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Infant Observation

ISSN: 1369-8036 (Print) 1745-8943 (Online) Journal homepage: http://www.tandfonline.com/loi/riob20

A complex mixture of forces


Alan Shuttleworth
To cite this article: Alan Shuttleworth (2004) A complex mixture of forces, Infant Observation,
7:2-3, 43-60, DOI: 10.1080/13698030408405042
To link to this article: http://dx.doi.org/10.1080/13698030408405042

Published online: 04 Feb 2008.

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A complex mixture of forces


Alan Shuttleworth

Th

e paper argues that purely psychoanalytical theory, by itself,


is not suflicient to understand rnany of the complex, mixed
states carried by many of the children seen by child
psychotherapists. Mixed forms 1.f understanding are needed.
P.sychoanalyticthinking and hardscience are not the same as each other
but need to be brought into active dialogue. As an instance of this, the
paper looks at the relationship between Kleinian thinking and attachment theory and argues that a mixed, inner world and environment
sensitive fomri of thinking, that draws on both Klein and Bowlby, has
become characteristic of Kleinian child psychotherapy today. This established way of thinking is now being stretched in order to accornvrwdate
ne~~roscicntificpna~n~s.

Key words
Child psychotherapy; Attachment Theory; containment; holding; biopsycho-social.

Introduction
Margaret Rustin (1997,p 264) has written about the most difficult cases
that child psychotherapists see, in which there is a complex mixture of
forces at work, interacting with each other. These are children who are
carrying more than one kind of damage, or present co-morbidlty. In
terms of ZCDlO, they may have problems on multiple axes. In psychoanalytic terms, the difficulties that have brought them to a child psychotherapist are likely to have their origm in more than psychodynamics alone.
Where psychoanalytic child psychotherapy can be helpful, it is unlikely to
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lead to a complete cure. In order to help such children, radically different kinds of understanding and intervention may need to be combined.
Child psychotherapists are then required to face in two different directions: they need to retain a high degree of focus on their own specialised
task, for this is the only basis on which they can be helpful; and they also
need a more panoramic point of view, to see that what they can understand and help to bring about is only part of something larger.
This requires holding in mind things that have a strong natural
tendency to pull apart, to split. Child psychotherapists understanding of
this complexity has emerged in two main phases. Firstly, over a sustained
period of time, child psychotherapists in all theoretical schools became
substantially more sensitive to the importance of environmental factors
than they once were. In doing so, they risked the emergence of deep
inner world versus the environment - either/or - splits. But what actually gradually emerged was a both/and way of thinlung, highly sensitive
to the interaction between the inner world and the environment. This
has become fundamental to the thought and practice of child
psychotherapy as it exists today. Secondly, it is becoming apparent that,
over the last decade, child psychotherapy has entered a new phase, in
which that mixed inner world-and-environment way of thinking is beginning to be stretched again, so as to come to terms with the demonstrated
importance of biologically-based processes: for instance, the role of
genetics in causing certain child mental health disorders, the helpful role
of medication in the treatment of some disorders, and the important
contribution being made by neuroscience. This again brings with it the
danger of deep eitherlor splits - the brain uerssus the mind, bioloffy
versus interaction sensitivity, medication versus psychological therapy.
This papers argument is that such splitting again needs to be resisted.
Instead, we need to work towards an expanded kind of mixed thinking one built around inner world and environment and biological sensitivity
- that elsewhere I have described as a bio-psycho-social way of thinking
(Shuttleworth, 2003).

Double deprivation and primary and setondory handicap


One of the models child psychotherapists have drawn on in developing
mixed inner world-and-environment thought and practice is the theory
of double deprivation described by Henry (1974) in relation to Martin, a
fourteen-year-old boy in long-term foster care, presenting with increasingly unmanageable behaviour. Henry suggested that it was critically
important to recognise that Martin was deprived doubly:firstly, he was
deprived of what he really needed by his real, external, environmental

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A complex mixture of fortes


circumstances, both past and present; he also, secondly, deprived himself
because of the defences he had developed against the pain of this. These
secondary defences made it very hard for anyone to get close enough to
Martin to provide the substantial help he truly needed, leading to further
repeated deprivations. Henry is adamant in her view that her primary
task, qua child psychotherapist, was to focus on the second of these
forms of deprivation; that is, on her patients defences, his own active
responses to the unbearable but unavoidable pain of his given circumstances. But she is also clear that, in order to understand Martin, it was
essential to grasp that what he was doing was defensive; that these were
his ways of responding to extreme circumstances that were not of his
making and were bound to affect him in some way deeply and adversely.
Therefore Martin needed more than psychotherapy alone; he also
needed active, non-psychoanalyticinterventions in an attempt to ameliorate his situation in external reality. The successful progress of the
psychotherapy partly depended on these attempts and on Martins
understanding that Henry understood that they were needed.
The same basic model was subsequently developed by Hoxter (1986)
and Sinason (1986) as the theory of primanj and seconda y handicap.
Hoxter made clear how this gave child psychotherapists a way of articulating how the development of a childs inner life might be profoundly
affected by the combined operation of different forces, including (a)
their given environmental circumstances, which for some children
involve external traumas such as extremes of deprivation, the traumas of
physical or sexual abuse, murder or incest in the family; and (b) their
given biological circumstances, which may include the trauma of physical disabilities which often entail the risk of death and the repeated
frights and assaults of surgical interventions from infancy onwards and
sometimes organic brain damage, with islands and lacunae of functioning and dysfunctioning (Hoxter, 1986); arid (c) the childs own active
ways of responding, sometimes showing extraordinary resilience, sometimes involving a bewilderment of complex defences (ibid).
This both/and/and way of conceptualising the combined operation of a
complex mixture of forces is also well illustrated by Judds (1989)work,
carried out under the influence of Hoxters paper. It gives child
psychotherapists the beginnings of a hio-psycho-social way of thinking
which, with respect to complex cases, allows them to entertain a number
of possibilities. (1) Some primary disorders may result very largely from
organic damage alone, with rather little contribution froin the social environment, the childs own psychodynamic responses, or any psycho-social
interaction between them. Such disorders may, therefore, not be open to
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cure by either psychological or social interventions or by any combination


of them. Nevertheless, the theory suggests that, in such cases, there may
also be damaging secondary psychological (and, perhaps, social)
responses to the primary damage, and that these secondary responses
may be making things worse than they need be and may be helped by
psychological (and/or social) interventions. (2) On the other hand, some
primary disorders may largely be the products of social damage p h ~ s
psychodynamic response, with no substantial primary organic component. Here, the primary disorder may only respond positively to interventions that are psychologically and/or socially based. ( 3 )Some primary
disorders may be the combined product of complex interactive processes,
involving organic and social and psychodynamic factors. In this case,
combined biological and psychological and social treatments may be
needed to cure or reduce the severity of the primary disorder. Here,
again, secondary damage - that is, active defensive responses to the
primary disorder - may also be present and may be responsive to psychological and/or social interventions. In terms of the bio-psycho-social
model being proposed, it is crucial to note that it does not make any a
priori presumptions about which of these possibilities applies in a given
case. What the model does require is that a wide range of possibilities as
to the balance in a particular case should be left open to empirical inquiry
- both scientific and clinical. The child psychotherapist would need to
proceed knowing that it is possible that only some of what they will come
into contact with in therapy may be a product of the childs own agency,
individual personality, or the defensive measures which they have turned
to. Only part of the childs disorder may be open to understanding by, and
amenable to change by, psychoanalyhcdy-based work alone. Some of
what the child psychotherapist will get to know may not be.

The growing impact of science


Developments in hard science, that is, statistically based research using
experimental design, have been critical in bringing about the recently
increased understanding of the importance of biological factors in causing some important child mental health disorders. Particularly influential
on practice are: (a)the strong epidemiological evidence about the role of
genetic transmission in the causation of autism (Szatmari and Jones,
1998);and (b) the epidemiological evidence about the weaker (but real)
role of genetic transmission in causing ADHD, combined with outcome
studies about the value of the use of stimulant medication in its treatment (Sandberg, 2002). In relation to both autism and ADHD, there is
now the beginning of evidence about underlying brain processes. Child

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A complex mixture of forces


psychotherapists alert to this evidence now have no intellectually defensible alternative but to be straightforward in taking on board the significance of hard science-based developments such as these. There are of
course reductionist forms of nothing-but bio-medical thought and practice, which exclude the psychodynamic from consideration a priori, and
which oversimplify the experience of children with these disorders.
These need to be resisted. But there also needs to be a counter-balancing recognition that the relevant science contains things that are true,
that are different from what child psychotherapists previously thought,
that are relevant to their work, and that should change their thinking.
Hunter (2001)pertinently illustrates this in her discussion of two hyperactive children.
Something like this is, I take it, what Rustin had in mind when she
went on from the discussion of the complex mixture of forces, cited
earlier, to suggest that child psychotherapists approach to treatment
and research needs to be set alongside studies from other perspectives epidemiological, organic and sociological (ihid, p.269). Similarly, with
respect to autism, Alvarez and Reid (1999)state that it is our firm belief
that it is only in the synthesis of findmgs from research in epidemiology,
biology, neurology and psychology with those from qualitative research represented by . . . detailed clinical case studies . .. that we shall gain a full
understanding of the autistic condition (p.246).
To bring psychoanalytically-based and science-based approaches
together in this way is a very considerable challenge. The comprehensive, multi-factorial view that is required needs to have the capacity to
articulate how a mixture of radically different factors - the kinds of
defensive processes studied by psychoanalysis, the kinds of cognitive
processing studied by non-psychoanalytic psychology, the social factors
(both the micro-processes of intimate relationships with which child
psychotherapists are familiar and also the macroscopic social processes
and sometimes catastrophic political events studied by the social
sciences) and the organic factors studied by the biological sciences - all
operate in combination with each other in the most difficult cases.
To make progress with this task, we need to recognise that there is
something particularly challenging in it for child psychotherapists. Some
of the professions most fundamental attitudes were formed on a different premise, at a time when a radical a priori materialism and behaviourism, involving an in-principle denial of the mind, and therefore of
psychoanalysis, dominated science-based approaches to psychology.
What the philosopher Charles Taylor (1985)called a kind of Cold War
existed between the correlators and the interpreters (Shuttleworth,

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2000). Fonned in that context, the dominant way of thinking within child
psychotherapy came to involve a turning away from hard science
towards the arts and the humanities and a kind of phenomenological
humanism (Guntrip, 1961) leading to a near absolute eitherlor barrier
between science and child psychotherapy (Shuttleworth, 2003). Each
became largely self-contained and exclusively self-referring. This is
represented diagrammaticallyin Figure 1.

figure I: The Cold War beween child psychotherapy and science

ild Psychotherapy

The development of the British Object Relations School has been


closely linked to the view that profound values are at issue here. Guntrip
(1961) was an important spokesman for the view that psychoanalysis
proper began only when Freud turned away from neurology and from
what was taken to be the associated pull of a kind of scientific reductionism, and turned instead towards a much more complete focus on the
patient that involved a truly psycho-dynamic theory of the personality
implying a philosophy of man that takes account of his reality as an individual person (1961: 17). Guntrip argued that this required a turning
away from science, for when science begins to treat inan as an object of
investigation, it somehow loses him as a person (1961: 16). Science,he
says, is the emotionally detached study of . .. what phenomena have in
cornmon so that the isolated individual object or event can be grouped
with its fellows and understood according to what science means by
understanding. As a consequence, scientific explanation equals the
elimination of individuality ... aiming to produce theories which are
[therefore] . . . in principle materialistic and mechanistic (1961: 16).
I take the view that there is something right in what Guntrip was seeking to defend here: the importance of the reality of the individual person.
I also agree that there is something right in his characterisation of science:

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it is committed to the emotionallydetached study of what phenomena have
in common. There is, therefore, a crucial difference between psychoanalysis and science. But he is wrong to conclude, as I think he did, that this real
dlfference warrants a more-or-less absolute barrier between the two. It is
important here that developments within science have themselves been
helping to erode the Cold War stance. Firstly, as already outlined, hard
science has been much more successful in its exploration of child mental
health than many child psychotherapists anticipated. Secondly, this intellectual success has partly derived from the development of the cognitive
sciences, including cognitive psychology, in which the a priori commitment
to the denial of the mind has become substantially less complete, as
Gardners (1987) introduction illustrates. Moreover, thirdly, as increasingly
strong links have been formed between all the cognitive sciences and
neuroscience, cognitive psychologys initially exclusive preoccupation with
purely cognitive processing has diminished. The cognitive sciences have
started to develop an accelerating interest in the interaction between c o p tive and emotional processes. The work of Daniasio (1994, 1999 and 2003)
stands out in this respect (but see also Lane and Nadel, 2000, and Lewis
and Haviland-Jones, 2000, for overviews). These fundamentally important
shifts make it much more possible to set the relevant science alongside
child psychotherapists approaches to treatment and research and to
conceive that both psychoanalyhcally-based and science-based approaches
can be brought to bear, not as A Venus B, but as A and B, in conjunction
with each other and that this might be done without the elimination of
individualityor a sense of the reality of children as individual persons. This
possibility is represented in Figure 2.
This is a diagram in which substantial differences between child
psychotherapy and science are retained; there is nevertheless some overlap; and there is dialogue.

figure 2: Dialogue between child psychotherapy and science

s ild Psychotherapy

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Klein and Bowlby


In the rest of the paper, I will focus on the earlier of the two phases in
the development of mixed thinking within child psychotherapy that I
outlined earlier: the heightened awareness of the importance of interaction between childrens inner worlds and their external environments. I
do so partly to make clear that what the paper is proposing involves
extending this approach, not breaking with it. I will draw attention to
critically important aspects of Bowlbys role. The example of Bowlby is
bound to be significant for any attempt to set psychoanalysis and scientific theory alongside each other, since this is precisely what he
attempted. Particularly following Ainsworths development of his work,
attachment research has come to constitute the most sustained, influential, and empirically successful link between psychoanalysis and science.
It plays an important part in the work of some of those, such as Schore
(1994, 2003a, 2003b) and Panksepp (1998) who are active in trying to
make links today between psychoanalysis and neuro-science. It is therefore critically important to be clear about the current relationship
between attachment theory and child psychotherapy. If the door
between them is open, there is at least one pathway open between child
psychotherapy and hard science.
There is no doubt that in the early 1960s Bowlbys work led to a kind
of explosion and a sense of betrayal within psychoanalysis, a sense that
there was a profound incompatibility between his project and the
psychoanalytic one. This showed itself particularly in a sense of fundamental difference between Bowlbys thinking and Kleins. Eric Rayner
(1992) has summed up the feeling that the difference between them was
unbridgeable. He reports that Bowlby had marked a copy of a paper by
his analyst, Joan Riviere (1927), a leading Kleinian of the time. The
marked passage, slightly edited, reads as follows:
Psychoanalysisis Freuds discovery of what goes on in the imagination
. . . [it] has no concern with anything else: it is not concerned with the
real world, nor with the childs or the adults adaptation to the real
world . . . It is concerned simply and solely with the imaginings of the
childish mind, the phantasised pleasures and the dreaded retributions.
In the margin alongside this passage, Bowlby had pencilled scornfully
Role of the environment = zero.
Both Riviere (and other Kleinians) and Bowlby had a taste for
polemic, in which provocation was given and grievance taken, and
formulations on both sides pushed to absolute extremes. Clearly, the

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present paper rests on the belief that this taste should be resisted. The
subsequent development within child psychotherapy in all schools, not
least in the Kleinian, of a greatly heightened sensitivity to the interaction
between the inner world and the environment, can be said to combine
aspects of the work of both Klein and Bowlby. That is, there has been a
shift from construing the relationship between their work as an eitherlor,
Cokd War split towards the recognition of some common ground. This
shift is represented in Figure 3 .

Figure 3: Klein and Sowlby

It is not that Kleins and Bowlbys views are the same, nor is it the case
that they have no common ground. There are partial overlaps, some real
differences, and some complementarities.
This way of construing things is particularly supported by an aspect of
the middle phase of Kleins work, from 1935 to 1940, when her thinhng
was dominated by her concern with states of grief and depression. I
believe that this was a primary source for the development in all schools
of the internal world and environment sensitive type of child psychotherapy current today. In accounting for the overwhelming, direct and
unavoidable power of grief, Klein was led to articulate a number of fundamentals: the immense importance of real, whole object relationships in
human life; the centrality in this of love and its vicissitudes; their inextricable dependence on direct encounters with external reality; and the
importance of what might be called the mixednature of introjection.
The word love appears many times in Kleins work at this period.
Commenting on Kleins (1937) paper Love, guilt and reparation in
Volume 1 of her Collected Works, the editors state that she rectified her
former relative neglect of love and over-emphasis of aggression (Klein,
1975, p 432). In Love, guilt and reparation she refers, for instance, to
real and strong feelings of love (ibid,p 313); to a really loving relationship (ibid,p 317); and, in the later paper Mourning and its relation to

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manic depressive states (Klein, 1940) to the poignancy of the actual loss
of a loved person (ibid, p. 353). Interestingly, the word attachment also
appears several times. In Love, guilt and reparation, for example, she
comments that a satisfactory and stable relationship implies a deep
attachment (ibid, p 313). In this emphasis, the Freud-Abraham model
of the stages of infantile sexuality and aggression, and their conceptualisation as instinctual appetites, has receded. In its place, in her 1935-40
papers, the set of views that subsequently became known as object relations theonj substantially occupies the foreground, including a new
emphasis on the specific emotionality of relationship; not only love and
attachment, but also separation anxiety and grief.
In articulating what she means by love, Klein uses the word real
repeatedly at this time. In A contribution to the psychogenesis of manic
depressive states (1935) she refers to love for a good object, a whole
object and . . . a real object (ibid,p 270). She writes that a full capacity
for love depends on the realistic perception of external reality (ibid,p
285) involving looking at it and understanding it as it really is (ibid,p
271). She begins her 1940 paper by citing Freuds (1917) reference in
Mourning and melancholia to how extraordinarilypainful the testing
of reality is in mourning, carrying out the behest of reality bit by bit.
Klein (1937) also refers to interaction in a particular way, as when she
refers to the circle of reassurance (ibid, p 314) a baby obtains over and
over again in the love of the mother (ibid,p 286-7). It is in this context
that Klein (1935) discusses what might be called the mixed or
compound (environment and phantasy) nature of introjection, involving
the continuous interplay between .. . (the babys) actual experience and
its phantasy life (ibid,p 285). In Weaning Klein (1936) describes
spirals of interaction within the baby, both benevolent and vicious,
based on the interplay of external or environmental and internal psychical factors (ibid,p 292).
Thus an inner world is being built up in the childs unconscious mind,
corresponding to his actual experiences and the impressions he gains
from people and the external world, and yet altered by his own phantasies and impulses (ibid,p 345).
Clearly, these formulations are part of where Bowlbys subsequent work
came from. There is an important partial overlap between Attachment
Theory and this phase of Kleins work. However, it is e q u d y clear
that such overlap does not apply to other phases of Kleins work. Her
work prior to 1935 is rooted in her account of psycho-sexuality and

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aggression. Bowlby (1958, 1960a, 1960b) made very explicit the nature
of his disagreement with this aspect of Kleins earlier work. After 1940,
while it built on the 1935-40 foundations, Kleins work took her forward
in new and markedly contrasting directions.
Kleins later work was centrally concerned with understanding highly
disturbed patients, particularly schizophrenic and manic-depressive
adult patients. In this, the realistic part of introjection receded from the
foreground of her attention. She was, of course, concerned with abnormal forms of projection throughout her career but this came to occupy
the foreground of her late thinking more exclusively than it had between
1935 and 1940. It was here that the new developments in her thinking
occurred. These concerned persecutory anxiety and destructiveness and
how, under their aegis, phantasy, projection and splitting overwhelmed
the more realistic and more integrated kinds of awareness that she had
focused on between 1935 and 1940.
Some distinction between more and less disturbed states is critical for
the argument of this paper. In Kleins view, in less disturbed states, love
and realism are jointly ascendant. Backward-and-forward,projective and
introjective circles and upward spirals of interaction and a repeated
constructive interplay between phantasy and reality are possible. In
more disturbed states, anxiety and aggression are in the ascendant.
When reality makes its unavoidable presence felt, but cannot be borne,
it provokes and is fought off and obscured by an increased, downward
spiralling, defensive storm of phantasy and projection.
Thus, the spirit in which objects are approached is critical for late
Klein. She had important specific theses about this - the theories of the
paranoid-schizoid and depressive positions, for instance. What is more
critical here is that some theory of this general type is common to all
psychoanalytx-based schools. Psychoanalysis,as such, rests on something
like the following fundamental empirical thesis: there are major variations
in the spirit in which individuals approach their objects; what varies is
both the emotionality and the cognitive processing employed in the
approach; variations result from a constant and complex interaction
between what is inborn and what is experienced; these variations play a
substantial part in determining outcomes of indlvidualsinteractions with
the world, consequently generating states of mental health and ill-health;
all individuals have both more and less disturbed forms of approach available to them internally and are in states of more and less internal conflict
in relation to them; psychoanalytic psychotherapy is helpful through
addressing these variations, thus helping individuals shift from more to
less disturbed forms of approach.
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Bowlbys work caused the concern it did within psychoanalysis by
significantly challenging these fundamental propositions. In contrast to
Kleins, Bowlbys work was always more to do with normal childhood
development and the impact made on it by the reality of actual environmental states. What matters most throughout his work is not the motivation through which the object is approached but what its state is, what its
approach is; for instance, how parents approach a child, including their
real comings and goings. His deepest interest was in the realism of introjection, the role played by realistic perception of the object. This led him
to his characteristic lists of real environmental events - the death of a
parent, prolonged separation from a parent, abusive parental care in a
variety of forms, and so on. The passage cited from Hoxter earlier, in
which she refers to extreme external traumas, clearly echoes Bowlbys
lists. Bowlby repeatedly insists on the extent to which children do realistically perceive and take in extreme states. Internal working inoclels in
Bowlby are primarily understood as based on realistic perception of the
actual environment. He insists on the therapeutic difference made when
a childs disturbance is understood as a response to what is realistic in
their perception.
The reading of the evolution of Kleinian child psychotherapists
thought and practice that is being proposed here is that it has, in effect,
turned an either-late-Klein-or-Bowlby split into a bothland complementarity; and that something equivalent has occurred in child
psychotherapys other theoretical schools. The suggestion is that the
undoubted difference in the main directions of Kleins and Bowlbys
thinking after 1940 has come to be read as difference-but-complementarity, in which part of what is at the focus of Kleins late work, to do
with the spirit of the childs approach to their objects, and part of what
was at the focus of Bowlbys work, to do with the emotional effects on
the child of their realistic perception of their objects, are construed as
coexisting and interacting, both playing important parts. That is, a key
element in Bowlbys challenge to fundamental features of psychoanalytic thinking was accepted and folded back into it. This has become
the foundation on which child psychotherapy today is built. As a consequence, inquiry has become less based on a priori one-process-only
exclusivity; it has become more empirical. Particular situations are
considered one at a time in an attempt to judge what the balance is, in
this instance, as between the active contribution a child is making to
their own difficulties by the way they are approaching their objects and
the contribution the childs objects are making by the way they are
approaching the child.

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Attachment, holding and containment


In 1958, Bowlby published The nature of the childs tie to his mother, in
which he used the term attachinant for the first time. Over the next two
years, he followed this with a closely linked series of papers, particularly
those on separation anxiety (Bowlby, 1960a) and grief and inourning
(Bowlby, 1960b) in which the main elements of attachment theory were
laid out. In 1960, Winnicott published The theory of the parent-infant
relationship (Winnicott, 1960) in which the term holding emerged, a
term previously used by both Clare and Donald Winnicott, but less
formally. In 1962, Bion published Learningfrom Experience, in which he
used the term containment for the first time. If these texts are all read in
sequence, the reality of at least serendipity is unmistakeable. Since then,
these terms - attachment, holding and cnntainrnent - have been at the
centre of inner world and environment sensitive thinking within child
psychotherapy. Not withstanding the differences, some common ground,
partial overlap or convergence between them could be visualised as a serious of partially overlapping circles, as in a Venn diagram.
The crux of what is convergent can be put as follows. There is an
innate, instinctual, human impulsion to seek something vital in human
relationships that can be conceptualised as attachment or holding or
containment. The theory supposes that this need then meets whatever
human care is, in fact, available. Out of that conjunction, states of relationship develop with distinctive emergent properties. The development
of the internal psychological states of babies and children is highly vulnerable to what really happens at this emergent level: either what is available
stimulates upward spirals of development and the growth of internal
states conducive to mental health or it stimulates downward spirals and
the growth of internal states that are damaging to mental health.
There are convergent preoccupations with the role played by primitive traumatised states in generating downward spirals. These states are
seen as following from profound breaches in states of relationship. Such
traumatised states are construed as being primary, distinct from and not
fully caused by any other form of anxiety or by the childs own aggression
or destructiveness or by any other emotion - though they may be
compounded by these. Bowlbys formulation was that, where there is a
failure to meet a childs attachment needs, separation anxiety mounts.
Ainsworth subsequently developed this as a theory of anxious forms of
attachment. In Winnicott, when a ~einbraneis breached by impingements, annihilation anxiety and unthinkable anxiety may follow. In Bion,
when a contact barrier is overwhelmed, giving way to a storm of beta
elements, catastrophic anxiety and iia~nelessdread may follow. It is

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The International Journal of Infant Observation

supposed that these states play an important part in the causal processes
that lead to serious mental health disorders in childhood.
Theories of cognitive development, concerned with how the capacity
to think emerges in response to experience, also overlap. Bowlby
referred to cognitive development and to the growth of internal working
models - that is, models of what has been experienced. Attachment
theory has subsequently developed a more elaborated model in referring, for instance, to the development of a capacityfor narrative and to
the growth of autobiographical capacity. Holding and containmmt have
a double meaning in Winnicott and Bion: not only is a baby or child held
or contained within their environment of care, but the developing mind
also comes to hold or contain experience. Both Winnicott and Bion refer
to the importance of realisation, a concept that resonates with Money
Kyrles (1961) account of cognitive development and Sandlers (1960,
1962) account of representation of experience. The common theoretical
supposition is that there is a developing relationship, beginning in early
infancy, between experience and thought; with its own distinctive kinds
of emergent formal properties and distinct pathologies, fragmentations
and disorganisations. This affects a childs capacity to internally represent, and thereby cope with, the real impact made by experience.
Though many child psychotherapists have a particular preference for
either Bowlby or Winnicott or Bion, my impression is that there is a general
recognition today that, alongside real differences, the partial common
ground outlined here does exist. Its existencehas brought great advantages.
It has nourished the development of (roughly) similar forms of internal
world and interaction sensitive thought and practice in all schools and this
has helped open dialogue between schools. It has strengthened the link
between clinical practice and infant observation, and has contributed to the
development of subtle accounts of transferencekounter-transference interaction between child psychotherapist and child. It has helped re-establish
child psychotherapys link to attachment research, and has enabled child
psychotherapy to make important links to infant development research
(Judy Shuttleworth, 1989).The work of Stem, Trevarthan and Hobson, and
the concepts of attunement and priinuy intemubjectivit!y,have all been
important influences on child psychotherapiststhought and practice. They
are now helping in forming links to neuroscience (Green, 2003).

Conclusion
The paper has argued that child psychotherapists are starting to attempt to
develop their way of understanding the most difficult cases,since it is now
clear that these are cases in which there is a complex mixture of forces -

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A complex mixture of forces


biological, psychological and social - at work. In doing so, it is necessary to
find ways to set psychoanalytically-based thinking and relevant science
alongside each other, so as to achieve a combined, more panoramic view.
This is a challengmg task but it is one that I have suggested there is no
evading. It presents itself in clinical practice today as much as it does in
theory. Mixedtheories are needed that have the capacity to bring fundamentdy different kinds of processes into live interplay with each other. I
have outlined three bodies of theory widely used in child psychotherapy
today that I suggest have this capacity: the combination of the theories of
dmble deprivation and prima y and secondary handicap so as to form the
begmnings of a hio-psycho-social theory; the combination of Klein and
Bowlby to form inner world and environinent sensitive theory; and the
overlap that exists between the theories of attachment, holding and
containnzent. Each of these mixedtheories either explicitly opens a door
between child psychotherapy and science or has the capacity to do so.
In order to develop models of the interaction of mixed forces, diference has to be articulated since the whole point is that one kind of force
is not just the same as another. But the encounter with difference readily gives rise to splitting among all concerned, leading to the giving of
provocation and the taking of grievance, and the consolidation of Cold
War barriers that become disabling. But when it is possible to contain the
differences, bothland, mixed, less a priori, more empirical forms of
thought and practice may emerge, that have the capacity to be stronger
than what came before. This possibility should be held in mind in child
psychotherapys struggle to retain the strengths of its existing ways of
thinking while exploring how to extend them, in order to take account of
the important developments that are taking place in the application of
scientific discoveries in the treatment of children with mental health
disorders. I have suggested that this is leading child psychotherapists
towards the development of new bio-psycho-social ways of thinking. I
have tried to indicate how, if real pressures towards splitting can be
resisted, this can be done while still retaining child psychotherapys characteristic accent on the reality of children as individual persons.

Acknowledgements
Many thanks are due to Tom and Annie Shuttleworth for their technical
assistance in preparing this paper for publication.

Notes
1. I say re-establishbecause chiId psychotherapyin the UK and attachment
research began life together, cheek by jowl in the Tavistock Clinic. Two of

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the first generation of Tavistock child psychotherapy trainees, Mary
Boston and Dina Rosenbluth, were also first generation attachment
researchers.

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