Mutual attention and joint gaze as developmental forerunners of the therapeutic alliance.

Mutual Attention and Joint Gaze as Developmental Forerunners of the Therapeutic Alliance Bennett Roth This paper attempts to integrate child developmental research and early childhood neural-cognitive development within the complexities of the early infant–mother relationship as described by psychoanalytic theory. Accumulating research evidence for the importance of the complex transition from mutual gaze to joint gaze calls into question the origin and analytic significance of the alliance relationship that emerges from the primary relationship between the mother and child. This paper explores the apparently neglected relationship between the respective theories of the therapeutic alliance of Zetzel, Greenson, and Brenner, and the developmental progression from mutual gaze and joint gaze, upon which important aspects of mental and cognitive development rest. Nonblind infants and children rely heavily on the ability to see in order to learn and form representations ,while trauma affects these dynamics and perception. This issue is particularly relevant given the high incidence of unresolved childhood trauma in the form of neglect, loss, and abuse in those who seek out therapy. Freud’s original conception of developmental phase progression has been unsubstantiated by recent researchers in terms of chronological progression and the receptors through which the infants experience the world. In this paper the author applies specific developmental lenses to this basic conception of the dyadic relationship in psychoanalytic treatment, and will reexamine and redefine both working and therapeutic alliance in the frame of an essential developmental stage of joint visual attention. A clinical example will reveal compromised normal preverbal interactive development, exposing faults in the complex transition from mutual gaze to joint gaze.

The phenomena and complex interpersonal dynamics evoked by one person’s attention (analyst) to another (patient) is fundamental and essential to the psychoanalytic situation, and provides Psychoanalytic Review, 101(6), December 2014

© 2014 N.P.A.P.

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a variety of emotions, fantasies, and expectations that emerge as the central and essential veins of the psychoanalytic experience. This special analytic attention, or “gaze” (to use a metaphor) of the analyst, evokes revealing, regressive experiences of shame, sympathy, hate, anger, admiration, and amusement, or feeling empathically understood, attacked, criticized, or admired within multiple-forming, layered transferential frames. The complex (visual and mental) attention and intention inferred through another person’s gaze and verbal pointing has been the focus of developmental research, and has been recognized as emerging from developmental maturational processes that are hard-wired into the child (Bruner, 2005; Butterfield, 2004): first locating the mother’s face, then inferring her motives, and later developing varieties of interactive joint attention (Eilan, Hoerl, McCormack, & Roessler, 2005; Gergely, Király, & Egyed, 2007; Moore & Dunham, 1995) by the end of the first year of life. Although some aspects of this mutual process have been descriptively defined from a variety of theoretical vantages, there is no doubt that receptivity to joint attention—infant and caretaker simultaneously looking at the same object—is not simply a crucial stage in human social development; it distinguishes humans from some other mammals, and is significantly absent in autistic children (Baron- Cohen, 1995; Butterfield, 2004.) A range of developmental research of infant–mother behavior reveals joint visual attention as an essential building block for later developmental achievements that are comprised of perception, pointing, language acquisition, cognitive skills, and an awareness of sharing a subjective orientation with someone else in a special and necessary form of interpersonal engagement (Hobson, 2005), if not cooperation (Gergely et. al., 2007; Tomasello, 1999) and security (Gergely & Unoka, 2008). Joint visual attention specifically refers to early developmental stages or processes occurring when mother and infant are capable of jointly looking at a third object.1 This interactive event builds crucial elements necessary for the later emergence of important cognitive capacities in the child. Shared or joint visual attention is likely one significant manner in which the infant or child mentally processes sensory and cultural information, and whether initiated by either mother or child, it may be essential

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bedrock for later social learning processes and the acquisition of relatedness (Butterfield, 2004). In this paper this interactive developmental process is described, and the example of a patient who has difficulties with alliance behaviors and animate dialogue will illuminate different impediments in joint attentional behaviors. The clinical material will shed significant light on joint visual attention as a developmental precursor of what is generally referred to in the psychoanalytic literature as the therapeutic alliance, or working alliance. In retrospect, from the vantage point of developmental research on joint attention, it would seem a brilliant, intuitive act that Freud placed his patients on the couch, interrupting the dynamics of mutual and joint gaze, to evoke regression in his patients. In historical fact, he explained that he could not tolerate being “looked at” all day, or being the passive recipient of mutual gaze (Freud, 1913). In the analytic literature, despite Kris’s description of aspects of maternal gaze and Spitz’s (Spitz & Cobliner, 1966) attention to the child’s focus on the mother-s face while breast-feeding, only Weissman (1977) attended to gaze dynamics, describing the treatment of a patient who was deprived as an infant of her mother’s smiling response. His clinical findings of a “shaky, unreliable sense of herself” and the absence of “a sense of personal security” (p. 443) confirm the earlier findings (Omwake & Solnit, 1961) of the treatment of blind children.2 Lacan (1964) linked being gazed upon to the passive experience of being a subject who is valued, while his clinically useful “mirror-stage” remains autocentric and excludes the maternal participation in joint attention on the third object of gaze. A CASUAL EVENT THAT CHANGED MY PERCEPTION

While riding on a cross-own bus, I observed the following interaction between a mother and child. An child, approximately two and a half years old, wearing only one sandal, was sitting within my immediate gaze. Her mother walked over and, looking directly at the stockinged foot, said in a maternal tone, “Where is your sandal?” The child looked at her mother’s eyes to determine the direction of her gaze, and then looked at her own unsandaled foot, where her mother was looking. The child again looked up at

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her mother’s face, and saw that her mother was looking under the seat. Following her mother’s gaze, the child moved her feet and looked at, then picked up, her sandal. She next smiled at her mother, who smiled back. Neither mother nor child noticed my observing. After immediately looking at the mother’s contented face, I thought, “I have a patient who can’t do that with me. . . .” That was a complex alliance interaction between mother and child, with visual and verbal elements. After returning home I began to research the considerable underpinnings of this paper. JOINT ATTENTION

There is considerable research on the developmental capacity of infants joining another person’s visual attention on a “third” element. Developmental researchers describe this as the achievement of “joint attention,” a term that has come to mean triadic attentional engagement in the primary mother–child unit (Reddy, 2005.) From a developmental dynamic perspective, most communication within the therapeutic dyad assumes some reflective capacity to create and use a third physical or mental element to jointly observe the self; this issue is discussed later in this paper. In psychoanalytic practice and theory, accommodation to the significance of research on developmental stages has been both ongoing and conflictual. It is generally understood that as development goes forward, behavior and psychic structure become reorganized at successively more complex hierarchical levels (Coates, 1997). For example, studies of separateness (Mahler, Pine, & Bergman, 1973) and attachment (Bowlby, 1951, 1969, 1973) identified the primordial human sharing situation as the primary root for the emergence of the separate object/self in the development of self-reference and of the capacity for both interpersonal boundaries and complex thinking. Emphasis on early, dyadic, mutual engagement as central to psychic development has been only partially adopted by psychoanalytic theorists such as Greenacre (1967) and A. Freud (1965), although the emergence of an independent, related, yet safely attached individual has become a psychoanalytic ideal. Greenacre (1967) presciently


drew attention to “any factor” that impairs the mother–child relationship as being the flawed foundation of object relationships and of damage to the early ego with special reference to the development of a sense of reality and the early start to a sense of identity. Earlier, A. Freud (1965, p. 286) speculated that early trauma affected the sequential unfolding of libidinal phases, tying trauma to disruption of libidinal phase development. Early therapies of blind children stressed the child’s struggle to attain stable self- representation and a stable inner representation of the caretaking mother without visual corroboration (Omwake & Solnit, 1961). Currently, despite the increasing research in child and infant development, certain basic psychoanalytic ideas and definitions remain embedded in earlier analytic concepts, while observation of infant and child behavior likely will set limits on psychoanalytic theories of child development (Fonagy, 1996) and shift attention to the developmental origin of disturbances in social communication and interpersonal interaction (Stern, 1985). There may be no simple resolution to current development research and clinical psychoanalytic theory, and likely this outcome will be dependent upon one’s individual psychoanalytic model and clinical experience. For my current purpose I propose that Zetzel’s (1966) conception of the therapeutic alliance and Brenner’s (1955, 1979) classical ideas on the same concept can be viewed as referring to different developmental models and outcomes that imply very different developmental progressions of internal psychic structures (Shane, 2000). Within these disparate models, long-standing controversies exist whether a basic maternal transference is at the core of all analytic attachments and possible progress, and, further, whether good-enough mothering is essential for the psychic abilities required to maintain a working therapeutic alliance. THE CONCEPT OF THE THERAPEUTIC ALLIANCE RECONSIDERED FROM A DEVELOPMENTAL PERSPECTIVE

The quality and depth of interactive mental “work,” “containment,” and partnership are processes that are fundamentally important in psychoanalytic treatments. Such complex interactive process

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variables are difficult to define and are implied in the broader discussion of working and therapeutic alliance. Initially Freud cautioned that in order for treatment to begin the analyst must establish “rapport” with the patient (1912) and ally with the ego of the person undergoing treatment (1937) to enable the patient to become an active “collaborator.” The concept of the therapeutic alliance is best considered a process construct that is thought to make the analysis move forward interactively and, although focused on the patient, is perceived quite differently by each of the two participants (Abend, 2000). Whereas Erikson (1963) offered the concept of “trust” as an umbrella for therapeutic work, Stone (1961) offered a two-pronged dynamic definition of the alliance. Stone argued that the patient regressively seeks not only the primal mother, but also the “secondary” mother, a figure that fosters growth through separation and the acquisition of understanding, knowledge, and effectance. According to Zetzel (1966), a therapeutic alliance precedes analytic processes and is both different and distinct from the emerging transference neurosis. This alliance is essentially, in her view, a recapitulation of the very early (secure) relation between mother and infant. In her basic understanding, as an infant turns with expectant faith to its mother for recognition of that infant’s needs and response, so does a patient turn to his or her analyst. An analyst, in this view, must be like a good mother, with “intuitive adaptive responses” (p. 97) to each patient’s needs and anxieties. Thus, “the initial stage of analysis involves achievement of a special therapeutic relationship leading to a new generative ego identification” (p. 92), that is, an identification, a trusting alliance with the analyst who is attending and responsive to the patient. Whether this is described as a developmental precondition for a trusting alliance (Erikson, 1963) a part of the early transference, a nonverbal holding environment (Winnicott, 1965), or an essential, early element of an alliance appears to be a matter of theoretical perspective. Greenson’s (1966) concept of therapeutic alliance—he prefers the term working alliance—essentially corresponds with Zetzel’s (Greenson, 1965,1966, 1967.) Like Zetzel before him, Greenson (1965) distinguished working alliance from transfer-


ence neurosis. The latter, he said, must be analyzed for analysis to be successful, while the former must be established for the latter to be analyzable. In other words, basic maternal trust is both essential to and precedes analytic processes for the patient. For Brenner (1955, 1979; Arlow & Brenner, 1966), both therapeutic alliance and working alliance refer to dynamics of the transference that, in his view, neither deserve a special name nor require special treatment, while, critically, Meissner’s (1996) review of the concepts concludes the concept of transference has had its meaning so broadened that its effective meaning in analytic work has faded. The related topics of frustration/gratification in the transference, the analyst’s personality and requirements of patients, and the intermingling of fantasy, conflict, and reality in the analytic process complicate all efforts to distinguish therapeutic alliance from transference dynamics (Hoffer, 2000). Recently, Shane (2000) concluded that while the notion of the alliance survives, it apparently vaguely refers to the “fit” between analyst and patient, and helps to distinguish between the real and transference relationships in treatment. Such distinctions are even more troublesome for the treatment of patients in the borderline spectrum and those with severe narcissistic disorders who, as De Johnge, Rijnierse, and Janssen (1991) pointed out, may require “a reliving” of the earliest preverbal forms of functioning, including the earliest preverbal period in which the return of regressive elements of the very early joint relationship between mother and child is both fraught and essential. Such “difficult” treatment is frequently seen as an analysis of developmental arrest (Nagera, 1966), offering an archaic-mind or deficit model of the patient, which includes a model of ego and superego malformation due to developmental trauma or de viations, as Greenacre (1967) anticipated. Adler and Buie (1979, p. 85) asserted that for such patients the capacity to form a therapeutic alliance is a major therapeutic achievement, and this can be interpreted in various ways: that these difficult patients are then ready for analytic treatment or that trust allows a new working partnership. The historical difficulty in distinguishing transferential and nontransferential elements in the dynamics of the working or

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therapeutic alliance remains a complex issue. One solution is to discard the notion completely, but that creates a vacuum of meaning concerning the exact interactive “work” taking place in psychoanalysis. While the classical theoretical position focuses almost exclusively on the patient’s mental and emotional capacities for analytic work, the subtleties of variations in meanings of the concepts seem to evolve from one-person and two-person emphasis in the analytic situation (Shane, 2000). My own view is that what is referred to as the patient’s “alliance” is composed of a number of different dynamic elements and ego capacities—transference, fantasies, subjective memories, developmental history and projections of self, and awareness of one’s experience with the significant capacity to verbalize that experience—and these capacities are not a cohesive unit. In addition, there is the analyst’s capacity to “contain” these events, to mark them verbally when necessary, and to make sense of them in a manner tolerable to the patient. Subtle shifts in meaning of the concept of the alliance by varying analysts likely represent a preferential focus on one or another of these qualities, elements, or dynamic veins of interaction that are emphasized in the patient–analyst interaction. The recent attempts to expand the alliance into a vague and somewhat elastic perspective of “the third” may also be viewed as an attempt to broaden the concept of the alliance to dynamics occurring within the analytic dyad in which the analyst is also a psychic contributor, creating an interactive context within which interactive “knowing” and reflective awareness emerges (Aron, 2006). As generally conceptualized in the nonrelational model, the therapeutic alliance requires separate ego functions or differing capacities and functions in both participants, among them the capacity for self-observation, the capacity for complex psychic experiences, and the capacity to verbalize these experiences. My current focus is on one distinctive element of the “alliance,” of the patient’s joining with the observing and synthesizing functions of the analyst. This capacity of the patients to observe different aspects of their self and self-experience while part of the analytic dyad is understandable as a mature reflective aspect related to the concept of joint perception. However, the dual interactive activity of the minds of the pa-


tient and the analyst, including analytic activity derived from the unique analytic set-up and the “basic requirement,” can be conceptualized as a distinctly different “third element.” My dissertation (Roth, 1973) established another model for examining that “third” relationship, an analogical model. In this model, analyst and patient are in a unique relationship, in which a dynamic and unique third entity is formed, a product of both participants’ psyches at any given time. It follows that all analytic events and processes are a unique product of that dual construction and are transformed into “veins” of understanding of the products and created relationship. This representation of the analytic dyad as an analog model allows a different and complex level of understanding of the dynamics of that relationship, while creating a distinct third element. The products, impact, and singular focus on the responsibility of the patient is an unnecessary denial of the “jointness” of the combined relationship, while a focus on the analytic relationship and work excludes the unique “third” creation that is an analog.3 Both those who value the concept of the alliance and those that find it problematic fail to distinguish the unique products of the two psyches’ encounter in creating an “analysis.” The analog model expands the conceptual space of the analytic process and does not diminish the role of either transference or unconsciously organized events in the analytic encounter; rather it locates these elements as a psychic “link ‘ or avenue of influence in the interactive field. In a current psychoanalytic context, mutual attention refers to a two-person event. Joint attention originally referred to an infant and caretaker’s coordinated attention to a third element, a coordinated and patterned triangular event in which the two participants observe another element together, which likely is one developmental forerunner of reflective attention. Both mutual and joint interactions are dynamic, with emotions, information, and interactive anticipatory signals exchanged, although joint sightings generate additional interpersonal separateness. In the following I apply specific developmental lenses to this basic conception of a dyadic analytic relationship, and reexamine and redefine both working and therapeutic alliance in the frame of an essential developmental stage of a joint visual reference. This ear-

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ly, exquisitely interactive relationship between the mother and infant, initially hard-wired in the child, is fundamental to the social embeddedness of the emerging mental capacities of the child’s mind and the child’s cooperative and independent looking away from the interactive aspects of the primal dyad. It seems clear that analytic therapy can be understood to be built upon the developmental acquisition and dynamics of these two forms of mental attention referred to in the literature of developmental research: mutual, or dyadic attention, and triadic attention. MUTUAL ATTENTION

Mutual attention arises developmentally between infant and caretaker through an emerging or sharing of a subjective orientation with someone else (Tomasello, 2008, p. 207). It is founded on early developing neurocognitive capacities of the infant to recognize and later identify with the bodily expressed attitudes (particularly face and eyes of the caretaking other): a special form of interpersonal engagement. Mutual attention involves the communication of feelings through gestures and facial expressions that emerge in the early infant–mother mutually responsive relationship. The rhythms and responses established within the infant– mother dyad in eye gaze, reciprocal speech and sounds, gestures, movements, and mutual mirroring form the “glue” of attachment. By the end of the first year of life, the infant has become aware of the potential linkage between his or her own self and other familiar persons’ attention. The interpersonal coordination of attitudes is critical between mother and child (Hobson, 2005), as actions alone are not sufficient for “identification” and “representation and recognition” to take place. Sometime around the first birthday, most infants begin to engage in sustained episodes of attending jointly and following their caretaker’s gaze to other elements in their environment. By eighteen months, most children are engaged in full-blown cued episodes of joint attention (Jaffe, Beebe, Feldstein, Crown, & Jasnow, 2001). As Bruner (1977) first summarized, joint attention “sets the deictic limits that govern joint reference, determines the need for a referential taxonomy, establishes a need for signalling intent, and eventually provides a


context for the development of explicit predication” (p. 287). After thirty years of developmental research, Bruner (1995) added that questions about how infants and toddlers “come to know about other minds or how they come to realize that other minds know theirs” are entering the discussions (p. 1). Such question are now relevant following the writings and research of Fonagy, Gergely, Jurist, and Target (2002), with the awareness that some form of interiorizing representation or mentalization is inferred in the infant–mother episodic interactions between mutual to joint perception. This important transition to joint triadic visual attention has some vital significance for the origin of the working/therapeutic alliance in which there is a shared perception: that is, between self and observing other. Prior to the development of joint attention, objects are thought to exist for the infant as “things of action” to which the child responds. A fundamental mental transformation begins to occur when joint attention sets in—the infant begins to transform perceived objects as (infant) ego-distant things of awareness or contemplation, and likely (it is believed) a correlative distancing and/or distinction of the infant from the mother and other people takes place. When the child targets the object to another person, usually by pointing or gesturing accompanied by vocal sounds or gaze, he or she eventually must take into account the existence of another perspective. This both entails a distancing of the infant from the objects in reality and further affects the emergence of mental regulation. These early cognitive steps are crucial to the internal development of both a mind- independent world and a mind capable of observing and being reflected upon. Eilan (2005) describes the evolution of joint attention as follows: There is an object that each subject is attending to, which implies a causal connection between the object and each subject, and awareness of the object by each subject: • There is a causal connection of some kind between the two subjects’ acts of attending to the same object. • The two subjects’ experiences exploit their understanding of the concept of attention.

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In joint attention each subject is mentally aware, in some sense, of the external object that is present to both subjects; the fact that both are attending to the same object is mutually manifest, and their “feeling” about the object is likely manifestly different. While this is the start of an essential developmental process, the interpersonal ingredients that deepen this transaction are iteration and the expression and direction of emotion toward the other objects in the triangulation of joint attention. Later rich developmental stages that serve functional and developmentally necessary communicative links between mother and child are dependent on the acquisition, awareness of, and deployment of joint attention (Butterfield, 2004). THE CASUAL EVENT REEXAMINED

The witnessed sandal event on the bus is an example of a later stage in development in which dynamics of joint attention and declarative language are cooperatively present, but not fully developed in the mother–child dyad. In the scenario the mother notices that the child’s sandal is not on her foot and is under the seat. She secures the child’s visual attention by her voice, using questioning words and asking where the sandal is. Her verbal behavior is best functionally described as verbal pointing through use of a question, while giving a visual cue by looking at the shoeless foot, and asking a question about something not being present. The child, in response to the question, does not look at her own foot, but looks at the mother’s eyes/face, attempting to discern what the mother’s intention is and what she is looking at, perhaps not fully understanding the mother’s words. She follows her mother’s gaze and then looks at her foot without a sandal. The child then looks back again to the mother’s face, not initiating independent action by looking under the seat, but looking instead for the mother-as-helper to apply or cue a solution to the verbal and visual problem. In this interaction regarding the sandal, the dynamics exhibit both joint attention and individual attention. The child seeks information from the mother, and receives it by following where the mother is gazing, then joins her gaze to see, recognize, and then find the missing sandal and her


own foot without the sandal. The mother’s initial question is answered by a complicated interaction between evoked joint gaze and independent gaze. The mother’s initial use of language and looking created a scenario of teaching about questions, being aware of something not present, and, at each level of verbalization, the child seeks to join the mother’s gaze to find the meaning of her words, her intention, and the problem’s solution. At the end of the scenario there are smiles and “confirming” glances of approval and understanding that are mutual (Weissman, 1977). Clearly, the sandal incident indicates a complex social solution that is dependent on verbally evoked joint attention. Human children without this capacity fall into a state of grievous pathology (Baron-Cohen, 1995, p. 11), unable to read social intent in themselves and others and unable to form cooperative actions. In summary, developmental research clearly reveals that infant attention emerges through developmentally timed internal architectural maturating best understood as a diffuse awareness that becomes focused as the infant’s brain matures in safety, rather than as a discrete act or discovery. Three kinds of participations, or mutuality in engagement, may form the basis of a growing and expanding gyre of interactions—between the infant-self and caretaking others, between the infant-self and the actions of the self, and between the infant-self and a distal object. The infant-self may present itself to inner attention through the caretaking actions of the other in response to an emerging reaction to the other’s attention to body parts, self-actions, or discomfort. In the following clinical material, keeping these developmental distinctions in mind, it will become evident to the reader that there are interactive faults in the described patients’ acceptance of the therapist’s attention to their mutual behavior through spoken words and self-awareness. There are likely developmental linkages that will need to be made between the early development and dynamics of joint attentional states and the subsequent emergence of the capacity to recognize and orient to the mental life of others, to be aware of one’s own intentions and behavior, and to experience empathy or understanding as an intentional act from a joint observer. In a complex series of articles, developmental linkages

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involving mirror neurons and language used in understanding other people’s minds have been explored.4 THE PATIENT

The patient that changed my way of thinking, Ms. M, is difficult, irritable, and interpretation-resistant, with a mixed diagnosis of affective and cognitive problems. I am her second analyst and, over the course of years of psychotherapy and analysis, she has made considerable progress in her social and professional life through a “barely working negative transference.” While her early years were marked by many cumulative traumas, those are not relevant to this paper. Affect regulation and self-awareness have improved, as compared to the affectively explosive early phase of treatment, but remain a continuous challenge. My words and ideas—whether used as surface description, a deeper interpretation, or a clarification of her behavior, manner, gestures, or emotion in the room—are either ignored, immediately eliminated from her awareness, or externally assigned and described in another person. For one example, she is frequently eight to fifteen minutes late for sessions, and through the years has offered repetitive surface explanations ranging from the naïve “I’m running late today” to “I had to give a friend something.” She is equally unaware of time at the end of the session, and I often interrupt her talking to establish a time boundary. Any efforts to increase her awareness of “time” lead nowhere, and so I am forced to accept her behavior and explanations. Through the course of this treatment she has secured a Ph.D. in a helping field and had three children. When the children were small she would often bring them to sessions, and I became aware she did not posses a “mother’s” singsong babble, but rather spoke to them in almost an adult manner. She frequently expresses worry about the children’s behavior or accomplishments, but there is a general absence of maternal empathy in her tone; she instead has a harsh self-blaming attitude toward herself or her behavior. Life as a child in her family of origin was reported as filled with dramatic and chaotic events, particularly around dinnertime, along with emotionally explosive separations that centered about


her alcoholic mother and a bulimic, brilliant older sister, and a house filled with assorted grandparents in physical and mental distress. In therapy sessions she frequently responds to intense transference fantasies with accusations that I am “exactly like” her mother and unable to understand her. Our dialogue is frequently disrupted: She loudly talks over me, becomes belligerent, or acts as if I have not said anything after I have made a comment or a suggestion; although agitated, she always remains seated in the consultation room. Any remark I make to “events” within her mind, or reflections about her behavior in therapy, or any emotion she reveals in treatment are only recognized outside of herself in other persons. Only well into the treatment, when she was sitting up and facing me, did I recognize that when she talks of these displaced events she “averts her gaze” by directing her eyes downward and to her right. Her action disrupts “mutual gaze,” and she continues to look away to her right as she speaks. Earlier attempts to bring this behavior into the therapeutic discourse through various naming procedures have failed to engage her attention or any dialogue. Among these attempts were the following comments: “When I talk about you, you talk about someone else.” “You cannot take in what I say to you about you.” “You need to control what you take in.” “You can only see what I say outside yourself.” “You place what I say outside and only then can recognize it.” “You need to control the interpersonal distance.” “Try and stay in the room with me when I talk to you about you.” “You do not find what I say useful to you and spit it out.” “I don’t hear that you use any idea or word I offered to explain your action, feelings, and events.” “You can’t use my language because it represents leaving your tie to your mother.” All these remarks have had limited or no success, and over time the behavior continues with only slightly less intensity. At the same time her “life” outside of the treatment has been mostly more successful. In a recent session, when I focused specifically on her gaze and her constant looking away, she was able to respond immediately, openly, and easily, stating that she believed I wanted to punish her with my remarks and that she was sure, without then looking at me, that I was angry at her. I suggested that “with her eyes

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down it was as if she expected to be hit, maybe with words.” She continued with relevant associations, saying that she always “scanned the other’s face to determine what she could say,” and that’s why her first therapist said she had a false self, because she couldn’t say what she thought. I said, “You weren’t looking at me,” and I thought, but did not say, “I am an other!” After some silence she said, “I always checked my mother’s alcoholic face to see if she was paying any attention to me or was in her own world. I wanted to scream, ‘Here I am! Pay attention to me!’” This memory I understood to reveal that her mother was not cued to return her gaze when she looked at her. Looking away from eye contact with me was a paradoxical defense against and reenactment of her fantasy and emotions in response to being ignored. (When she was not looking at me, I thought that “she doesn’t know what she is thinking and feeling—yet she believes she knows what I thought and felt.”) THE IMPORTANCE OF INTERACTIVE JOINT ATTENTION

Every psychoanalyst is confronted by the question of how it is possible for early, necessarily presymbolic experiences to emerge and be understood in a psychoanalysis (O’Shaughnessy, 1984). From a developmental perspective, the early vulnerable infant-self is the first receptive target of the primary caretaker’s attention. This primordial experience provides a framework for other forms of attention to the emerging self and to ideas about other objects that become complex representations. Infant responses to the caretaker and attempts to direct attention to the self, to actions of the self, and independently to distal targets may initiate and form the initial cooperative basis of an expanding understanding: between the infant self and caretaking other, between the self and actions of the self, and between the self and an inanimate object. These states may reappear in the treatment of certain patients in the transference situation. As stated metaphorically by Fonagy (1996), the child finds his or her self in the gaze of the mother, and some patients need find themselves in their analyst’s gaze. While all social engagements emanate from mutual gaze, all behavior cannot be understood in terms of joint or mutual gaze,


as additional emotions are bound up with the attention from a primary other. Starting at about two months, these basic emotional reactions to attention are not only a crucial indicator of the maturing infant’s understanding of its caretaker’s attentionality, they also serve to signal this understanding to the caretaker. These basic emotions that arise most powerfully in (primary) mutual attention and when eliciting attention from caretakers will mediate all further understanding of forms of attention. This shared attentional focus and gaze not only reflect on the capacity for informational exchanges and strategies, but also allow the parent/caretaker to observe and monitor moment-to-moment changes in “the state” of the infant (Fonagy et al., 1995; Jaffe, Stern, & Perry, 1973; Kita, 2003). The complex mutual communication interaction between mother and maturing child, vulnerable to disruption from either participant, can also signal failures in development of crucial interactive maternal functions and stable attentive relationships. Such failures will affect the child’s emotional states and acquisition of an essential capacity for both mutual attention and joint observation, upon which other cognitive abilities depend. On theoretical grounds, there is good reason for thinking that gaze-following is not only an important early component of language acquisition (naming), but is likely a basic component in the therapeutic alliance. The early ego-representational failures that reappear in the treatment alliance can be understood as emerging from failures in mutual and joint attentive behaviors. The clinical material reveals forms of developmental failures of joint attention. THE SIGNIFICANCE OF DYNAMIC JOINT ATTENTION

There are a number of developmental vantage points from which to discuss this patient. One place to focus seems to be exploring the dynamics of gaze: M responds to my declarative interventions by looking away from me, or gaze aversion, glancing to her right and down, disrupting mutual eye contact. Gaze has its own distinct dynamics; sclera gives perceptual information concerning the directional gaze of another person’s eyes, and seeing the sclera is usually associated with fear, while looking down may indi-

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cate deference or shame. Often when M did not look down and looked at me with eyes wide open, she often spoke over me, as if to drown out my words, a likely revenant of or strategy from repetitive verbal arguments, or a defense against shame. Although it was difficult to determine exactly who the interactive argumentative players in her past were, and from what developmental time, it was clearly a complex enactment. The declarative and framing nature of my words offered no element that could jointly be attended to or agreed with, and she resisted the various proto- imperatives to direct her attention to her own behavior when gazing and attending to me. While often clinically viewed as hypervigilance, it is also a basic form of disruption in the dialogue, more directly signaling a deficit in early child–mother joint attention. By attending only to her gaze, I elicited significant collaborative material that, while attributed to a later developmental time, revealed that her “sense of her mother’s attentionality” was permeated with her mother’s lack of availability, her watchful response to her mother’s absence, and her hurt, rage, and withholding speech. From a perspective of mutual attachment gaze, her earliest form of secure mutuality was damaged, and in its place were projections of both her self-punishing remarks and a memory of her mother’s inability to make emotional/visual contact. Shortly after her revelation in that session, she surprised me by being aware of time and saying “the session is over,” as she started to get up. I responded, “I am the guardian of the time, what is going on that you want to leave?” (My looking at you?) She sat back down and she sobbed while covering her eyes with her hands. I asked her if she could look at me and cry, and her reply was ‘that would cause me too much pain.” Thus, another meaning of her looking down emerged: When experiencing psychic pain, she could not safely seek or attempt a mutual gaze, as she could not imagine a soothing gaze in return. SUMMARY DISCUSSION

Psychoanalysts have struggled to incorporate developmental research into psychoanalytic theory, establishing the critically im-


portant role of early childhood development and the vicissitudes of the early infant–mother relationship. The shift to direct observation and research of children creates an enormous challenge to the existing system of psychoanalytic interpretation because it introduces much more information and complexity to child development. In this framework, knowledge of normal processes in development is required to facilitate understanding of the processes of pathological development and, conversely, the understanding of abnormality is thought to assist in the discovery of normal developmental processes (Fonagy, 1996). Developmental psychologists have provided an array of valuable data about the basic emergence of cooperation, imitation, perception, and language in the early mother–child unit and the capacity for recognition of emotions in oneself and others. Unfortunately, such valuable information lacks a strong unifying theoretical background and fails to impart practical knowledge that can enable psychoanalysts to reliably understand joint behavior in the analytic setting. In almost all psychoanalytic textbooks and articles, discussions of the therapeutic alliance is treated as a unified concept, when it is best considered as a highly variable composite of differing formulations. Cooperation as well as joint intention and attention, not to mention analysis of regressive states as a response to alliance failures, are almost totally ignored. One current fallback position appears to be the vague idea of mentalization, a communicative process that is difficult to apply to infants and young children. The ability to mentalize, that is, to perceive and communicate mental states such as beliefs, empathy, and desires, requires clarification. Fonagy’s d efinition of mentalization is also quite different from the original neuropsychological one that refers to a biologically prepared mechanism to help engage in spontaneously sensing and reading human behavior—our own and others—mostly without conscious effort (Frith & Wolpert, 2004). As the infant interactively develops, joint gaze in turn influences and enhances the developing mentalization capacity of the infant to emerge from the primal holding environment with self- directive, interactive, and self-reflective skills and language under the mother’s shielding protection. It seems clear that analytic

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therapy can be understood to be built upon the developmental acquisition and dynamics of these two forms of mental attention referred to in the literature of developmental research: mutual, or dyadic attention, and triadic attention. From a psychoanalytic perspective, the turning toward the mother that Zetzel (1966) described as the initial part of the therapeutic alliance, and the two- pronged alliance described by Stone (1961), have as their ignored developmental vehicle the crucial establishment and continuous use of mutual and joint visual gaze between mother and child. Attending to gaze and joint problems of perceptual attention embedded in the analytic dialogue may not account for all the dialogic problems of so-called difficult patients; however, it will prompt accessibility to these subtle, disrupted, conjoined events, and adds powerful dynamics to therapeutic treatment. The theoretical challenge psychoanalysts now face is to outline a theory of psychological development in which imitation, mutual and joint perception, and language acquisition and use are conceived as the initial dynamic setting from which development proceeds. The human infant’s development is not as organized as Freud advanced, and psychoanalytic theories and therapy strategies must account for the interaction of neurobiological inheritance with ongoing development. NOTES

1. The patient’s emergence as a jointly perceived “third object” deserves to be examined separately, in a future paper. 2. Without vision from birth the child has considerable difficulty in transforming perceptual experiences into mental representations, “with a primary failure to perceive the loving and angry mother as the same person. They not only depend on sound they show fear of their own aggression” (Omwake & Solnit, 1961, p. 401). 3. The analog model is given A as analyst and B as patient. Thus A: B creates C prime. C is a unique and dynamic construct of A: B. 4. See, for example, the series of research by A. Melzoff (2005).

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The Psychoanalytic Review Vol. 101, No. 6, December 2014

Joint attention without gaze following: human infants and their parents coordinate visual attention to objects through eye-hand coordination.

The concept of the therapeutic alliance.

Harnessing the potential of the therapeutic alliance.

The lasting impact of the therapeutic alliance: Patient-oncologist alliance as a predictor of caregiver bereavement adjustment.

Therapeutic aptamers: developmental potential as anticancer drugs.

[Relationship between defense mechanism and therapeutic alliance].

Trauma group therapy: the role of attachment and therapeutic alliance.

Palliative Care and the Family Caregiver: Trading Mutual Pretense (Empathy) for a Sustained Gaze (Compassion).

Obama cares about visuo-spatial attention: perception of political figures moves attention and determines gaze direction.

The effect of central vision loss on perception of mutual gaze.

Therapeutic alliance in videoconferencing psychotherapy: a review.

Working memory load disrupts gaze-cued orienting of attention.

Therapeutic alliance in the personal therapy of graduate clinicians: relationship to the alliance and outcomes of their patients.

Use of technology for note taking and therapeutic alliance.

Eye gaze triggers reflexive attention shifts: evidence from lateralised ERPs.

Multisensory integration and attention in developmental dyslexia.

Client characteristics as moderators of the relation between the therapeutic alliance and outcome in cognitive therapy for depression.

Object representation quality, therapeutic alliance, and psychotherapy process.

Labeling, attention and perception, a developmental study.

The Role of Global and Local Visual Information during Gaze-Cued Orienting of Attention.

Joint attention, shared goals, and social bonding.

TRPV4 as a therapeutic target for joint diseases.

The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome.

Selective Medial Prefrontal Cortex Responses During Live Mutual Gaze Interactions in Human Infants: An fNIRS Study.