How Psychotherapy Works: Learning from Infants

A sense of worry fell over our Friday morning group whenever we discussed Casey, who had lost custody of her newborn and 5-year-old sons when she tested positive for stimulants at the time of delivery. In our program supporting families in recovery from substance use, peer recovery coaches, clinicians, and supervisors meet weekly to review cases. We all noticed that Casey seemed unable to think about the baby. Each of her interactions with staff revolved around her rage at the Department of Children and Families (DCF) for taking the older boy, who was now living with his father. Not once did she mention her infant, now in her sister’s custody.

All members of our team had viewed Ed Tronick’s still-face experiment together at multiple trainings. In the classic version viewed over 10 million times on YouTube, following a period of typical play the mother presents a still face to her infant. The baby responds right away with efforts to engage the mother followed by vigorous protests. When the mother’s face comes back to life after a short period, the baby almost immediately smiles and meets her mother’s gaze, communicating that all is forgiven. The primary message is one of hope- the baby has done this millions of times in ways that go unnoticed, so she knows what to do to reclaim her mother’s engagement. In healthy relationships such as this one, brief moments of mismatch are typically followed by repair. But the experiment exposes the viewer to the potential devastation for the infant when the repair is prolonged or absent. Our experience of Casey’s inability to hold her child in mind brought us all into that painful place of unrepaired mismatch. Yet our collective efforts to bring Casey’s relationship with the baby into her thoughts seemed to fail.

One Friday morning that changed. Casey’s DCF worker told her that she would need to wait outside while they visited the home of her sister and infant. Rage threatened to overwhelm Casey. She told her primary therapist, Ivy, of plans to storm the house and take her baby. As Ivy filled us in at the meeting, she shared that alongside alarm, she also felt relief. Finally an opening in Casey’s mind appeared. All of us on the case conference call that morning felt the rage give way to sadness. We saw how the anger at DCF functioned to cover over the profound grief at her separation from her newborn son.

Ivy told us she had offered to meet with Casey later that morning while the DCF worker was with her baby. Casey declined the offer. But when Ivy updated our group the following week, she described exchanging texts throughout the day, staying connected in a way that Casey could tolerate. Over the course of that afternoon Casey fluctuated between anger and despondence, with her thoughts turning dark and her words communicating threats of violent and self-destructive behavior. But she got through it. In her last conversation with Ivy late Friday Casey had said, “I won’t do anything stupid. I’ll be OK.”

Ivy spent the weekend in a state of anxious uncertainty, but when she met with Casey for her therapy session the following Monday she sensed a dramatic shift. Casey began for the first time to speak of her childhood, telling the story of her own mother’s intermittently unavailable under the influence of alcohol. Following a domestic violence incident which she witnessed, her father went to prison. Casey had wept as she connected her current situation with her past. She knew what it felt like to lose a parent. How could she now put her own child through that? As they shared this moment of mourning, Ivy experienced a sense of deep connection with Casey.

This clinical vignette offers evidence for the Repair Theory of Development, rooted in decades of research that followed the original still-face experiment. Detailed videotape analysis of parent-infant pairs, in findings replicated over decades in a wide variety of settings and applications, reveal that healthy relationships are characterized not by perfect attunement but by a messy process of mismatch and repair. This continuous moment-by-moment meaning making builds resilience and trust. The capacity for both self-regulation and intimacy grow from countless interactions in our earliest relationships. These experiences change our brain and body, organizing the way we function in new relationships throughout our lives.

The series of texts exchanged that Friday afternoon represented an ongoing process of mismatch and repair as Ivy worked to connect with her sad and angry client. Strung together these moments allowed Casey to move from hopelessness to hope. The trust she gained in this new relationship in turn gave Casey a different sense of herself, opening up the possibility of new connections in her wider social world.

Repair Theory has significant implications for treatment of emotional suffering. It offers a model of mental health that differs dramatically from the medical model of mental illness. Rather than being fixed, our emotional wellbeing evolves in a continuous process over time. Early interactions lacking in robust repair create meanings of hopelessness that lead to emotional suffering and derailed development.  New sets of relationships with different quality of interactions can promote healing and growth across the lifespan. When we move from hopelessness to hope even in one brief moment with another person, we gain a new meaning. The repair itself fuels growth and change.

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