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The Injured Self: The Psychopathology and Psychotherapy of Developmental Deviations

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The book examines the clinical implications of innate developmental individuality. The authors present a model of what they call "developmentally informed" therapy, based on the assumption that biologically determined (or co-determined) maladjusted behaviours and deficiencies of ego functions cannot be resolved by interpretation of an unconscious conflict, but need to be "validated", analysed, and integrated with the personality. Several clinical case histories illustrate the authors' approach. The case presentations are followed by a discussion of counselling parents of children with developmental deviations. The authors also discuss the theoretical issues that arise from this and the role of cognition, especially learning, in the therapeutic relationship and the therapeutic process. Finally, the authors present some recent advances in neuro-behavioural sciences which appear relevant to the issues discussed in the book and close with a concluding discussion.

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CHAPTER ONE: Psychotherapy of a borderline child: Uri

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When Uri's former therapist found a note saying that Uri had called from a military base, she became concerned. Was the phone call a signal of distress? Could this sensitive youngster make it in the rough world of military service? Her concern was understandable, because most of Uri's early childhood had been an unrelieved misery, and his treatment stormy and arduous. As it turned out, there was no reason for concern after all. Uri, having learned that the therapist had recently moved to a city near his base, had called to tell her proudly that he had been admitted to the Israeli Air Force Academy, the most selec tive and demanding military flight training program there is.

Looking back at Uri's therapy we believe that its success and the stability of the treatment gains were due to an integration of psychoanalytic and developmental insights. The analytic approach was applied to interpretation of conflicts and defences. The insight into developmental pathology helped to shed light on the aberrations of emotional development and their impact on Uri's self-image and family interaction. The diagnosis of idiosyncratic development wascrucial in building up and sustaining a therapeutic alliance with the child and his parents, and relieving the sense of perplexity, impotence and hopelessness that dominated the family atmosphere. Understanding the deviational development and its impact was also essential in order to mobilize the considerable resources with which the child and his parents had been endowed. Therefore, we present in detail the case of Uri and his treatment to illustrate the practical as well as scientific need to integrate psychoanalytic and developmental approaches.

 

CHAPTER TWO: Early development and the developmental matrix

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The twentieth century, heralded as “the century of the child” (Key, 1911), lived up to that name. The past decades have witnessed a growing interest in the study of children in general and infants in particular, reflected in an expansion of developmental studies. Volumes have been written on child development, and prestigious journals devoted to the subject are being published. The exponential growth of scientific data necessitates a re-assessment of psychoanalytic theory of emotional development. The early developmental theories formulated by Freud (1905, 1915) and his students, as well as those of most later psychoanalytical writers, were, by and large, inferred from reconstruction arrived at during the process of psychoanalysis of adults or older children. Mahler, Pine, and Bergman (1975) were the first psychoanalysts to conduct systematic observations of infants and toddlers. Studies conducted more recently by psychoanalysts such as Stern (1977, 1985) and Shuttleworth (1989) attempt to integrate data from systematic observations of infants and toddlers with data derived from adult or child analysis and are, therefore, more valid empirically than earlier studies. Even so, the subjective experience of the preverbal infant eludes our investigative tools, and theories of early emotionaldevelopment are based, at best, on extrapolation and conjecture, and at worst on fantasies and projections of the adult patient or of the investigator. In spite of these limitations, systematic observations of the infant's behaviour, of his emotional expressions, and of his response to his caregivers provide us with valuable data that have greatly modified our early views on emotional development.

 

CHAPTER THREE: Clinical manifestations of developmental deviations

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Developmental deviation, in the context of this chapter, refers to a variety of patterns of idiosyncratic development, including temperamental variability, developmental lags, circumscribed functional impairments, and relatively minor cases of discrete clinical syndromes such as Attention Deficit Hyperactiv-ity Disorder (ADHD). We do not refer to gross pathological conditions such as Autistic Spectrum Disorders or mental retardation. Rather, we discuss relatively subtle deviations that allow a person to develop and function within a seemingly normal range yet may have a profound effect on emotional development and personality. The common element in the conditions we discuss is the presence of a demonstrated or presumed biological factor resulting in emotional or behavioural maladaptation. The nature of such a biological factor is not always easy to establish, but we know that genetic factors, the intrauterine environment (such as maternal stress or nutrition), and the early physiological and social environment all influence brain development and hence later emotional and interpersonal development. In many cases it appears probable that multiple factors operate in synergy to disrupt optimal development. The case of Uri (Chapter One) illustrates the need to take such biologicallyinfluenced idiosyncrasies into consideration when dealing with patients whose development has been irregular or impaired.

 

CHAPTER FOUR: Emotional effects of developmental deviations: the injured self

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Developmental deviations do not appear as isolated entities. To the contrary, they affect the emotional and social development of the infant and of the child, and they become incorporated into the structure of personality. We have already mentioned some of the effects of idiosyncratic development on how the infant perceives his environment and reacts to it; the response of the caregivers will be discussed in more detail in Chapter Seven. Here we will discuss the effects of developmental deviations on how the infant (and later the child) perceives himself.

Emotional development revolves around the polarities of gratification and frustration. The loving, empathic care of the mother (or an alternate caregiver) assures the prompt satisfaction of physical needs, such as hunger, and of emotional needs, such as the wish for attention or physical closeness. Satisfaction of needs instils in the infant a sense of security, or “basic trust” (Erikson, 1963). Satisfaction of needs, however, is not always possible or prompt, and as a result the infant experiences frustration. If the frustration is neither too distressful nor too prolonged it stimulates growth. The child learns to anticipate satisfaction and delay the satisfaction of his need. For example, a hungry infant who was crying dejectedly a momentago may laugh at the sight of his familiar cup even before gulping the cereal it contains. Anticipation occurs when the infant recognizes the signs of approaching satisfaction; hence, anticipation involves a degree of cognitive organization and an ability to relate the present perception to a remembered one and to the gratification experienced in the past. At the same time, the cycle of frustration and satisfaction stimulates cognitive growth and the ability to contain drives. In other words, emotional development and perceptual-cognitive organization depend on each other. Frustrations also motivate the child to find the means to overcome obstacles and satisfy his wishes; in this way frustration, too, stimulates cognitive and motor development. This stimulation occurs, however, only if the child's efforts lead frequently enough to a successful outcome. If the child's efforts remain futile too often, the result is a temper tantrum or loss of interest, withdrawal and listlessness. Only the sequence of wish-frustration-effort-satisfaction-pleasure has a growth-promoting effect.

 

CHAPTER FIVE: Effect of deviations on the progression of developmental stages

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There are different ways to describe the stages of emotional development, though most investigators agree on their approximate chronology. Freud referred to them as stages of “psychosexual development”, emphasizing the vicissitudes of the sexual drive (Freud, 1905). Most later psychoanalytic investigators emphasized the infant–mother relationship (e.g., Mahler, Pine & Bergman, 1975; Shuttleworth, 1989; Stern, 1977) or the consolidation of personality (Erikson, 1963, 1979). Most investigators refer to the maturation of a developmental milestone as the ushering in of a new stage. It is useful for our purpose, however, to describe emotional development in terms of the developmental aim of each stage.

The aim of the first stage of infancy is the consolidation of an infant– mother (or infant–caregiver) bond. In the terms of Bowlby and his students, a most favourable outcome of this stage is a secure attachment (Ainsworth, 1982; Ainsworth, Blehar, Waters & Wall, 1978; Bowlby, 1982).

The crucial importance of early attachment for later emotional development cannot be overstated and is amply documented in clinical and in research literature. Bowlby and Ainsworth attributed secure attachment to the availability of an empathic caregiver. It is, however, equally important that the infant's perceptual, motor and emotional functions be reasonably well integrated so that the child can benefit maximally from such care-giving. Such integration is facilitated by empathic and consistent care-giving, but it also requires adequate innate endowment. Therefore, any innate idiosyncrasy that interferes even slightly with attachment, e.g., hypersensitivity or excessive propensity to anxiety, may have long-lasting adverse effects. This, however, need not be taken as a verdict of inevitable fate: infants, as well as parents, have a great capacity to adapt, to respond to feedback and to learn from experience. The effect of innate factors is an increased risk of unfavourable outcome, not an inevitable cause. Having said this, we will examine the possible interference of developmental factors with optimal attainment of attachment.

 

CHAPTER SIX: Coping with maladaptive development

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Both children and adults whose development was less than optimal adopt different defensive manoeuvres to minimize the resulting distress and to maintain reasonably gratifying social relationships. There is considerable overlap between those manoeuvres and what we call “defence mechanisms”, but there is also a basic difference.

“Defence mechanism” is a term coined by Freud and elaborated by Anna Freud (A. Freud, 1936). It refers to psychic functions (and more specifically unconscious ego functions) whose ultimate goal is to prevent the subject from acting upon “forbidden” impulses, i.e., impulses (most often sexual or aggressive) contrary to the subject's own moral values and to his self-image (or his ideal self-image, i.e., how he wants to be). Those inhibitory devices arise originally from internalization of parental injunctions and parental values and reflect the society's moral code. The feature common to all mechanisms of defence is that they achieve their aim by keeping forbidden wishes out of consciousness, by repressing them.

 

CHAPTER SEVEN: Raising a child with idiosyncratic development: a mission barely possible

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We refer in this chapter to parents rather than caregivers in general, as we did in previous chapters, because parents have an emotional investment in their child different from and more complex than that of any other caregiver, no matter how strong another caregiver's attachment to the child might be. Parents, as a rule, perceive their offspring, to some extent, as extensions of their “Selves”. That perception may be very dominant or slight, conscious or not, but it is hardly ever absent. As a result, some of the narcissistic investment directed toward the Self binds to the person of the child. Therefore, a parent projects his or her narcissistic aspirations on the child, often hoping the child will succeed where the parent has failed. Another, not unusual, narcissistic need of the parents is for the child to serve as “proof” that the parents are “good” and competent in their roles, consonant with their perception of “good” parenting and with the expectations of the society. The criteria for “good” parenting vary across cultures. For instance, in European societies of the nineteenth century, the child, in order to demonstrate parental competence, had to be healthy and well fed, preferably plump (in Yiddish the word for “healthy” also means “fat”), and well behaved when older. Today, a fat child is more oftenthan not a sign of parental disregard for a healthy diet. With the advent of child development studies in the last century, the child of competent parents is supposed to be intelligent and, in some circles, happy most of the time. The school system still mostly wants well-behaved children (the schools call it “motivated”), and not all teachers value critical inquisitiveness or vivaciousness. All this taken together imposes rather arduous demands on any parent, and it becomes a mission almost impossible when the innate abilities of the child simply do not fit such goals.

 

CHAPTER EIGHT: Diagnosis of developmental deviations

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The diagnosis of a developmental deviation may be obvious, as in the case of a hyperactive child, or it may be subtle, as in impairment of working memory in an adult. The problem may be apparent to the patient, his parents, or even a casual observer, or its identification may require professional expertise and specialized instruments. The age of the subject and his developmental stage determine the diagnostic procedure. In most cases, a detailed history is indispensable; a family history may often be helpful, since genetic factors may play a role, as we have already mentioned.

We will examine the diagnostic procedures according to age: infancy and toddlerhood, childhood, and adulthood.

We will first discuss the subject of risk factors for developmental irregularity. Such risk factors are the domain of obstetrics and of neonatology and are much too numerous to review here; we will mention only a few common ones, some of which we have encountered ourselves. As a rule, any condition that can adversely influence the pregnancy may represent a risk factor for the development of thechild. Such conditions include maternal diabetes (a very common unfavourable influence on the developing foetus), malnutrition, infections, especially viral infections, exposure to radiation, many prescription drugs, heavy smoking, and most substances of abuse, especially alcohol and opiates. Paternal exposure to alcohol or ionizing radiation is also likely to have an adverse effect (Abel, 2004; Morgan, 2003). Foetal factors comprise anything that can adversely influence the development or maturation of the foetal brain, including inborn errors of metabolism (e.g., hypothyroidism or phenylke-tonuria), cardiovascular malformations interfering with brain blood supply, neonatal prematurity, a small-for-age neonate, heavy medication during labour, foetal anoxia, and neonatal jaundice.

 

CHAPTER NINE: Developmentally informed therapy

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There are several therapeutic modalities for patients whose maladjustment is, in part, a result of developmental impairment. Pharmacotherapy, remedial tutoring, physiotherapy, occupational therapy, and even exotic methods such as therapeutic horseback riding have been employed with varying degrees of success. As a matter of fact, in many cases the optimal treatment plan seems to be a combination of several modalities that complement one other. Our concern here is with remedying the adverse consequences of an atypical endowment for the emotional development of the subject, and therefore our main focus is on psychotherapy, including psychoanalysis. Nevertheless, we will briefly refer to other means of helping the patient, since they need to be included in an overall treatment plan. Such a multimodal treatment plan is illustrated by the case of Dror (Chapter Six).

Our approach to the treatment of patients (and children in particular) who are affected by developmental impairments encompasses the following core elements (the order of presentation does not necessarily imply chronology or degree of importance):

 

CHAPTER TEN: Psychotherapy of a girl with minimal ADHD: Giselle, the “Girl who Tamed Dinosaurs”

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Giselle was nine years old at the time of referral for consultation. She was described by her mother as “irritated and irritating”, and the main complaints were difficulties in relationship with her parents and her younger brother, two years her junior, with whom she fought most of the time. She was friendly toward her youngest brother, who was twenty months old at that time, and she willingly participated in taking care of him. Giselle's parents reported that she often refused to comply with reasonable requests, overreacted to minor frustrations, and was occasionally physically aggressive toward her seven-year-old brother, whom they described as a friendly and lovable child. When the parents attempted to discipline her by sending her to her room, she would slam the door and kick it or throw things around to the point of causing damage.

Her school performance was satisfactory though uneven: when motivated she achieved high grades, but not infrequently she would neglect or forget her assignments and sometimes did poorly on tests. There were no behaviour problems at school. Her social life, however, was fraught with difficulties: she had no girl friends, engaged occasionally in some games with a few boys from the school, but was close to no one. Attempts by the parents to engageher in extracurricular activities were short-lived, in spite of Giselle's initial enthusiasm.

 

CHAPTER ELEVEN: Reconstruction in psychoanalysis: Ms. C., the “Slow Scientist”

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Freud, working with Breuer (Breuer & Freud, 1893–1895), made the historic discovery of the relationship between the symptoms of psychoneurosis and early childhood life events, including the early relationship with parents and other close family members. Since then, reconstruction of those events and relationships has become a cornerstone of the therapeutic process, as has the analysis of defences and of the transference. The primary aim of the latter is, as a matter of fact, to open the way to the reconstruction, which maintains its status as a mainstay of psychoanalysis and psychoanalytic psychotherapy (Blum, 2005). All methods of psychotherapy based on psychoanalytic theory (and not only psychoanalysis proper) include a measure of exploration of childhood life events and relationships and their relevance to a patient's present difficulties. The task of reconstruction is not merely to uncover repressed infantile wishes and traumatic events of childhood, but also to integrate them with the adult personality: a man's or a woman's loves and hatreds, his or her values, fears, and hopes.

 

CHAPTER TWELVE: Psychoanalysis of a patient with borderline personality disorder and minimal encephalopathy: Mr. G., the “Great White Hunter”

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The issue of possible innate or acquired biological determinants in personality formation and in psychopathology is particularly relevant in cases of BPD. This diagnostic category comprises various clinical entities with some common and characteristic features (Gunderson, 2008; Gunderson & Singer, 1975). One of these features is an impairment or weakness of the integrative functions of the ego, such as repression, affect control, drive inhibition, or reality testing under stress (O. F. Kernberg, 1984). Such functions depend on effective operation of the brain, and it is therefore understandable that numerous investigators assumed that conditions that interfere with the optimal functioning of the brain might contribute to the formation of a borderline personality. More advanced techniques for the exploration of the structure and function of the living brain have confirmed that assumption. (We have listed the relevant publications in Chapter Three.) Over the last decade, researchers have shown increasing interest in psychotherapy of BPD and in the evolution of therapeutic modalities designed for that purpose (Gunderson, 2008), such as Dialectical Behaviour Therapy (Shearin & Linehan, 1994), Transference-Focused Therapy (O. F. Kernberg, Yeomans, Clarkin & Levy, 2008), and mentalization-based psychotherapy (Bateman, 2009).Here we describe a “developmentally informed” psychoanalysis of a young man diagnosed as suffering from Borderline Personality Disorder and presumably from a subclinical form of encepha-lopathy, and we discuss the factors that seemed to have facilitated a favourable outcome.

 

CHAPTER THIRTEEN: Shahar: art therapy of a boy with Attention Deficit Hyperactivity Conduct Disorder

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Hyperactive children are prone to be also impulsive and aggressive, especially if the home environment does not provide both adequate limit-setting and emotional support. The problems of behavioural maladjustment of such children are frequent and occasionally serious enough to justify a distinct diagnostic category, namely Attention Deficit Hyperactivity Conduct Disorder (ADHCD). We have already mentioned in Chapter Six that such a diagnosis should not automatically imply that the child presents the features of an antisocial personality, and it should be applied sparingly. Children with ADHD are frustrated by their developmental impairments (it should be remembered that many children with attention deficit present also other impairments) and angry, like most other devel-opmentally handicapped children. In most cases, however, children with ADHD have an internalized sense of social values (in other words, an integrated super-ego) and a capacity to form affectionate relations, both in the family and outside of it. Their main difficulty is not inadequate socialization but impairment of drive inhibition, affect dyscontrol, and impulsivity. Such children can deriveconsiderable therapeutic benefit from “developmentally informed” psychotherapy, supplemented by parental guidance, in addition to any other therapeutic modality, as described in Chapter Nine.

 

CHAPTER FOURTEEN: Parent counselling and early intervention

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Helping an infant or a child afflicted by a developmental problem is a joint endeavour of the therapist and the parents, and the parents' cooperation is a prerequisite to any intervention. Moreover, in many cases, especially those involving younger children, the clinician merely provides guidance, and the agents of change are the parents. Therefore, the topic of early intervention overlaps almost completely with that of parental guidance. In our many years of clinical practice, we have very rarely encountered parents who truly did not care about being “good enough” parents. The motivation may be genuine affection for and empathy with the child. It may be a narcissistic wish to prove to others (and to oneself) that one is capable of competent parenting. Most often the motivation is a combination of both. It is prudent, therefore, for the clinician to start with the premise that parents who fail to provide adequate parenting are probably aware of the fact (though they may find it difficult to admit it) and pained by it. It is also helpful to assume that their parenting, misguided as it may be, is the best they are capable of doing without external help. Even parents who aggressively project blame do so out of helplessness, and they may be able to respond positively to a frank discussion of the problem, painful as it may be.

 

CHAPTER FIFTEEN: Mastery, aggression, and narcissism

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“[The will to power …] is the primeval tendency of the protoplasm.”

—(Nietzsche, 1901)

“There's gold, and it's haunting and haunting; it's luring me on as of old;

Yet it isn't the gold that I am wanting, so much as just finding the gold.”

—(Service, 2001)

Ori, a two-and-a-half-year-old toddler, tries very hard to join some pieces of Lego in a manner known only to himself. He is visibly frustrated by the difficulty and angrily rejects offers of help, saying, “Not that!” Finally he succeeds in putting together a sort of a landing platform, which he raises in a triumphal gesture, his face beaming with pleasure, and announces proudly: “My Auntie Ettie 'teached' me!”

What is the motivational force driving Ori's efforts? What drive release provides the source of his joy? These seemingly simplequestions pose a challenge to the psychoanalytic theory of drives. Exploratory behaviour, manipulation of the physical as well as the social environment, practicing skills for their own sake: all these seem to form a life-long continuum of an urge to master one's own body as well as the environment. Like Ori, we all invest occasionally considerable effort into these activities and derive joy or frustration from success or failure.

 

CHAPTER SIXTEEN: Cognition in psychoanalysis and psychotherapy

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Psychoanalysis, from its very inception, was conceived of as a cognitive process, influencing the emotional life of the subject, i.e., the person undergoing psychoanalytic treatment. We have in mind, naturally, Freud's first model of the mind, the “topographical” model (Freud, 1923). Freud recognized three domains of psychic processes motivating behaviour: conscious, pre-conscious (i.e., not conscious but available to consciousness), and unconscious. This division was not, in itself, an innovation. The existence of unconscious mental processes had already been recognized by philosophers and psychologists from Leibnitz onward (Massey, 1990). Freud's groundbreaking idea was the concept of the dynamic, i.e., repressed unconscious, an idea so revolutionary that it is being disputed by some cognitive theorists (e.g., Daniel Schacter) and neu-roscientists (e.g., Karl Pribram) even today (both quoted in Loden (2001)). Freud came to the conclusion that some unconscious contents are maintained in that state by the force of repression, and that some of those repressed contents, mainly unacceptable impulses and painful traumatic memories, are at the roots of psychoneu-rotic symptoms. Therefore, the process of psychoanalysis involves removing the repression and bringing the unconscious contentinto consciousness. Other models of the mind followed, and the understanding of psychoanalytic therapy became more complex, during Freud's life and after Freud, but the fundamental idea of making unconscious, repressed content conscious remained one of the mainstays of psychoanalysis. The declared goal of psychoanalysis— i.e., gaining insight—implies, therefore, acquiring new knowledge about one's own unconscious psyche, and this process is unquestionably a form of learning, i.e., a cognitive process. In view of this, it is quite notable that exceedingly few psychoanalytical theorists studied cognition and learning, neither in general nor in the specific context of the psychoanalytic process (Bieber, 1980a; Bucci, 1997; Greenbaum, 1985). The reason for such apparent neglect, most probably, was that Freud, like Breuer, considered affect to be the primary mover in the causation and in the cure of psychoneurotic disorders, and he assigned cognition an auxiliary role in both (Bieber, 1980a, p. 25). Other analysts followed the same approach and implicitly treated cognition as merely an instrument in the process of psychoanalysis. In general, psychoanalysts who did study cognitive processes directed their interest predominantly to the issue of memory and repression (Shevrin, 2002).

 

CHAPTER SEVENTEEN: Neurobiological perspective

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The last decades have witnessed dramatic progress in neurobiology, largely owing to the introduction of new brain imaging techniques such as CT, MRI, fMRI, positron emission tomography (PET), and single photon emission computed tomography (SPECT). These imaging techniques, together with more advanced methods of interpreting EEG tracing, give an unprecedented picture of the structure and function of the living brain. These methods do, however, have their limitations and shortcomings. For instance, fMRI, the instrument most widely used to study brain function, has been criticized as showing simultaneously areas of the brain (“vixels”) containing very large numbers of neurons and as giving only an indirect, not always reliable, indication of neuro-nal activity (Logothetis, 2008; Logothetis, Pauls, Augath, Trinath & Oeltermann, 2001). Therefore, we should interpret with caution such findings as an enhanced fMRI signal (i.e., increased blood flow) that occurs in a certain brain area while the subject is experiencing a certain affect or engaged in a specific task: It would be premature to consider this type of finding as clear-cut evidence that the function under observation is “localized” in the active brain area. Nevertheless, the yield of the new imaging methods is prodigious, and the insights they afford would have been relegated to the realm of science fiction half a century ago. The same applies to the decoding of the human genome and the consequent genetic explorations. It would not be an overstatement to say that the twenty-first century has ushered in new chapters in the study of human nature.

 

CHAPTER EIGHTEEN: Conclusions

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Developmental aberrations, temperamental idiosyncrasies, and subtle deficits in sensory, motor, or cognitive development are frequent occurrences. Their impact on the early infant–caregiver relationship, their effect on the way the infant experiences his world, and their role in shaping the personality are profound. Their significance is often recognized in theory, but largely ignored in clinical practice. Developmental deviations are the subject of exceedingly few investigations, in contrast to the vast amount of research dealing with the effect of the early environment and of traumatic events. Few, if any, psychoanalysts or psychotherapists pay attention to innate, presumably biologically determined factors in the course of therapy. The attention devoted to the early object relationships and to early traumas is entirely justified; the lack of attention to innate factors is not.

We have tried in this book to address the clinical issue of developmental individuality. Many of our patients, children as well as adults, manifested patterns of maladjustment, psychoneurotic symptoms or maladaptive personality patterns that were determined or (more often) co-determined by developmental idiosyncrasies. Such idiosyncrasies often lead to a “mismatch” betweenthe developing infant or child and his caregivers. The aberrations may be innate, genetically determined, or acquired very early in life owing to adverse events (e.g., foetal distress or physical trauma), and their cause is biological rather than interpersonal. More often than not they remain unrecognized, to the detriment of the therapeutic process, be it psychoanalysis or psychotherapy.

 

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