affect. Theydescribe the ways that insecure-avoidant children manage their distress by shiftingattention away from the parent, remaining “cool,” polite, and neutral. More overtexpression of anger or neediness might alienate the attachment figure. In childhoodand adolescence, studies of the representation of attachment patterns, or internalworking models, suggest that insecure-avoidant individuals develop biases in theways that information is processed, so that the attachment system is deactivated, oridealized images of self and other are created (Cassidy and Kobak 1988).

Distress regulation in adolescence is associated with attachment patterns. Kobakand Sceery (1988) showed systematic differences in affect regulation associatedwith attachment patterns as measured by the Adult Attachment Interview (AAI), self-report measures, and peer ratings. Whereas the secure group was more resilient, lessanxious and hostile, reporting little distress, the insecure-avoidant (“dismissing”)group was less resilient, more hostile, and more lonely. The insecure-anxious(“preoccupied”) group was less resilient, more anxious, and reported more distress.

We illustrate distress regulation in psychoanalysis with a vignette taken fromBeebe and colleagues (2003, in press). This vignette from a videotapedpsychoanalytic session of a female patient in a three times-per-week treatment, sittingup, can illustrate distress regulation in psychoanalysis, and the contributions of bothpatient and analyst to the success of the distress regulation. This description primarilyaddresses the nonverbal level of the interaction.

The patient was increasingly distressed, gesturing rapidly with her hands,torso leaning forward tautly, face screwed into a pre-cry, speaking tensely.The analyst silently listened, his face very attentive. As the patient'sagitation began, the analyst slightly shifted the orientation of his chairtoward the patient. Both maintained continuous eye contact. As the agitationmounted, the analyst's foot made intermittent brief, rapid jiggles, matchingthe rhythm of the patient's body. He then moved slightly forward in hischair. At this point the heads of both analyst and patient went up insynchronous movement. At each escalation of the patient's agitation, the

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analyst participated, crossing and uncrossing his legs, and nodding his headup and down in rhythm with the patient's movements, each time saying“yes” softly. Gradually the patient began to calm down; the analyst's headmovements became slower. There were several long moments of silence.Then slowly they began to speak to each other.

In this vignette, the analyst participated in the sequence of escalating agitation andcalming down. Although the patient's sequence can be conceptualized primarily interms of self-regulation, presumably the analyst's movements also influenced hermanagement of the arousal. The analyst did not match the patient's level of arousal.Instead, at critical shifts in the patient's arousal (increasing and decreasing), theanalyst “marked” the shifts with ones of his own. The analyst's own self-regulatorymovements revealed his inner state as a response to the patient. His efforts to regulatehis inner state showed the patient that he was with her: these efforts aresimultaneously self-regulatory and communicative to the patient, presumably out ofawareness of both.

How are Qualities of Attachment/Affiliation/Intimacy Transmitted inPsychoanalysis?

Because vocal rhythm coordination, facial mirroring, and distress regulation ininfancy predict one year attachment, and remain operative throughout life; andbecause one year attachment predicts a transformational trajectory to young adultattachment, we propose that vocal rhythm coordination, facial mirroring, and distressregulation also carry qualities of attachment and intimacy in psychoanalysis, asorganizing principles of implicit relational knowing.

In the case of Karen (treated by Lachmann) that follows, we concentrate on theimplicit dimension of relatedness, although both implicit and explicit domains wereimportant in the treatment (see Beebe and Lachmann 2002, for a full discussion ofthe case). Vocal rhythm coordination was used to reach Karen, who began hertreatment with a suicide attempt. Facial mirroring of increments of sadness was alsoused to reach Karen, who was dissociated and remote. Karen's attempts at self-regulation of distress were extreme and unsuccessful, culminating in sleeplessness,list-lessness, lack of desire, episodes of dissociation, derealization, and suicideattempts. Interactive regulation of distress occurred in the treatment of Karen throughthe analyst's facial mirroring of increments of sadness;

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through the analyst's dampening and constriction of his own affective range so as tobe closer to her range; as well as through verbal interpretation of what she was afraidto perceive, feel, wish, imagine, or remember, which facilitated an increased sense ofagency in Karen. For her part, Karen was able to use these interventions to respond,to modulate her distress, and to find alternative self-regulation strategies. Much ofthis work took place in the implicit domain, out of awareness of the patient, and oftenthe analyst.

Clinical IllustrationKaren began her 8-year psychoanalytic therapy, 3 sessions per week, after her first

suicide attempt at age 27. When her then-boyfriend flirted with another woman, shetook all the pills in her medicine cabinet as she watched her actions “from a bird'seye view from a corner of the room.” Her life had been declining since hergraduation from high school, when her parents dragged her from her room to deposither at an out-of-town college. She excelled in some of her courses, and barely passedothers. After graduation, she attended a drama school in England for a year. Upon herreturn to the U. S. she looked for work as an actress, but her severe sleep disturbanceturned her night into day and thus day into night. Unable to mobilize herself, shemissed many auditions, callbacks, and even acting jobs when she did get hired.

Karen found it difficult to speak to me. She began sessions by asking, somewhatmechanically, “What shall we talk about?” I inferred her distress behind heraffectless demeanor. So as not to increase her discomfort, I often responded bysummarizing previous sessions, for example, “Last time we spoke about how messyand dingy your apartment is.” She might then speak about an apparently unrelatedtopic, for example, encounters with various acquaintances. Over a period of time Iwould then label these encounters as leaving her with feelings of abandonment,disappointment, a sense of exploitation, or regret about her withdrawn manner. Icame to understand Karen's opening question as an attempt to orient herself and todetermine whether or not a connection could be established with me. Overtly, Karenhardly acknowledged my presence, although her question, “What shall we talkabout?” did contain “we.”

From the vantage point of the nonverbal, implicit organizing principles, herattempts at distress regulation were extreme, creating an imbalance: She

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was preoccupied with self-regulation in the absence of interactive regulation. That is,efforts to regulate distress, regulation of affect and arousal, were severely impairedas evidenced by her sleep disturbance, listless state, lack of “desire,” and episodesof dissociation. Karen was born shortly after her parents' graduation from highschool. She recalled her parents' nighttime fights and their regret that their futureplans were scuttled by their marriage and Karen's birth. By the time she was 7, Karenhad made a deal with God. She would give up her life if He would stop her parentsfrom fighting. Thereafter she was preoccupied with suicide and suffered from severe,persistent sleep disturbances.

In high school, Karen frequently cut classes because she could not tolerate thenoise made by other students. She would then spend the day studying alone. Duringafternoons and evenings she worked as a cashier at a local shopping mall. In fact, sheworked continuously until the end of her high school years. Since then and until hertreatment was well under way, she had not held a job. By the age of 17, Karen hadformed an intimate sustaining relationship with a fellow student. When heunexpectedly died of a brain tumor, she was despondent. Her parents insisted that sheget over her loss quickly. Instead, she retreated to her room, felt “without desires”and increasingly aimless.

When Karen began therapy, ten years later, these states were still prominent.Although we sat facing each other, Karen looked away from me. Her face wasimmobile. Her voice had no contouring. She kept her coat on. In response to Karen'sextreme forms of self-regulation of distress, I dampened my facial expressions. Evenwhen I spoke to her she did not look at me. Her self-constriction powerfully affectedme. I felt reluctant to jar her precariously maintained presentation. To coordinate ourvocal rhythms more closely, I partially constricted myself, allowing myself to beclosely influenced by her rhythm, and narrowing my own expansiveness to moreclosely match Karen's narrow affective range. Many of these adjustments were madeinitially out of my own awareness. Only after discussing the treatment with Beatrice(Beebe) did I become more aware of them.

I looked at Karen continuously, but I kept my voice even and soft. In my initialcomments I remained within the limits of the concrete details that she offered. I thusaltered the regulation of my arousal, keeping it low. Gradually, her tolerance forpositive, affective arousal increased and I could become more expansive. Our verbaland nonverbal range expanded. She

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was able to talk about affectively more difficult material. Her voice remained soft butwith more contouring. She spoke about social relationships and acting auditions thatraised the specter of competition. She withdrew from these situations lest she drawattention to herself. Initially, these explorations had little effect on her life. Ourdialogue, however, did increase the affective range that she could tolerate in thesessions.

Karen moved from descriptions of her environment, the inanimate world, todescriptions of interpersonal relationships, and to explorations of her subjectivestates. At the same time I also shifted from summaries of the previous sessions toelaborations of her feelings and reactions. Sometimes anticipating her formulaicopening, “What shall we talk about,” I began sessions by asking her how she wasfeeling. Sometimes, before verbally responding, her right upper lip would twitch andconstrict briefly, or her leg would jiggle rapidly. Inadvertently, my face would takeon a more somber quality, mirroring her distress. We came to understand Karen'ssignals as an indication that she was tense and had been feeling moody, depressed, orwithout energy since our last meeting. We focused on her specific reactions andsearched for their context. I detailed nuances of feelings and moods such asannoyance, rebuff, eagerness, enthusiasm, or disappointment. It seemed to me that sheexperienced many emotions as annoying intrusions. After some time, I was able toadd descriptions of Karen as “considering,” “hoping,” “planning,” or “expecting.”That is, I distinguished among categories of affect and time, and acknowledged herauthorship of her experience. I kept apace with Karen's gradually more personalizedcommunications. Nevertheless, her visible discomfort waxed and waned.

We discussed the vagueness that characterized much of her life as indicating whatshe was afraid to perceive, feel, believe, wish, imagine, or remember. My commentswere directed toward facilitating her attempts at self-definition. In this way her prior,almost exclusive reliance on drastic self-regulation of distress on her own throughwithdrawal, depersonalization, and derealization began to shift. Her sense of agencyincreased. For example, as her dread of new situations diminished, she showed awider variation of facial expressions. Occasionally, she smiled and my facebrightened, too. Furthermore, she registered for, attended, and participated in somegraduate school classes. Nonverbal mechanisms played a role throughout Karen'streatment. They interfaced with, amplified, and subsumed the many dynamic issuesthat were explored, such as her dread of alienating her

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mother and the extent to which she sacrificed her health and comfort to maintain herattachment to her. Her suicidal preoccupation, her neglect of her physical well-being,her propensity to disregard physical illness, her social withdrawal and minimumfunctioning in life, her retreat from attention much as she desired it, all converged inher conviction that her parents' life would have been better off had she not been born.

During the first two years of the treatment, Karen missed at least one of her threeweekly appointments and arrived late for the other two. When I gently inquired aboutthis pattern, she told me that it was an achievement that she could get herself to thesessions as often as she did. Toward the end of the second year of treatment, Karenmade a second suicide attempt. I had referred Karen for medication. But fortunately,the unused medication was not at hand. Instead, again she used whatever was in hermedicine cabinet. Following this attempt, I met with Karen and her parents, but theycould not grasp the severity of their daughter's difficulties.

I felt that Karen was still a high suicide risk and to wait to see whether or not shewould arrive for her appointments became very anxiety arousing for me. I needed tofeel less worried. Thus, at the beginning of her third year of treatment, I decided totelephone Karen about two hours before every appointment. I reminded her of thetime of our meeting and told her that I looked forward to seeing her. Within aboutthree to four months, Karen no longer missed sessions. In regulating my distress andin Karen's response, we attempted to mobilize a new interactive pattern.

ConclusionQualities of attachment, affiliation, and intimacy are transmitted in psychoanalysis

in the implicit mode through patterns such as vocal rhythm coordination, facialmirroring, and distress regulation. These are all co-constructed patterns. Usually theyoccur out of the awareness of analyst and patient, as “hidden regulators” (see Coates2002, Hofer 1994), but the analyst's awareness of them can promote therapeuticaction.

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Article Citation [Who Cited This?]Beebe, B. and Lachmann, F. (2002). Organizing Principles of Interaction from Infant

Research and the Lifespan Prediction of Attachment: Application to AdultTreatment . J. Infant Child Adolesc. Psychother., 2:61-89

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http://www.pep-web.org/search.php?whocitedthis=jicap.002d.0061a

Dyadic Systems View Readings... · organizing principles entails the integration of self- and...

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