Mutual Attention

Abstract There is a growing tension between the findings of child developmental research and classical psychoanalytic theory. Accumulating research evidence for the importance of the critically important role of early childhood neural-cognitive development and the complexities of the early infant-mother relationship significantly stress the importance of the early pre-verbal experiences and highlight how infants learn. The infants’ evolution from mutual gaze to joint gaze emerging from the primary relationship between the mother and child requires re-examination of the components of the analytic alliant relationship. This paper explores the neglected relationship between the theories of the therapeutic alliance by Zetzel (1966), Greenson (1965,1966, 1967) and Brenner (1955, 1980), and the developmental progression from mutual gaze and joint gaze, upon which important aspects of mental and cognitive development rest. Non-blind infants and children rely heavily on the ability to learn by seeing in order to learn while childhood trauma regularly affects the dynamics of 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 psychoanalytic therapy. Mutual or bi-directional patterns of gaze that arise in the mutually sensitive micro-behavioral paths of interactive communication within the mother-child dyad are subsequently re-enacted in the therapist-client relationship.  In the following a specific developmental lens will be applied to this basic conception of the dyadic relationship in psychoanalytic treatment that will require a reexamination and redefinition of both working and therapeutic alliance in the frame of an essential developmental stage of joint visual attention. Clinical examples presented reveal compromised normal pre-verbal interactive development with faults in the complex transition from mutual gaze to joint gaze. (The patient’s emergence as a jointly perceived “third object” deserves to be examined separately.) References Abend, S. (2000). The problem of the therapeutic alliance. In S. Levy (Ed.), The therapeutic alliance (pp. 1-16). Madison, CT: International Universities Press. Adler, G., & Buie, D. H., Jr. (1979). Aloneness and borderline psychopathology: The possible relevance of child developmental issues. Int. J. Psycho-Anal., 60, 83-96. Arlow, J., & Brenner, C. (1966). The psychoanalytic situation. In R. E. Litman (Ed.), Psychoanalysis in America (pp. 23-43). New York: International Universities Press. Baron-Cohen, S. (1989). Perceptual role-taking and protodeclarative pointing in autism. British Journal of Developmental Psychology 7, 113-127. Baron-Cohen, S. (1995a). Mindblindness: An essay on autism and theory of mind. Cambridge, MA: MIT Press. Baron-Cohen, S. (1995b). Eye direction detector (EDD) and shared attention mechanisms (SAM): Two cases for evolutionary psychology. In C. Moore, P. J. Dunham & P. Dunham (Eds.), Joint attention: Its origins and role in development (pp. 41-59). Hillsdale, NJ: Erlbaum. Bowlby, J. (1951). Maternal care and mental health. Geneva, Switzerland: World Health Organization. Bowlby, J. (1969). Attachment and loss: Vol. 1: Attachment. New York: Basic Books. Bowlby J. (1973). Attachment and loss: Vol. 2: Separation, anxiety and anger. Int. Psycho-Anal. Lib., 95:1-429. London: The Hogarth Press and the Institute of Psycho-Analysis. Bordin, E. S. (1976). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice 16:3, 252-260. Brenner, C ( 1979) Britton, R. (1992). Keeping things in mind. New Library of Psycho-Anal. 14, 102-113. Bruner, J. (1977). Early social interaction and language acquisition. In H. R. Schaeffer (Ed.), Studies in mother-infant interaction (pp. 271-289). New York: Academic Press. Bruner, J. (2005). From joint attention to the meeting of the minds: An introduction. In N. Eilan, C. Hoerl, T. McCormak, & J. Roessler (Eds.), Joint attention: Communication and other minds. Issues in philosophy and psychology (pp. 1-14). New York: Oxford University Press. Butterfield , G. (2004) Joint Visual Attention in Infancy In Bremner G and Slater A. Theeories of Infant Development. P 317-354 Blackwell Publishing Malden MA De Johnge, F., Rijnierse, P., & Janssen R. (1991). Aspects of the analytic relationship. International J. Psychoanalysis 72, 693-707. Eilan, N. (2005). Joint attention, communication, and mind. In N. Eilan, C. Hoerl, T. McCormak, & J. Roessler (Eds.), Joint attention: Communication and other minds. Issues in philosophy and psychology (pp. 1-33). New York: Oxford University Press. Eilan, N., Hoerl, C., McCormak, T. & Roessler, J. (Eds.). (2005). Joint attention: Communication and other minds. Issues in philosophy and psychology. New York: Oxford University Press. Farrell, E. (2000). Lost for words: The psychoanalysis of anorexia and bulimia. New York: Other Press. Freud, S. (1958a). The dynamics of the transference. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Volume XII, pp. 99-108). London: Hogarth Press. (Original work published 1912) Freud, S. (1958b). On beginning the treatment. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Volume XII, pp. 121-144). London: Hogarth Press. (Original work published 1913) Freud, S. (1968). Analysis terminable and interminable. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Volume XXIII, pp. 209-253). London: Hogarth Press. (Original work published 1937) Greenacre, P.(1967). Infantile trauma and genetic patterns I n Emotional Growth; psychoanalytic studies of the gifted and a variety of other individuals (pp.260-299) International Universities Press. Greenson, R. R. (1965). The working alliance and the transference neurosis. Psychoanalytic Quarterly 34, 155-181. Greenson, R. R. (1966). Contribution to discussion of the psychoanalytic situation. In R. Litman (Ed.), Psychoanalysis in the Americas (pp. 131-132). New York: International Universities Press. Greenson, R. R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. Hobson, R. P. (2005). What puts the jointness into joint attention? In N. Eilan et al. (Eds.), Joint attention: Communication and other minds. Issues in philosophy and psychology (pp. 185-205). New York: Oxford University Press. Hoffer, A. (2000) Neutrality and the therapeutic alliance: What does the analyst want? In S. Levy (Ed.), The therapeutic alliance (pp. 35-55). Madison, CT: International Universities Press. Mahler, M., Pine, F., & Bergman, A. (1973). The psychological birth of the human infant. New York: Basic Books. Meissner, W. W. (1971). Notes on identification. II. Clarification of related concepts. Psychoanal. Quarterly 40, pp. 277-302. Meissner, W.W. (1996). The therapeutic alliance. New Haven, CT: Yale University Press. Moore, C., Dunham, P. J., & Dunham, P. (Eds.). (1995). Joint attention: Its origins and role in development. Hillsdale, NJ: Erlbaum. Nagera, H. (1966). Early childhood disturbances, the infantile neurosis, and adulthood disturbances. New York: International Universities Press. O'Shaughnessy, E. (1981). A clinical study of a defensive organization. Int. J. Psycho-Anal. 62, 359-369. Reddy, V. (2005). Before the third element: Understanding attention to the self. In N. Eilan et al. (Eds.), Joint attention: Communication and other minds. Issues in philosophy and psychology (pp. 85-110). New York: International Universities Press. Shane, M. (2000). The therapeutic alliance. In S. Levy (Ed.), The therapeutic alliance (pp. 109-123). Madison, CT: International Universities Press. Steiner, J. (1993). Psychic retreats: Pathological organisations in psychotic, neurotic and borderline patients. London: Routledge. Stone, I. (1961). The psychoanalytic situation: An examination of its development and essential nature. Madison, CT: International Universities Press. Tomasello, M. (1999). The cultural origins of human cognition. Cambridge, MA: Harvard University Press. Tomasello, M. (2008). Origins of human communication. Cambridge, MA: MIT Press. Weissman, S. (1977). Face to face: The role of vision and the smiling response. Psychoanal. St. Child 32, 421-450. Werner, H., & Kaplan, B. (1963). Symbol formation: An organismic-developmental approach to language and the expression of thought. New York: John Wiley & Sons, Inc. Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York: International Universities Press. Zetzel, E. R. (1966). The analytic situation. In R. Litman (Ed.), Psychoanalysis in the Americas (pp. 86-106). New York: International Universities Press. Bennett Roth, PhD 161 West 15th Street New York, NY 10011 Member American Psychoanalytic Association International Psychoanalytic Association IPTARMutual Attention and Joint Gaze as Developmental Forerunners of the Therapeutic Alliance The phenomena and complex interpersonal dynamics evoked by one person’s attention (analyst) upon another (patient) is fundamental and essential to the psychoanalytic situation and provides 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, 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 (Bruner, J., 2005, Butterfield, G. 2004) that are hard-wired into the child: first locating the mother’s face, inferring her motives and then developing varieties of interactive joint attention (Moore & Dunham, 1995; Eilan et al., 2005, Gergely, G., et.al 2007) 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, S.1995a : Butterfield G. 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 (Tomasello, M.; 1999, Gergely G. et. al. 2007A) and security (Gergely and Unoka, 2008) Joint visual attention specifically refers to early developmental stages or processes occurring when mother and infant are jointly looking at a third object building crucially interactive elements necessary for the later emergence of important cognitive capacities in the child. Shared or joint visual attention is likely one significant manner that the infant or child mentally processes sensory and cultural information and whether initiated by either mother or child, may be an essential bedrock for later social learning processes and the acquisition of relatedness (Butterfield G, 2004.) In this paper this developmental process will be described and then “problems” in two patients who have difficulties in alliant behaviors and animate dialogue will be shown by describing their different failures in joint attentional behaviors. I believe 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, S., 1913). In the analytic literature, despite A. Kris description of aspects of maternal gaze 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, resulting in a “shaky, unreliable sense of herself” and the absence of “a sense of personal security” (p. 443). A Casual Event that Changed My Perception While riding on a cross-town bus, I observed the following interaction between a mother and child. An approximately 2 ½-year-old child, 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, then looked at her own un-sandaled foot, where her mother was looking. The child again looked up at 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 alliant interaction between mother and child with visual and verbal elements. After returning home I began to research the 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, V., 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, and more about this will be 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 S.W.1997.) For example studies of separateness (Mahler, Bergman and Pine, 1973) and attachment (Bowlby, 1965, 1969, 1971) identified the primordial sharing situation as the primary root for the emergence of the separate object/self in the development of self-reference, and 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, yet safely attached, individual has become a psychoanalytic ideal. Greenacre (1967) presciently drew attention to “any factor” that impairs the mother-child relationship as 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 (P.286) speculated that early trauma affected he sequential unfolding of libidinal phases (A. Freud, 1965) tying this notion to traditional ideas of libidinal phase development. 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, P. 1996) and shift attention to the developmental origin of disturbances in social communication. There may be no simple answer to any resolution of infancy 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, 1980) classical ideas on the same concept that can be viewed as referring to different developmental models and outcomes that imply very different developmental progressions of internal psychic structures and clinical experience (Shane, M.2000). Within these disparate models long-standing controversies exist whether a basic maternal transference is at the core of all analytic attachments, and further, the essential 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 fundamentally important in psychoanalytic treatments. Such complex interactive process 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 (Freud, S., 1912) and ally with the ego of the person undergoing treatment (Freud, S., 1937) to enable the patient to become an active “collaborator”. The idea of the therapeutic alliance is a process construct thought to make the analysis move forward interactively, and while focused on the patient is perceived quite differently by each of the two participants (Abend, S., 2000). Stone (1961) offered a two-pronged dynamic definition of the alliance in which 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 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 relation between mother and infant. In her basic view, as an infant turns with expectant faith to its mother for recognition of that infants needs and response, so does a patient turn to his/her analyst. An analyst, in this view, must be like a good mother, with “intuitive adaptive responses” (1966, 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” (1966, p. 92), i.e., an identification, a trusting alliance with the analyst who is attending and responsive to the patient. Whether this is described as a precondition for an alliance, a part of the early transference, a non-verbal holding environment (Winnicott, D.W., 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) separated working alliance from transference 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, 1980; Arlow, J., & Brenner, C., 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, H., 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 et al. (1991) pointed out, may require “a reliving” of the earliest pre-verbal forms of functioning, including the earliest pre-verbal 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, H., 1966), offering an archaic-mind or deficit model of the patient, which includes a model of ego and super-ego malformation due to developmental trauma or deviations as Greenacre anticipated. Adler (2000, 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 non-transferential elements in the dynamics of the working or 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 of the analytic situation (Shane.M.2000.) My own view is that what is referred to as the patients “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, mark them verbally when necessary and 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, L. 2006.) As generally conceptualized in the non-relational model, the therapeutic alliance requires separate ego functions or differing capacities and functions in both participants, among them the capacity to observe, 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 joint perception. However, the dual interactive activity of the minds of the patient 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 established another model for examining that “third” relationship, an analogical model (Roth, B. 1973). 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 as 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. (Footnote. The analog model is given A as analyst and B as Patient A:B creates C prime. C is a unique and dynamic construct of A:B).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 “, vein or avenue of influence in the interactive field. In a current psychoanalytic context, mutual attention refers to a two-person event, while joint attention originally referred to an infant and caretaker coordinated attention to a third element; a coordinated and patterned triangular event in which the two participants observe an element together, is considered as the forerunner of reflective attention. In both mutual and joint interactions emotions, information and interactive signals are exchanged although the joint sightings create additional interpersonal distance. In the following I will apply specific developmental lenses to this basic conception of a dyadic relationship, and will reexamine and redefine both working and therapeutic alliance in the frame of an essential developmental stage of a joint visual reference. This early exquisitely interactive relationship between the mother and infant, initially hard-wired in the child, is fundamental to the social embeddedness of the emerging mental attributes 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, M., 2008, p. 207). It is founded on early developing neuro-cognitive capacities of the infant to recognize and later identify with the bodily expressed attitudes (particularly face and eyes of the care-taking 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 mother-infant 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 the two perceivers (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 together with their caretakers on other elements in their environment. By 18 months most children are engaged in full-blown episodes of joint attention. (Jaffe, J., Beebe, B., Feldstein, S., Crown, C., & Jasnow, M., 2001.) As Bruner (1977, P287)) first summarized, joint attention “sets the deictic limits that govern joint reference, determines the need for a referential taxonomy, establishes a need for signaling intent and eventually provides a context for the development of explicit prediction. (After thirty years of developmental research Bruner (1995 P 1) added that questions about how infants and toddlers “come to know others’ minds or how they come to realize that other minds know theirs” are entering the discussions. Such question are now relevant following the writings and research of Fonagy, et al. (2002), with the awareness that some form of interiorizing representation or mentalization is inferred in the infant-mother movements from mutual to joint perception. I believe this important transition to joint 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 other. Prior to the development of joint attention, objects 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 to (infant) ego-distant things of awareness or contemplation, and likely (it is believed) a correlative distancing and/or distinction of the infant from the adult and other objects takes place. When the child targets the object to another person, usually by pointing or gesturing with 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 both the objects 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. One description of evolution of joint attention is as follows (Eilan, 2005): 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 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 towards 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 , G. 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 attention by her voice using questioning words and asking where the sandal is. Her verbal behavior is best functionally described as verbal pointing through a question, while giving a visual cue by looking at the shoe-less foot, and asking a question about something not being there. The child, in response, 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 mothers 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 seeing 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 have 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, intention, and the problem’s solution. At the end of the scenario there are smiles and “confirming” glances of approval that are mutual (Weissman, 1977). Clearly, the sandal incident indicates a complex social solution that without a ready ability for evoked joint attention is not possible. Human children without this capacity fall into a state of grievous pathology (Baron-Cohen, 1995 A p. 11), unable to read social intent in themselves and others and unable to cooperate. In summary developmental research clearly reveals that infant attention emerges through maturationally-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 an expanding gyre of interactions—between the infant-self and care-taking 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 care-taking 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 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. There are also possible development linkages involving mirror neurons and language development, which have been explored. The First 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 for this presentation. Affect regulation and self-awareness have improved, as compared to the 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, her 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 8-15 minutes late for sessions, and through the years has offered repetitive surface explanations ranging from “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. My verbal 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 have 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 haven’t 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, “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 successful. In a recent session, when I focused 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 down it was as if she expected to be hit, maybe with words.” She continued, 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 reveals her memory 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 re-enactment of her fantasy and emotions in response to being ignored. (When she was not looking at me, I thought “she doesn’t know what she is thinking and feeling—yet she believes she knows what I thought and felt.”) The Second Patient With Ms. I., I will describe the impact of the absence of any visible response to my interventions. A former attorney, the patient retired—against analytic advice—from a successful firm. She had established herself as the reliable aide to the head of the firm and made herself indispensable. Since the end of her marriage some 25 years before, she’d had one brief heterosexual relationship; during the course of treatment she had one casual friendship in reality, and another relationship, mostly in fantasy. During sessions she often became silent and “blank,” and when asked to describe the blankness, she was unable to use words. Questions such as, “Is it like a fog?” or “Does the blankness have texture?” elicited no verbal reply, but rather a direct and straight stare though not fixed. ventually she would say flatly, “I don’t have anything on my mind,” or “Everything flew out of my mind.” She also reported that when traveling between my office and her home, in either direction, she “forgot” what she was thinking, what happened in the session or what she was planning to talk about. For a brief time anti-depressant medication helped her to be more verbal, although “links” were absent between events she described and past events that emerged in the therapy. There was an “isolated” frame, and the therapy offered no two-person “container function.” She seemingly lacked an inner process for producing some thoughts that could be kept in mind, and she also appeared to lack a mind that could keep things in it. Curiously, absent were my awareness of normal counter-transference associations, as if I too was deprived of receiving projected emotionally significant information and there was “ space between us .” I came to understand that a “thought-destructive superego” had developed in her mind, associated with headaches—which drove her thoughts from her “head”—as well as other inner-emptying defenses: Her internal dynamic forbade her to think, and demanded that she rid herself of both her thoughts and mine, in addition to this mental evacuation of “something bad” that she would not name or communicate with me. She also reported attempts to keep her mind empty by reading the same book three or four times, to control her thinking, and not remembering what had been said to her, or what she had said. Due to her felt anxiety she found it impossible to travel outside an imaginary boundary that restricted her movements in general, and had earlier led to her retreat to her apartment as a sanctuary, except to visit some long-time female friends. Eventually she offered that she was a “sub-clinical” bulimic, that she was empty and starving, and was reading a book, “Lost for words” (Farrell, E., 1995), which emphasized, without explaining, that people like her have not found the words to express and name to themselves and others the turmoil of their inner experience. Her inability to contain and name her emotions suggested a disruption of joint looking during her early years, when that interactive learning emerges. When I asked her ‘to look at ‘what she had said, she reported blankness; it was “disappeared.” She couldn’t hold words I verbalized and “mentally” look at them. Almost all of her descriptions reflected externalized defenses and were restricted to events outside herself in reality as if a recording. She received a profound pleasure and sense of safety from deadening the sessions, thwarting me verbally, and doing the same thing to interpretations and understanding of both the malignant processes and the internal images present in her mind. Away from the sessions she had headaches, panic anxiety, and paranoid thoughts whenever she contemplated leaving her sanctuary or returning to work. At the resumption of treatment after summer break waiting for an opportunity to describe the patient’s withdrawal and forgetting I didn’t have to wait long. She forgot something I said and I brought to her attention that she could not expose herself to my gaze, that she “couldn’t bear being seen, being looked at by me.” She replied that she expected to be looked at in “an unbearable, critical way.” I stated, after some further exchange, that she wasn’t hungry for anything from me, and this had something to do with how she and her mother interacted and looked at each other. She replied “it was better to be safe, fed, and alone.” I said, “It feels like your mother fed you but didn’t see you and talk, or babble to you. There was no dialogue. You always were alone.” She replied, “She just did it. Last year you said that treatment was like surgery to me—it was done to me—that’s the way my mother took care of me. She did it. What I expected didn’t matter. I didn’t matter.” I said, “She didn’t talk to you and didn’t explain to you.” She answered, “That’s the way she was—she just did it.” Discussion of Patients Every psychoanalyst is confronted by the question of how it is possible for early, necessarily pre-symbolic experiences to emerge and be understood in a psychoanalysis (O'Shaughnessy, E., 1984) From a developmental perspective the early vulnerable infant-self is the first receptive target of the primary caretaker’s attention, and it is from this primordial experience that other forms of attention to other objects arise and become complex and mentalized. 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 care-taking 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. As stated metaphorically by Fonagy (1995), the child finds his or her self in the gaze of the mother: and some patients need find themselves in their analysts 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 and 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 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 reflects on the capacity for informational exchanges, but also allows the parent/caretaker to observe and monitor moment to moment changes in ‘the state’ of the infant (Kita, S., 2003; Fonagy, P., & Target, 1995; Jaffe, J., Stern, D., & Perry, J., 1973). 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 be an important early component of language acquisition but is likely a basic component in the therapeutic alliance. The early ego failures that re-appear in the treatment alliance can be understood as failures in joint attentive behaviors. Each of the following patients’ reveals forms of developmental failures of joint attention. Patient One  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, 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 indicate deference or shame. Often when M. did not look down and looked at me, she often spoke over me, as if to drown out my words, a likely revenant of 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 attend to or agree with, and she resisted the various proto-imperatives to direct her attention to her own behavior when gazing and attending to me. While often viewed as hyper-vigilance 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 and rage. 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 she surprised me by being aware of time and saying “the session is over,” and 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. Discussion of Patient Two This patient presents as lacking abstract reasoning and in an externalizing and concrete manner, making therapeutic inferences difficult. Therapists generally perceive a deeper bond when people have fewer deficits in this area, while O'Shaughnessy (1981) accurately calls such behavior a “defensive organization” through which patients seek “refuge in a stable but pathological organization which is meant to provide equilibrium, a warding off of anxiety, but prevents dialogue in treatment.” Steiner (1993) describes this “style” as a psychic retreat that provides the patient with a decreasing area of relative safety and protection from psychic strain. When meaningful contact with the analyst is experienced as threatening, as I reported., the analyst also experiences feeling” alone” when with the patient I believe this defended clinical presentation is also a hallmark of very early problems in the mutual and joint interaction between mother and child; a fault or regression to an early interaction in which there was a failure by the mother to empathically attune to the child’s inner states, which in turn facilitates self awareness and allows the child’s needs to become observable and responded to. For example, questions such as “Are you tired/hungry/dirty?” are part of the process of the child’s learning the “helping attentionality and intentionality” of the gazing mother while building internal recognition and names for feeling states within the child. Subsequent to my bringing her anxiety regarding her mother’s gaze into the session, she reported having no remembered experience of shared interaction and mutual gaze; her experience was either being done to or doing to. There was apparently no experience of mutual attentionality that could lead to “shared” empathic mutual looking. I understood that as I spoke to her, she looked only to the outside, rather than reflectively at herself; my gazes were unprocessed, except when she imagined being criticized. Repeatedly, for a week after this exchange she could not take any suggestion, co-association or reflective remark from me and respond to its content as an inner experience. She defended against, attacked, or ignored what I said to her, living out the absence of shared or mutual perception with me. Her behavior created a particular aloneness in the sessions that prevented, for a time, my finding and being with her. As her treatment progressed she revealed a constant “ sensitivity “ to conflicts concerning looking and being looked at. This suggested an impaired developmental line of gaze” that included primal scene issues, to fears of people seeing expressions on her face, to being found/seen as having sexual needs, to her dog being seen “peeing” and people seeing her written work or her “ dirty apartment.” It is possible that her visual sensitivity, looking and being looked at progressively evolved from disruptions in mutual and joint gaze Summary Discussion The post-classical period of psychoanalysis has struggled to incorporated developmental research into psychoanalytic theory, establishing the critically important role of early childhood development and the vicissitudes of the early infant-mother relationship. The shift to direct observation 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, P. 1996) Developmental psychologists have provided an array of valuable data about the basic emergence of cooperation, perception and language in the early mother child unit and the 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 best considered a highly variable composite. Cooperation, joint intention and attention, not to mention analysis of regressive states as a response to alliant failures, are almost totally ignored. One current fallback position appears to be Fonagy’s 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 and desires, requires clarification. Fonagy’s definition 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, C., & Wolpert, D., Eds., 2004). As the infant 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. From a psychoanalytic perspective, the turning towards the mother that Zetzel (1966) described as the initial part of the therapeutic alliance, and the two-pronged alliance described by Stone (1961), has as its ignored developmental origin 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, con-joined events, and adds powerful dynamics to therapeutic treatment. *. 2