Journal of Infant, Child, and Adolescent Psychotherapy

ISSN: 1528-9168 (Print) 1940-9214 (Online) Journal homepage: http://www.tandfonline.com/loi/hicp20

Zones of Proximal Emotional Development

— Psychotherapy Within a Neuroaffective
Perspective

Susan Hart & Stine Lindahl Jacobsen

To cite this article: Susan Hart & Stine Lindahl Jacobsen (2018) Zones of Proximal Emotional
Development — Psychotherapy Within a Neuroaffective Perspective, Journal of Infant, Child, and
Adolescent Psychotherapy, 17:1, 28-42, DOI: 10.1080/15289168.2018.1425588

To link to this article: https://doi.org/10.1080/15289168.2018.1425588

Published online: 06 Mar 2018.

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JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY
2018, VOL. 17, NO. 1, 28–42
https://doi.org/10.1080/15289168.2018.1425588

Zones of Proximal Emotional Development — Psychotherapy

Within a Neuroaffective Perspective
Susan Hart, Ph.D. Student and Stine Lindahl Jacobsen, Ph.D.

ABSTRACT
This article outlines a conceptual framework for assessing personal and emo-
tional functions of a person’s zone of proximal emotional development. The
framework is based on the integrative theory Neuroaffective Developmental
Psychology (NADP), which brings together attachment theory, neuropsychol-
ogy, developmental psychology, and trauma theory. Within the NADP frame-
work, this article describes a way of understanding children’s normal emotional
mental organization and of examining how this mental organization may be
developed or disturbed by relational issues. It also describes how a child’s mental
organization can be disturbed and thus, without intervention, disturb the child’s
personality development on a lifelong basis. The article presents three case
vignettes, describing three children growing into adolescence with three differ-
ent attachment patterns and suggested individually tailored intervention plans
for each of them, relevant and useful for clinicians working with vulnerable
children and families. Because the nervous system retains its plasticity through-
out life, attachment is not necessarily an unchangeable pattern. That is why we
as clinicians should develop psychotherapeutic methods and a research-based
way of determining “what works for whom” by assessing the zone of individual
proximal emotional development. The text outlines the characteristics of NADP
and how it can be used to structure an intervention plan.

Introduction
“Are there critical periods of self-development? If so, what are they? Do specific aspects of the self develop as
specific periods? If self-development is a maturational process, how flexible is it? If there is a fixed timetable,
what are the implications for the clinical intervention? Are there important data from contemporary
development neuroscience that may inform our theories of self? Might there be precocious self-
development analogous to precocious ego development? … how does the child’s self emerge from the
mother-child matrix, and is this process ever completed?” (Gergely et al., 2000, p. 25). These were all
questions formulated by Gergely, Alvarez, Mayes, Bach, Slade, and Ellman in 2000 at a panel discussion on
development and the self. In this article, small humble steps are laid to consider these huge developmental
questions through the theoretical framework: Neuroaffective Developmental Psychology (NADP).
NADP rests on research-based knowledge about the emotion-regulating structures in the human
brain, studies of attachment in developmental psychology, developmental psychopathology, and trauma
research (Hart, 2008, 2011). This theoretical synthesis began in the 1990s, and the groundbreaking
publication from Alan Schore, Affect Regulation and the Origin of Self (Schore, 2016), became an
inspiration for many in the field. His thorough work made an important foundation for linking
psychoanalysis and attachment theory with the latest brain research findings.

CONTACT Susan Hart [email protected] Sandlodsvej 95, 4400 Kalundborg, Denmark.

This manuscript was prepared as part of a Ph.D. project at the Aalborg University.
Susan Hart is currently affiliated with the Department of Communication & Psychology, Faculty of Humanities, Aalborg University,
Aalborg, Denmark.
Stine Lindahl Jacobsen is currently affiliated with the Department of Communication & Psychology, Faculty of Humanities, Aalborg
University, Aalborg, Denmark.
© 2018 JICAP Foundation, Inc.
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 29

In the same period, Daniel Siegel (1999) commenced his integration of neuroscience with an
understanding of mindedness and mindfulness, Louis Cozolino (2017) with child development and
psychotherapeutic practice, Bruce Perry (1994) with the effects of childhood trauma, Stephen Porges
(1995) with neuroception and the vagal theory, and Jaak Panksepp (1998) with the basic emotional
brain structures. In Scandinavia, there has been a strong focus on synthesizing developmental
psychology with neuroscience based on the the research from Louis Sander (1985), Daniel Stern
(2000), MacLean (1990), and Colwyn Trevarthen (1989), which has been linked with findings from
Fonagy, Gergely, Jurist, and Target’s (2002) research on mentalization. The theoretical approach in
this article is derived from the three decades of findings in these approaches to integrating affective
neuroscience and clinical fields.
NADP incorporates the neurologist MacLean’s (1990) elaboration on the construction of the human
brain as a hierarchy of functional levels, where structures that develop early in life progressively, through
separate developmental stages, are understood as subordinate to later-developing structures in a process
that increases the complexity of the brain. In NADP this is termed “levels of mental organization.”
MacLean introduced a heuristic model, the triune brain, which offers a useful but simplified overview of
the complexity of the brain (Panksepp, 1998; Sapolsky, 2017). MacLean used the term “triune” to point out
that the whole is greater than the sum of its parts because the exchanges among the three brain structures
contain more information than the sum of the individual brain structures would, if they operated
independently (MacLean, 1990).
Some neuropsychologists have the opinion that psychologists misuse and overexaggerate the
results from neuroscience, for example, to give direct evidence of specific therapeutic interventions,
and that NADP has been the target for this criticism (Dalgleish, 2004; Overgaard, Ramsøy, & Skov,
2005). It is therefore necessary to emphazise that NADP is a theory based on relation and attachment
theory derived from a psychodynamic tradition, and a psychological understanding of emotional
development. In NADP, neuroscience is used as an overall structural understanding of the complex-
ity between pscyhological issues and how the nervous system matures.
MacLean’s model is a construct to understand evolutionary development (phylogenesis), where
mental organizations develop progressively over successive time periods. This construct is brought
into NADP by the understanding that ontogenesis follows the same principles as phylogenesis (Hart,
2008). According to NADP, the nervous system needs adequate stimulation in the proximal zone of
development for mental organizations to mature (Hart). In the following, three case vignettes will be
outlined; these vignettes will later illustrate how NADP can be used to analyze the three individuals’
personal development over time, offering clinicians both a model of understanding clinical cases as
well as relevant interventions. The three case vignettes are all fabricated but are based on many years
of clinical experience. They are fabricated to illustrate three different attachment patterns and to
exemplify the NADP understanding and the use of this theoretical framework as a foundation to
tailor the focus of intervention (Hart, 2016c).

Case presentation
Toby was 12 years old when his parents, who were divorced when he was 10, brought him to a
psychologist. In the two years since they divorced, they had come to worry about him. He had
become increasingly isolated at home, and his schoolteachers described him as withdrawn and
depressed. After a few consultations, he was able to overcome the crisis through a dialogue-based
psychotherapeutic method.
Catherine provoked repeated arguments with her mother when she reached her early teens, and
her explosive outbursts of anger eventually became so intense that Catherine had to go into foster
care. After approximately six months, the foster parents gave up, and Catherine returned to her
home. In school, Catherine was a “drama queen,” quickly changing from idealizing to hating her
close friends.
30 S. HART AND S. L. JACOBSEN

Benjamin was 11 months old when he was placed in an orphanage. A year later, he was placed in
a foster home but was sent to a rehabilitation home at the age of 5 because his behavior was too
challenging (e.g., unempathic, aggressive, indifferent, careless) for his foster parents. When he moved
into a flat on his own at the age of 18, he developed substantial alcohol and cannabis abuse and was
violent toward others. While collecting on a drug debt, he committed homicide and was sentenced to
prison.
Within the framework of NADP, we will establish an overview enabling an understanding of the
general principles of development and then outline relevant aspect in the three young people’s lives.
During the course of the article, we will relate these cases to different developmental levels and
attachment patterns according to NADP and outline possible interventions to support a healthy
development (Bentzen & Hart, 2015; Hart, 2016c). The clinical cases can be analyzed and interpreted
from many different attachment-based and psychodynamic theoretical approaches, so NADP is only
one of many ways to understand development. The uniqueness of NADP, however, is that this
theoretical framework of understanding has been developed from clinical practice and may help the
clinician to choose focus in the intervention.

The theoretical foundation of NADP

As mentioned earlier, Maclean’s model depicts the human brain as a three-tiered structure with
closely interconnected levels. He attributed the three brain structures with three forms of mentation:
proto-mentation as the most primitive, emoto-mentation as the middle level, and ratio-mentation as
the top level (MacLean, 1990).
In NAPD, the area labeled proto-mentation in MacLean’s model is referred to as the autonomic
and sensory level of organization (Hart, 2008, 2011, 2017). This section of the brain operates
instinctively and consists of midbrain and brainstem structures that govern the autonomic nervous
system and which are active from birth (Hart, 2008). The area labeled emoto-mentation in
MacLean’s model is referred to as the limbic and emotional level of organization in NADP and
develops around 2–3 months of age. The limbic system enables the development and refinement of
social interactions, including social emotions such as happiness, playfulness, sadness, and anger
(Hart). The area labeled ratio-mentation in MacLean’s model is referred to as the prefrontal and
mentalizing level of organization in NADP. About eight months after birth, the last major brain area
develops, that is, the frontal lobes, especially the prefrontal areas. According to NADP, areas in
particular enable human beings to develop the rational level of organization, including some
volitional control of all three levels of mental organization (Hart).
When all three levels of mental organization are developed, in a NADP understanding they
influence each other and are interconnected. The are interconnected in such a way that overactive
prefrontal structures have a downward impact on the function in the lower, that is, limbic and
autonomic, structures. Overactive limbic structures weaken prefrontal structures and have a down-
ward effect on the function of autonomic structures. Imbalances in the activity of the autonomic
structures weaken the function of limbic and prefrontal structures (Hart, 2008, 2011).
Through differentiation and hierarchical neural integration, any mastery of a development task is
integrated and coordinated with the previous organization, and reorganization moves the individual
further in his or her development (Cicchetti & Tucker, 1994). In NADP, the structures of the brain
are understood as organized hierarchy, which for Toby would mean that despite his inborn
sensitivity, he has much greater resilience to overcome later setbacks than, for example, Benjamin,
since Toby’s parents were able to create a safe base for him from birth, which creates self-regulation
capacity on both autonomic, limbic, and prefrontal levels of the brain (Hart, 2011; Schore, 2016).
Research suggests that at the time of birth, the functional brain connectome largely involves brain
regions responsible for sensation and action, whereas only weak involvement is found for hetero-
modal brain areas (Fransson, Aden, Blennow, & Lagercrantz, 2011). The regulation of the basic brain
areas has a significant impact on the person’s self-regulation capacity, which is fundamental for
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 31

personality development (Greenspan, 2007; McClelland et al., 2018). Even if a child is born with
vulnerabilities, the intersubjectivity between the primary caregiver and the child helps the nervous
system develop a self-regulation capacity and coping strategies to interact with the environment
(Trevarthen & Delafield-Butt, 2017).
Thanks in part to the development of the prefrontal cortex, in a NADP understanding the brain
becomes able to handle a huge number of different stimuli. The higher the hierarchical structure, the
higher the degree of complexity (Hart, 2008; Schore, 2016). From around the age of 2, language plays
an increasingly crucial role in the child’s ability to convey experiences (Anisfeld, 2014; Bruner,
1990)). Although the child also expresses emotions and bodily impulses through play and other
behavior, language is the dominating medium of dialogue. Exchanging narratives with others
reinforces and develops the brain’s emotional and impulse-inhibiting structures, and it is through
the process of narrative organization that raw emotions are transformed into symbols. Verbal
symbols make sense of the felt and perceived experience (Hart, 2008, 2011).

Early attachment formation

The attachment system is built into the child’s interaction with his or her caregivers, and psycho-
social development and the development of attachment are closely interrelated (Allen, 2002). The
work of Ainsworth (Ainsworth, Bell, & Stayton, 1971; Ainsworth, Blehar, Waters, & Wall, 1978) and
Main (Main & Cassidy, 1988; Main, Kaplan, & Cassidy, 1985) inspired key concepts of how children
develop different attachment patterns during their first year of life and how secure and insecure
attachment patterns can be distinguished, even at this early stage of life.
The three case vignettes further illustrate how the course is set early in life for developing
different attachment patterns, although an attachment pattern may change during the lifespan
according to experiences (Sroufe, 2005; Sroufe, Egeland, Carlson, & Collins, 2005). Toby’s attach-
ment pattern could be understood as secure, although he was born prematurely and had always been
a sensitive child. His parents’ positive internal representations and expectations, their mentalization
capacity, and ability to create a well-structured setting gave Toby the stability, space, and peace to
develop self-esteem and trust that others would meet him with a positive and open mind. They
provided him with challenges that were within his reach, but he also learned to cope with challen-
ging situations on his own.
Catherine might have an unresolved ambivalent attachment pattern. Although her mother loved
Catherine, the girls’ unpredictable mood swings made the mother annoyed with her. As a result,
Catherine’s needs for nurture and contact were often unmet, and Catherine became anxious when her
mother pushed her away. Catherine responded with whining and clinginess on the one hand and with
anger and constant demands on the other, which made her mother feel powerless and unable to
comfort her.
Benjamin probably has a disorganized attachment pattern. Before Benjamin was 1 year of age, he
had experienced so much insecurity, such little synchronized stimulation, and so many frightening
experiences that he threw all his energy into trying to navigate in the chaos that surrounded him.
Because of her probably insecure attachment pattern, Catherine is with reference to NADP more
vulnerable to future stressors, while Benjamin suffers from a disorganized attachment pattern and is
in real danger of developing serious dysregulation problems. Even though Toby has a secure
attachment pattern, he is not vaccinated from overwhelming experiences and trauma. His secure
attachment pattern has provided him with more mental flexibility and resiliency to overcome this
type of experiences.

Emotional development
The late Russian psychologist Lev Vygotsky (1978) emphasized that the higher psychological
functions are learned in interactions; only later are they internalized as mental skills. The
32 S. HART AND S. L. JACOBSEN

internalization process takes place in what he called the “zone of proximal development,” which he
defined as features under development. This principle also applies to social interactions and
personality formation. There will always be certain dialectics between inter- and intrapersonal
regulation; an inner process is thus always regulated through both self-regulation and interpersonal
regulation. Both processes are always present and influence each other (Beebe & Lachmann, 2002;
Hart, 2012). This issue is important in understanding “what works for whom” in psychotherapy and
family therapy (Bentzen & Hart, 2015; Roth & Fonagy, 1996).
The term “windows of opportunity” is used to describe periods in childhood development where
a competency is normally and ideally developed, marking the precise timespan when the nervous
system is most accessible to a given type of learning, and are usually periods characterized by great
neural plasticity (Gergely et al., 2000; Ismail, Fatemi, & Johnston, 2017). However, once the child
moves past the window of opportunity, the nervous system becomes less open to the given type of
learning, and the child will require a focused effort to acquire the skill. Presumably the window of
opportunity for basic emotional skills occurs from the late fetal stage to approximately 1–1.5 years of
age, long before the child has developed language skills (Hart, 2011; Trevarthen, 2005). There may be
a huge disparity between intellectual and emotional levels of development, both in adults and
children (Hart, 2016b, 2017).
Within the first year of life, the child’s basic skills of synchronization capacity, sensory integration
skills, and skills of affective attunement are developed (Stern, 2000; Trevarthen, 2001). The brain’s
need for stimulation may be described as follows:

(1) At the sensory brainstem level, developmental interactions occur through the synchronized
interactions between the caregiver and child based on the child’s sensory impressions
(Trevarthen, 2001).
(2) At the emotional limbic level, developmental interactions occur through affect attunements
with the child’s emotions through the caregiver’s marked mirroring (Fonagy et al., 2002;
Stern, 2000).
(3) At the prefrontal mentalizing level, developmental interactions occur through mentalized
dialogues that the caregiver creates in his or her interactions with the child (Bruner, 1990).

Toby was born four weeks premature, and he was a sensitive infant. He was a wanted child, and
his parents were resourceful. In nursery school and kindergarten, he was well liked, and in that sense
he was a confident and secure child. He was a quiet and thoughtful boy, but gradually, with help
from his parents, he became more outgoing. Although Toby was a sensitive child, his parents were
good at regulating him, and his presence made them happy. As an infant, Toby was well stimulated,
regulated, and comforted, which made him resilient, and when his parents divorced when he was 12
he quickly adjusted to the situation after a few psychotherapeutic sessions.
Catherine, on the other hand, was from birth a robust and easily regulated infant, but early in life
she became clingy and difficult to satisfy; she insisted on her mother’s presence but still seemed
dissatisfied even when her mother was with her. This might have been caused by her mother’s life,
with changing partners and alcohol abuse. Once in a while, Catherine’s mother would leave home,
leaving Catherine alone. The insecure attachment pattern between the mother and Catherine was
internalized from Catherine’s early childhood experiences, and working through her instability and
dramatic attitude as a teenager would require considerable effort in an outpatient treatment course
(Hart, 2011, 2016c).
Benjamin’s mother had difficulties bonding with her child, and when he was about 1 month old he
began to withdraw. The mother had many changing and violent partners, and the police was regularly
called in to respond to domestic violence. When Benjamin was 11 months old, he was placed in an
orphanage, where he was described as being hyperactive. Not receiving much regular love or care, and
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 33

constantly being exposed to trauma due to neglect or abuse, left him with few emotional strategies and
an inadequate development of emotional brain structures associated with social engagement, empathy,
and delay of gratification (Damasio, 1998; Decety & Meyer, 2008; Porges, 2011). His lack of emotional
coping strategies also left him extremely vulnerable, and to overcome early traumatization and neglect
he required an in-depth intervention in a residential home.

The consequences of a lack of early emotional stimulation

The inability to regulate affects and emotions is one of the most profound and persistent conse-
quences of early neglect and a cause of vulnerability to psychological trauma (Perry & Pollard, 1998;
Schore & Schore, 2008).
According to NADP development progresses, behavior patterns and expectations developed
earlier in life integrate hierarchically with new and more complex behaviors. As new capabilities
develop, earlier capabilities become subordinate, but are still potentially active. Under intense stress,
these earlier behaviors are activated while the newer and more mature behaviors are deactivated
(Fonagy et al., 2002). Later-maturing behavior patterns are more vulnerable to disturbances and
deactivate more rapidly than earlier ones. The presence of early and less differentiated behaviors can
often be correlated with the caregiver’s rigidity or anxiety, which may interfere with continued
adaptation (Sroufe, 2005; Sroufe et al., 2005).
Presumably as a consequence of his mother’s inadequate parenting, Benjamin had no positive
expectations of interactions with others, but he seemed chronically tense and insecure. He was
remarkably inattentive and sometimes had sudden, unpredictable, and unmotivated impulse break-
throughs and attacked other people for no apparent external reason. This made others insecure and
nervous in his company. To understand his behavior, we need to look at the hierarchic levels of his
emotional development, especially at the disturbances on the autonomic sensory level.

The autonomic sensory level and disorganized attachment issues

The autonomic sensory level begins to mature in human beings in the final trimester of pregnancy and
is fully active around the age of 3 months old. It is associated with processes in the brainstem, midbrain
structures, and the autonomic nervous system (Trevarthen, 1989, 2001). Arousal regulation is con-
trolled by the brainstem neuromodulators, which also regulates attention functions and hedonic
processes (Newberg, D’Aquili, & Rause, 2002). Early stress, whether physiological or psychological,
can make immature neural networks hypersensitive and risk hindering the child in adapting flexibly to
new challenging situations and developing new strategies (Cicchetti, 2015). In children with a
disorganized attachment pattern, such as Benjamin, their emotional development is especially at risk
if the autonomic nervous system lacks sufficient organized stimulation (Hart, 2011). The autonomic
nervous system is the foundation for personality development, and with an unstable and dysregulated
foundation the personality structure is left vulnerable, rigid, and easily overwhelmed (Hart, 2011).
The capacity to attune emotionally with others is a social phenomenon of shared emotional
expression that occurs at a basic level of conscious awareness (Decety & Meyers, 2008). Benjamin
lacked facial expressions; he was hypervigilant and could not detect hunger or satiety. He
sometimes went out in cold weather wearing a T-shirt, without sensing the cold, and in summer
he might wear large woolen sweaters without noticing he was too hot. When he was hurt he did
not perceive pain, and he could drink extremely hot drinks without noticing the blisters they
caused in his mouth. Paradoxically, he was also hypersensitive, and the slightest touch could
overwhelm him. On the one hand, he seemed an insecure and anxious boy characterized by
restlessness, poor impulse control, and an undeveloped body sense and identity; on the other
hand, he was fearless and failed to register danger. He did not develop an emotional attachment
to anybody and did not seek help from adults when life challenges became overwhelming. In play
situations, alone or with others, he was extremely destructive, and in structured play with rules he
34 S. HART AND S. L. JACOBSEN

lacked communicative skills and was highly dependent on external rules. These characteristics
reveal that Benjamin had substantial sensorimotor and sensory integration problems. A relevant
intervention strategy in Benjamin’s case would be aimed, for example, at developing a higher
degree of flexibility in his autonomic nervous system through relational synchronization, rhythm,
and turn-taking, perhaps through music therapy or theraplay (Mäkela & Hart, 2011), since these
processes generally appear to improve these autonomic functions (Lindvang & Beck, 2017;
Porges, 2011).
The neural regulation of the facial muscles serves both as an active social engagement system that
reduces psychological distances and as a filter that influences the perception of other people’s
engagement behavior (Hart & Kæreby, 2009; Porges, 2011). It also serves as a sort of social glue
maintaining emotional reciprocity in the dyad and later in groups (Decety & Meyer, 2008). In the
psychotherapeutic process, attuned facial expressions are, for example, an important facilitator of
self-regulation on deep autonomic levels (Sossin & Birklein, 2006). An intervention plan for
Benjamin must be focused on developing his social engagement system, for instance, by having
the therapist exaggerate his or her facial expressions in synchronized playful interactions and
inviting Benjamin to do the same in turn-taking games.

The limbic emotional level and the development of attachment behaviors

The limbic system begins to mature when the infant is approximately 2 to 3 months old and is fully
active around the age of 9–12 months (Chugani et al., 2001; Gunnar, 2001). The limbic system gives
perceptions an affective or emotional charge and enables the development and refinement of social
interactions, such as playfulness, delight, or sadness (MacLean, 1990).
During the period of limbic maturation, the caregivers show many different emotional expressions
during play and nurture activities. It is within these proto-conversations that a general mood or
perceived tone is recorded, and the infant’s feelings and emotions emerge through the mutual
attunement between the infant and the caregiver (Decety & Meyer, 2008). Emotions are the actual
observable expressions of affects by invariant movement dynamics, postures, and facial display, which
are seen around the age of 2–3 months. This is when the social smile emerges, and the infant begins to
engage in dialogic nonverbal interactions (Wörmann, Holodynski, Kärtner, & Keller, 2013). The
capacity for proto-conversations and arousal regulation within emotional intersubjective attunement
is a precursor for both internal representations and symbol comprehension (Hart, 2011; Stern, 1990).
The affective attunement between caregiver and infant lays the ground for the specific attachment
pattern (Hofer, 1995; Main, 1990). In the period from 2 and 9 months, infants such as Toby and
Catherine have already chosen specific actions in response to their mothers’ communication. Based
on these communication patterns, the children begin to experience different feelings and learn to
manage shifting emotional states (Eisenberg, Spinrad, & Sadovsky, 2006). During this period, infants
also learn what types of communication elicit a response. When the communication is either
misattuned, inconsistent, or dysregulated for long periods of time, the infant becomes dysregulated,
which may lead to an insecure attachment pattern (Tronick & Cohn, 1989; Tronick & Weinberg,
1997). For instance, Catherine’s way of managing insecurity was to develop an ambivalent attach-
ment pattern.
Research results suggest there is some sort of self-other distinction at play already from birth and
that infants imitate the actions of others in a flexible and goal-directed way (Trevarthen & Delafield-
Butt, 2017). This also suggests that infants represent the other as “like me” (Meltzoff, 2013) and sense
themselves as agents in their own environment from birth (Neisser, 1993). Bråten (2006, 2007)
proposes that an infant experiences what the other is experiencing, as if the child’s orientation and
perspective were centered in the other (alter-centric participation). Adopting another’s perspective is
integral to human empathy and sympathy and is linked to the development of altruism, moral
reasoning, and a decreased likelihood of interpersonal aggression (Eisenberg et al., 2006).
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 35

A failure to achieve an intersubjective connection will often spark anxiety and mobilize defensive or
self-protective strategies (Hart, 2011). Toby seemed to accept his parents’ separation without showing
any signs of anger, frustration, or objection and appeared willing to adjust to his parents divorce. Two
years later, the teachers perceived him as being distracted and depressed. When his parents tried to
establish a dialogue with him, he shut down, rejected them, and isolated himself in his room with his
computer. He became angry when they suggested he talk to a psychologist. Toby’s parents contained
his pain and helped him regulate his emotions. Catherine’s situation was different. In school, she easily
made friends, but they were frequently replaced. She went quickly from idealizing to hating her close
friends. They claimed she was distorting reality, and she was offended. She was fixated on illness and
constantly seeking attention. She had frequent arguments with her mother, who often interpreted
Catherine’s actions as being deliberately intended to tease or annoy her. Far too often, Catherine
perceived her mother as being unpredictable, and when Catherine turned her back to her, the mother
often reacted with anxiety; conversely, when Catherine sought her mother’s attention and showed
dependency, the mother frequently felt irritated by the girl’s demands.
When Catherine was referred to an outpatient facility as a teenager, the intervention focused on
providing attunement with her unregulated emotions while at the same time introducing frustration
at a manageable level without causing splitting and turmoil. Benjamin is disconnected from his
feelings and much of the early intervention focuses on activating his body sensations, his arousal-
regulating capacity and, later, his emotional impulses; for Catherine, the primary focus needs to be
on helping her self-regulate in interactions with others when she experiences emotions of joy, anger,
and sorrow. A therapeutic method based on symbolic play (Axline, 1969) or narratives (Sunderland,
2001) would be far beyond both Benjamin’s and Catherine’s proximal zone of emotional develop-
ment at the beginning of therapy.

The prefrontal level, and the development of delay of gratification and mentalizing
capacity
Compared to other regions, the prefrontal cortex develops slowly during ontogeny and does not
reach maturation until late adolescence (Bunge, Dudukovic, Thomason, Vaidya, & Gabrieli, 2002;
Eslinger & Long, 2016). It is not fully developed until around the age of 20–25 and continues to
expand (Giedd, 2009; Huttenlocher, 2002). It has connections to all action pathways in the brain and
converts signals from all sensory areas into images, thoughts, and bodily states that are represented
in a continuous stream (Trevarthen, 1990). The development of the prefrontal cortex is a prerequi-
site for stable friendships. The high degree of connectivity between the prefrontal cortex and the rest
of the neocortex is the source of human imagination and the ability to form complex ideas based on
a multimodal sensory system (Seung, 2013). The ability to make choices is guided by prefrontal
calculation, in which an assessment of the current situation can be weighed against desires, values,
and assumptions about the consequences of a given action (Decety & Meyer, 2008).
The maturation of the prefrontal level of mental organization is highly dependent on stimulation
and requires the caregiver to be able to socialize the child and actively inhibit his or her maladaptive
behavior. The inhibitory functions of the prefrontal cortex are internalized through culturally
conditioned and socially transmitted behaviors (Goldberg, 2009).
Due to its function in impulse control, executive functions, and meaning-making, the prefrontal
cortex is also crucial for maintaining emotional stability (Goldberg, 2009). The understanding of
one’s own and others’ mental states is functionally linked to executive functions, that is, the
processes that serve to regulate thoughts and actions, including self-regulation, planning, cognitive
flexibility, and impulse inhibition (Decety, 2005; Ochsner & Gross, 2005). The development of the
prefrontal cortex gives people the ability to reflect on their own and others’ emotions, thoughts, and
actions and enables them to alter thoughts and actions on the basis of associations. The maturation
of this area is accompanied by an integration of cognitive and emotional areas, which is a condition
for the ability to mentalize (Fonagy et al., 2002).
36 S. HART AND S. L. JACOBSEN

The maturation of executive functions, including emotion regulation, begins around 2 years of
age and contributes to the development of prosocial behaviors. The role of the prefrontal cortex
indicates that empathic concern is strongly related to effortful control and self-regulation (Rothbart,
Ahadi, & Hershey, 1994).
For example, it is difficult for Catherine to inhibit her impulsivity. Guided by her immediate
feelings, she has difficulty maintaining close relationships over time. Her ability to inhibit impulses,
regulate her emotions, and mentalize the relationship between herself and the other is disturbed in
interactions with others as a result of the sense of being emotionally overwhelmed that accompanies
the activation of her ambivalent attachment pattern.

Shame and pride

Feelings of shame and pride begin to emerge about the age of 12–14 months, and it is not until the
child has a sense of his or her own achievements that the feeling of shame and pride develops (Lewis,
2003, 2004, 2007). Experiences of shame and pride are important for the attainment of self-
regulation and a healthy superego structure. The child’s shame capacity is vulnerable and must be
attuned in a respectful way to develop adaptively, and just as the child needs to be socialized and
learn to obey rules, he or she also needs to be praised, which promotes the development of pride and
self-efficacy (Lewis, 2003). At the age of 8–10, the child begins to develop a conscience, making it
possible to attribute negative or positive emotions to his or her own actions and assess his or her
own intentionality (Hart, 2011). It is the development of the prefrontal cortex that makes it possible
to experience pride, shame, embarrassment, remorse, and regret (Goldberg, 2009).
Unfortunately, according to NADP, a lack of sensory integration causes a lack of empathy, which
in turn leads to a lack of shame reactions, remorse, and pride. Benjamin lacks a capacity for feeling
shame, pride, and remorse, which is a common consequence of a disorganized and avoidant
attachment pattern. Other insecure attachment patterns, such as Catherine’s, for example, alternate
between an inadequate and an exaggerated shame response when she is confronted with wrong-
doings. Toby, on the other hand, has developed coping strategies, a mentalizing capacity, and a
balanced capacity to regulate shame and pride.

Mental flexibility and mentalizing capacity

Mentalization capability is what allows human to “read” someone else’s mind and to predict and make
sense of other people’s behavior (Fonagy et al., 2002). The child’s previous experiences with others
make it possible to establish and structure multiple sets of self- and other-representations. Because
mentalization is such a key aspect of human social functioning, the development of mental structures
for interpreting interpersonal actions is crucial for the development of social skills and for the parent’s
ability to understand the child mentally and “having the child in mind” (Fonagy et al., 2002; Hart,
2016a).
The development of a mentalizing capacity is initiated around the age of 3–5, when the child
begins to reflect on the mental states and actions of others. The development of mentalization,
thinking about feelings and thoughts, is an integral part of achieving a more nuanced understanding
of oneself (Fonagy et al., 2002). Language seems to be a key mechanism for this integration; for
example, language combines actions with sensations and emotional perception and, through story-
lines, interlinks sensations, feelings, thoughts, and actions in ways that organize both our inner and
outer realities (Fonagy et al., 2002). For instance, Toby’s parents were able to improve their dialogues
with Toby about feelings and about their relationship. He was well behaved and considerate of
others, and although he was not always good at verbalizing his difficulties, it felt natural for him to
make the attempt. Even with a secure attachment pattern, it is normal to lose one’s mentalizing
capacity in situations characterized by emotional pressure (Fonagy et al., 2002), and it was difficult
for Toby to mentalize when he felt he had to be careful not to make his parents sad, after their
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 37

divorce, by favoring one parent over the other. He therefore benefited from dialogue-based psycho-
logical counseling because he felt comfortable with his therapist was able to avoid getting into a
loyalty conflict when he talked about the difficulties of living in two homes. He had access to an age-
relevant inner self-observing structure and was able to understand himself from multiple perspec-
tives. In other words, he had developed a mentalizing capacity, and with the right support he was
able to use it in practice (Hart, 2016c).

Tailoring an intervention plan

According to NADP, in tailoring an intervention plan it is necessary to assess the functional level of
intervention by assessing the client’s emotional level of functioning, resource areas, and the for-
mative level of his or her mental imbalance, since interventions must always begin by addressing the
given resource within the zone of emotional proximal development (Hart, 2011).
Neither Benjamin nor Catherine had developed a sufficient prefrontal capacity to profit from a
dialogue-based psychotherapy. A mature prefrontal cortex balances emotional and mental impres-
sions and enables mental journeys. All dialogue-based forms of psychotherapy rely on a sufficient
mental and emotional capacity to link past, present, and future and to maintain an inner sense of
interactions over time (Hart, 2011). For instance, a client such as Toby, who has a secure attachment
pattern and mentalizing capacity, will be able to profit from all forms of dialogue-based psychother-
apy (Bentzen & Hart, 2015).
For Benjamin, dialogue-based psychotherapy is outside his zone of proximal emotional develop-
ment, while Catherine would be able to work with a mix of experimental and dialogue-based forms
of psychotherapy. There are several psychotherapies that can be effective for Catherine, including
acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 2012), emotion-focused
therapy (EFT)(Greenberg, 2015), compassion-focused therapy (CFT)(Gilbert, 2010), and receptive
music therapy (Lindvang & Beck, 2017). The development of empathy, sympathy, and emotional
regulation is supported by an activation of the circuits between the limbic and orbitofrontal cortex
through both bottom-up and top-down interventions (Bentzen & Hart, 2015; Schore, 2016).

Intervention through synchronized interactions based on sensory perception and arousal

regulation
With his history of profound neglect and developmental trauma, Benjamin needed a different type of
intervention than Catherine and Toby. At the rehabilitation home, Benjamin reacted with anger and
aggressive behavior, and he was controlling and constantly challenged boundaries. He never recog-
nized his own role in disagreements, and when he was tense he showed threatening behavior. He
sold cannabis and other drugs, and in connection with collecting a drug debt he committed
homicide and was sentenced to prison. He was fortunate to be an inmate in a ward that had
received funding for a project aimed at supporting personality development. The staff took the
young inmates, including Benjamin, on demanding survival trips, which challenged his perceptions
and sensations and included cooperation tasks where the participants had to work together by
synchronizing their actions. Since he was fond of music, they also made him participate in a ward
band. The staff managed to develop a close bond among the young men, and many maintained that
bond of friendship even after they were released (Hart, 2016c).

Intervention through affective attunements by means of marked, contingent mirroring

Catherine needed a different kind of intervention than Benjamin. Catherine’s mother was
unpredictable, and her shifts between selflessness and selfishness made it difficult for Catherine
to navigate. Catherine was offered intensive outpatient individual therapy and group therapy with
other teenagers. In this setting she had a primary professional with whom she developed an
38 S. HART AND S. L. JACOBSEN

attachment, and who was able to support her by offering emotional stability, regardless of
Catherine’s behavior. At first, it was difficult for Catherine to adapt to this due to her negative
attitude toward others and her almost explosive outbursts of anger. However, after two years,
Catherine’s attachment pattern was far less ambivalent, and it was easier for her to regulate her
emotions (Hart, 2016c).

Intervention through dialogues

Although Toby has had optimal early conditions for emotional development, he is not spared the
challenges caused by the ups and downs that life includes and which may trigger regression. Stressful
situations, such as his parents’ divorce, may result in life crises that impair his coping strategies. In
his dialogues with the psychologist, it emerged that Toby was afraid of making his parents sad or
disappointed in him, and through mentalizing dialogues he became conscious of his anger and
sadness regarding his parents’ divorce. He gradually became more outgoing and began to socialize
with peers. Toby clearly profited from dialogue-based psychotherapy (Hart, 2016c).

Bottom-up and top-down interventions

According to NADP, a part from working directly on the three hierarchical levels in psychotherapy, it is
also necessary to activate both afferent and efferent structures in the brain by applying both bottom-up and
top-down processes to activate the formation of connectomes (Cozolino, 2017; Seung, 2013), for example,
by both working with sensations and arousal regulation, the emotions this evoke, and verbalizing the
experiences. When brain structures are underdeveloped they cannot support the regulation process, and
often top-down control is not a possibility (Hart, 2011). In the case of Benjamin, it is crucial to develop the
self-regulation capacity in the basic levels of his autonomic sensing brain before it is possible to activate
emotional regulation and top-down control through prefrontal structures (Hart, 2016c). With Catherine, it
is crucial to develop emotional regulation before she can profit from a solely dialogue-based psychother-
apeutic approach. By working in the proximal zone of emotional development, it is possible to work
bottom-up and top-down in developing structures. With Benjamin, this means combining autonomic and
limbic structures; with Catherine it means combining limbic and prefrontal structures. Benjamin’s
proximal zone of emotional development is based on emotional stimuli connected to the more basic
parts of the brain, which calls for an approach that has synchronization as its main focus, while Catherine
needs affective attunement combined with mixed methods of experimental and dialogue-based methods
(Hart, 2016c). Toby can profit directly from dialogue-based forms of psychotherapy with a psychotherapist
who combines affective attunement and marked mirroring with mentalizing dialogues (Hart, 2016c).
Both top-down and bottom-up intervention forms serve to connect the brain’s hierarchical levels and
to merge body, emotions, and conscious awareness. This integration includes a balancing of the arousal
system of both sympathetic and parasympathetic activity, the regulation of raw emotions and a devel-
opment of the capacity for processing, inhibiting and organizing impulses and emotions in the prefrontal
cortex (Cozolino, 2017). Whenever possible, it is important also to activate cortical processing through
the deliberate control of thoughts and emotions because top-down interventions facilitate an under-
standing of emotional reactions that affect feelings and behavior (Cozolino, 2017). The purpose of a top-
down intervention is to give the client an experience of being able to understand and manage his or her
symptoms (Hart, 2012). The more neural structures are activated, the greater is the possibility of neural
integration. As much as therapy is about establishing attachment and relationships, it is also about the
reorganization of brain structures, including the promotion of mentalization (Cozolino, 2017).

Conclusion
Within the theoretical frame of NADP, the understanding of human emotional development as
organized hierarchical and successively, interventions aimed at developing the capacity to self-
 JOURNAL OF INFANT, CHILD, AND ADOLESCENT PSYCHOTHERAPY 39

regulate involve stimulating neural structures within the zone of proximal emotional development,
according to the to the client’s specific emotional mental organization (Bentzen & Hart, 2015).
Interventions must always be directed at levels of emotional function where the client has emergent
properties (Bentzen & Hart). The aim of NADP is to understand emotional development, personality
vulnerabilities and disorders, and the maturation of emotional capacities within attachment-based
relationships and to translate this understanding into intervention plans that can be discretely
adjusted to match the complexity of human development (Beebe & Lachmann, 2002; Hart, 2011).
In this article, three case vignettes have been used to illustrate how NADP can be applied in real-life
settings, offering a model of understanding the importance of being aware of and tailoring inter-
vention methods and psychotherapeutic approaches. The case presentations have demonstrated how
NADP can be used to identify the client’s level of emotional development and match it with a
tailored intervention strategy.

Funding
This work was supported by the Department of Science of Humanities, Aalborg University.

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