Psychoanalytical theory is not a static body of knowledge; it is in a state of constant evolution. This was as true during Sigmund Freud’s life (1856-1939) as it has been since. Nevertheless, a core assumption of psychoanalytical theory throughout has been the so-called genetic or developmental point of view, seeing current functioning as a consequence of develop-mentally prior phases, which all psychoanalytical texts acknowledge as central. This places theories of individual development at the very heart of most psychoanalytical formulations.
An essential idea running through all phases of Freud’s thinking was the notion that pathology recapitulated ontogeny; that disorders of the mind could be best understood as residues of childhood experiences and primitive modes of mental functioning (S. Freud, 1905). A developmental approach to psychopathology has continued to be the traditional framework of psychoanalysis. It aims to uncover the developmental stages and sequelae of different disorders of childhood and adulthood, and the factors that influence them. Psychoanalytical theories have evolved through diverse attempts to explain why and how individuals in psychoanalytical treatment deviated from the normal path of development and came to experience major intrapsychic and interpersonal difficulties. Bringing together psychoanalysis and developmental psycho-pathology makes explicit what has been at the core of psychoanalytical theorizing and treatment, from Freud’s day onward. Each theory reviewed here focuses on particular aspects of development or specific developmental phases, and outlines a model of normal personality development derived from clinical experience.
Freud’s psychoanalytical theory
Freud (Fig. 1) was the first to give meaning to mental disorder by linking it to childhood experiences, and to the vicissitudes of the developmental process. For example, Freud’s theory of narcissism or self-development during infancy was invoked to explain adult psychosis, and, conversely, his view of psychic life during infancy was constructed largely on the basis of observations of adult psychopathology. His notion of infantile grandiosity is derived from that observed in many instances of psychosis (e.g., the delusional belief of an individual suffering from paranoia that he is being targeted by the combined intelligence agencies of the Western world or that he has superhuman powers).
One of Freud’s greatest contributions was undoubtedly the recognition of infantile sexuality. His discoveries radically altered our perception of the child from one of idealized innocence to that of a person struggling to achieve control over his biological needs, and make them acceptable to society through the microcosm of his family. Pathology was correspondingly seen as failures in this process. Childhood conflict was thought to create a persistence of the problem aggravated by current life pressures, generating significant anxieties that could only be resolved by ‘neurotic compromise’: giving in partially to infantile sexual demands, in the context of a self-punitive struggle against these.
Freud’s final model went beyond sexual concerns and posited aggressive or destructive motives independent of the sexual, which faced the child with a further developmental task of accommodation (Fig. 2). This involves gradually having to tame natural destructiveness or otherwise suffer from a life-time of psychic pain as destructiveness is dealt with by being turned against the self or projected outward and becoming a focus of anxiety. Freud, and many of his followers, considered genetic predisposition to be a key factor in abnormal reactions to socialization experience.
Beyond Freud: some general comments
Post-Freudian models of development, which dominated the second half of the last century of psychoanalytical thinking, broadly fall into three geographical-conceptual categories: (1) in the USA, Freud’s most complex model of the mind, the structural theory of id, ego, and super-ego, was expanded to include a concern with adaptation to the external or social world in addition to the intrapsychic. This approach is known as ego psychology; (2) in Europe, particularly in the UK, concern with internal representations of the parental figures dominated psychoanalytical thinking. This class of theories came to be known as object-relations theories because of the emphasis they give to the fantasies that individuals can have about their relationship with the internally represented object; (3) more recently, both approaches have given way in the USA to an interpersonalist tradition that is primarily concerned with the actual observable nature of the infant-caregiver relationship as well as the vicissitudes of the social construction of subjective experience. These approaches are generally considered under the heading of relational theories.
Figure 1. Sigmund Freud, 1920.
Figure 2. Freud’s structural model of the psyche, showing the relations of id, ego, and super-ego to the older terminology of unconscious and pre-conscious, and the interface of these systems with the system of perception-consciousness (Pcpt-Cs) at the top of the figure.
Heinz Hartmann (1844-1970)
Ego psychologists balanced the Freudian picture by focusing on the evolution of the child’s adaptive capacities, which he brings to bear on his struggle with his biological needs. Hartmann’s model (Hartmann, Kris, & Loewenstein, 1949) attempted to take a wider view of the developmental process, to link drives and ego functions, and show how very negative interpersonal experiences could jeopardize the evolution of the psychic structures essential to adaptation. He also showed that the reactivation of earlier structures (regression) was the most important component of psychopathology. Hartmann was also amongst the first to indicate the complexity of the developmental process, stating that the reasons for the persistence of particular behavior are likely to differ from the reasons for its original appearance.
While conflicts over oral dependency and gratification may account for an infant’s eating problems, this is unlikely to explain eating disturbance in adolescence or problems of obesity in adulthood. Amongst the great contributions of ego psychologists are the identification of the ubiquity of intrapsychic conflict throughout development, and the recognition that genetic endowment, as well as interpersonal experiences, may be critical in determining the child’s developmental path. This latter idea has echoes in the developmental psychopathological concept of resilience.
Anna Freud (1892-1982)
Psychoanalysts with ego psychological orientations were among the first to study development through the direct observation of children, both in the context of child psychoanalysis and the observation of children in the nursery. Child analysts discovered that symptomatology is not fixed, but rather is a dynamical state superimposed upon, and intertwined with, an underlying developmental process. Continuity of personality traits and symptoms across childhood was the exception rather than the norm.
Anna Freud’s study of disturbed and healthy children under great social stress led her to formulate a relatively comprehensive developmental theory, where the child’s emotional maturity could be mapped independently of diagnosable pathology. Particularly in her early work in the war nurseries, she identified many of the characteristics that later research linked to resilience. For example, her observations spoke eloquently of the social support that children could give one another in concentration camps, which could ensure their physical and psychological survival. Similarly, she found that children during the London Blitz were less frightened of objective danger than they were of the threat that separation from their parents represented, and that their caregivers’ anxieties predicted their own level of distress. More recent research on children experiencing severe trauma has confirmed her assumption of the protective power of sound social support and the risk of parental pathology in coping with threat or danger. Anna Freud’s work stayed so close to the external reality of the child that it lent itself to a number of important applications (e.g., child custody in case of divorce, treatment of children with serious physical illness).
Anna Freud was also a pioneer in identifying the importance of an equilibrium between developmental processes (A. Freud, 1965). Her work is particularly relevant in explaining why children deprived of certain capacities (e.g., sensory capacities or general physical health), by environment or constitution, are at greater risk of psychological disturbance. Epidemiological studies have supported her clinical observation. She was the first psychoanalyst to place the process and mechanisms of development at the center-stage of psychoanalytical thinking. Her approach is truly one of developmental psychopathology, insofar as she defines abnormal functioning in terms of its deviation from normal development, while at the same time using the understanding gained from clinical cases to illuminate the progress of the normal child. It is a logical development of her work to explore the nature of the therapeutic process also in developmental terms. It is important to remind ourselves that often psychoanalysts apply developmental notions to the therapeutic process metaphorically, but essential components of treatment, particularly with children, and with personality disordered adults, inevitably involve the engagement of dormant developmental processes.
Margaret Mahler (1897-1986)
A pioneer of developmental observation in the USA, Mahler drew attention to the paradox of self-development: that a separate identity involves giving up a highly gratifying closeness with the caregiver (Mahler, 1968). Her observations of the ambitendency of children in their second year of life threw light on chronic problems of consolidating individuality. Mahler’s framework highlights the importance of the caregiver in facilitating separation, and helps explain the difficulties experienced by children whose parents fail to perform a social referencing function for the child, which would help them to assess the realistic dangers of unfamiliar environments. A traumatized, troubled parent may hinder rather than help a child’s adaptation, while an abusive parent may provide no social referencing. The pathogenic potential of withdrawal of the mother, when confronted with the child’s wish for separateness, helps to account for the transgenerational aspects of psychological disturbance.
Joseph Sandler (1927-1998)
In the UK, Sandler’s development of Anna Freud’s work and that of Edith Jacobson (1897-1978) represents the best integration of the developmental perspective with psychoanalytical theory. His comprehensive psychoanalytical model has enabled developmental researchers to integrate their findings with a psychoanalytical formulation, which clinicians were also able to use. At the core of Sandler’s formulation lies the representational structure that contains both reality and distortion, and is the driving force of psychic life. He moved away from an emphasis on drives and proposed derivative affects as organizers of human motivation. An important component of his model is the notion of the background of safety (Sandler, 1987), which suggests that individuals seek above all to experience a feeling of security in relation to their internal and external world. Often what is familiar, even if objectively aversive such as situations of abuse, can feel paradoxically ‘safer’ than the alternative that is expected.
Melanie Klein (1882-1960)
The focus of these theories on early development and infantile fantasy represented a shift in world view for psychoanalysis from a tragic to a somewhat more romantic one. Melanie Klein and her followers, working in London, constructed a developmental model that at the time met great opposition because of the extravagant assumptions these clinicians were ready to make about the cognitive capacities of infants. Surprisingly, developmental research appears to be consistent with some of Klein’s claims concerning perception of causality and causal reasoning. Kleinian developmental concepts have become popular because they provide powerful descriptions of the clinical interaction between both child and adult patient and analyst. For example, projective identification depicts the close control that primitive mental function can exert over the analyst’s mind. Post-Kleinian psychoanalysts were particularly helpful in underscoring the impact of emotional conflict on the development of cognitive capacities.
W. R. D. Fairbairn (1889-1964) and D. W. Winnicott (1896-1971)
The early relationship with the caregiver emerged as a critical aspect of personality development from studies of severe character disorders by the object-relations school of psychoanalysts in Britain. Fairbairn’s (1952) focus on the individual’s need for the other helped shift psychoanalytical attention from structure to content, and profoundly influenced both British and North American psychoanalytical thinking. As a result, the self as a central part of the psychoanalytical model emerged in, for example, the work of Winnicott (1971). The concept of the caretaker or false self, a defensive structure created to master trauma in a context of total dependency, has become an essential developmental construct. Winnicott’s notions of primary maternal preoccupation, transitional phenomena, the holding environment, and the mirroring function of the caregiver, provided a clear research focus for develop-mentalists interested in individual differences in the development of self-structure (Fonagy etal., 2002). The significance of the parent-child relationship is consistently borne out by developmental studies of psychopathology. These studies in many respects support Winnicott’s assertions concerning the traumatic effects of early maternal failure, particularly maternal depression and the importance of maternal sensitivity for the establishment of a secure relationship.
Heinz Kohut (1913-1981)
There have been many attempts by North American theorists to incorporate object-relations ideas into models that retain facets of structural theories. Kohut’s self-psychology was based primarily on his experience of narcissistic individuals. His central developmental idea was the need for an understanding caretaker to counteract the infant’s sense of helplessness in the face of his biological striving for mastery. Kohut emphasizes the need for such understanding obtains throughout life and these notions are consistent with accumulating evidence for the powerful protective influence of social support across a wide range of epidemiological studies. He also borrowed freely from Winnicott and British object-relations theorists, although his indebtedness was rarely acknowledged. The mirroring object becomes a self-object, and the need for empathy drives development, which culminates in the attainment of a cohesive self. Drive theory becomes secondary to self theory in that the failure to attain an integrated self-structure both leaves room for, and in itself generates, aggression and isolated sexual fixation. However, the self remains problematic as a construct in Kohut’s model as it assumes both the person (the patient) and the agent control the person. Nevertheless, Kohut’s descriptions of the narcissistic personality have been powerful and influential examples of the use of developmental theory in psychoanalytical understanding.
Kohut’s hypotheses concerning the profound and long-term consequences of a self’enfeebled’ by the failure of emotional attunement of the self-object find a powerful echo in the risk literature. Recent evidence has shown a clear link between early trauma and disorganization and delay in self-development. The effectiveness of actions undertaken by the child is at the center of Kohut’s concept of self-esteem. Kohut’s formulations were probably helpful in the operationalization of the concept of self-confidence, although in some studies problem-solving skills and self-esteem appear to be independent indicators of resilience.
Figure 3. Personality disorders: their mutual relationships. BPO = borderline personality organization; NPO = neurotic personality organization; PPO = psychotic personality organization.
An alternative integration of object-relations ideas with North American ego psychology was offered by Kernberg. His contribution to the development of psychoanalytical thought is unparalleled in the recent history of the discipline. His systematic integration of structural theory and object-relations theory (Kernberg, 1987) is probably the most frequently used psychoanalytical developmental model, particularly in relation to personality disorders (Fig. 3). His understanding of psychopathology is developmental, in the sense that personality disturbance is seen to reflect the limited ability of the young child to address intrapsychic conflict. Neurotic object-relations show much less defensive disintegration of the representation of self and objects into libidinally invested part-object relations. In personality disorder, part-object relations are formed under the impact of diffuse, overwhelming emotional states, which signal the activation of persecutory relations between self and object.
Kernberg’s models are particularly useful because of their level of detail and his determination to opera-tionalize his ideas far more than has been traditionally the case in psychoanalytical writing. It is not surprising, therefore, that a considerable amount of empirical work has been done to test his proposals directly, and the clinical approach that he takes toward serious personality disturbance.
With the gradual demise of ego psychology in the USA and the opening of psychoanalysis to psychologists and other non-medically qualified professionals, a fresh intellectual approach to theory and technique gained ground in theoretical and technical discussions. The relational approach is arguably rooted in the work of Harry Stack-Sullivan (1892-1949) and Clara Thompson (1893-1958) in the USA and the work of John Bowlby in the UK. An outgrowth of the former tradition is the interpersonalist approach (Mitchell, 1988), which has revolutionized the role of the analyst in the therapeutic situation. Influenced by post-modernist ideas, this group of clinicians generally conceive the analytic relationship as far more of two equals rather than of patient and doctor. They recognize the fundamentally interpersonal character of the sense of self and thus the irreducibly dyadic quality of mental function. They consistently acknowledge the influence of the interpersonal nature of the mind on the process of therapy, and the active role that the analyst as a person plays in the treatment process. Particularly controversial is the insistence of many interpersonalists that enactments by the analyst within the therapy are almost as inevitable as those by the patient in the transference. Until recently, there has not been a strong developmental approach as part of this tradition.
John Bowlby (1907-1990)
In the meantime, in the UK, Bowlby’s work on separation and loss also focused developmentalists’ attention on the importance of the security (safety, sensitivity, and predictability) of the earliest relationships. His cognitive-systems model of the internalization of interpersonal relationships (internal working models), consistent with object-relations theory and elaborated by other attachment theorists, has been increasingly influential. According to Bowlby, the child develops expectations regarding a caregiver’s behavior and his or her own behavior. These expectations are based on the child’s understanding of experiences of previous interaction, and organize the child’s behavior with the attachment figure and (by extension) with others. The concept has had very broad application. Bowlby’s developmental model highlights the transgenerational nature of internal working models: our view of ourselves depends upon the working model of relationships that characterized our caregivers. Empirical research on this intergenerational model is encouraging as an accumulating body of data confirms that there is intergenerational transmission of attachment, security and insecurity.
A number of theories have drawn deeply from the developmental research tradition, combining attachment theory ideas with psychoanalytical conceptions within a general system theory frame of reference favored explicitly by Bowlby. There have been a number of major contributors such as Stern (1985) whose topic represented a milestone in psychoanalytical theorization concerning development. His work is distinguished by being normative rather than patho-morphic, and prospective rather than retrospective. His focus is the reorganization of subjective perspectives on self and other as these occur with the emergence of new maturational capacities. Stern is the most sophisticated amongst psychoanalytical writers in dealing with several qualitatively different senses of self, each developmentally anchored. Many of his suggestions have proved to be highly applicable clinically, including his notion of an early core self and the role of the schema of being with the other. Other general system theory interpretations of psychoanalysis originated in the work of practitioners of brief psychotherapy.
Most recently, the work of psychoanalysts as part of the long-term collaboration of the Anna Freud Centre and University College London has advanced a developmental model in the relational tradition (Fonagy et al., 2002). Their ideas originate within attachment theory, but also draw strongly on the object-relations tradition. They focus on the emergence of the self, not as a representation but as an experiential agent of change. They suggest that prior to the self experienced as a thinking and feeling entity is an intersubjective self that acquires understanding of its own functioning through the reaction of the caregiver. Thinking of the actions of self and other is teleological, cause-effect thinking based merely upon what is observable.
The development of a psychological self that is able to experience itself and others it interacts with as thinking, feeling, and desiring arises from the integration of two primitive modes of experiencing the mental world: psychic equivalence and pretend or non-serious modes. In the former, all that is felt to be happening inside the mind is also thought to be occurring in physical reality. In the pretend mode, physical reality and the mental world are totally decoupled and one is assumed to have no possible consequence for the other. The two modes of functioning are prototypically integrated through playful interactions with the caregiver. As a consequence, when such interactions are undermined by maltreatment or constitutional problems on the part of the child, mentalization (thinking of the other and the self as motivated by mental states) will not be acquired fully and severe attachment-related personality problems will arise.
We have seen that the assumption of a correspondence between development and psychopathology is present in all psychoanalytical formulations. There are divergences in terms of the exact period of development involved in particular disorders, or the aspect of the developmental process underlying a particular pathology, but there is a shared assumption that the study of development and the study of pathology concern the same psychic processes. Psychoanalytical theories have come under considerable criticism over recent years for excessive reliance on single case studies and lack of reliable observation to back up generalizations. Interestingly, information pertinent to psychoanalytical ideas has been accumulating from both cognitive science and neuropsychological studies at very rapid rates. In fact, we are at a historical point when as more is learnt about the brain the clearer the appropriateness of a number of basic psychoanalytical propositions might appear (e.g., the predominantly non-conscious nature of human cognition).
If psychoanalytical developmental theory is to become part of the intellectual future of the mind sciences, changes in the way psychoanalytical knowledge is accumulated must take place. In particular, psychoanalysis needs to restrict the number of assumptions concerning normal development it makes, and an increase in the effectiveness of its interface with other disciplines studying the mind in development will be necessary. At the moment, too many incompatible theoretical formulations are vying for acceptance. The choice is made on the basis of usefulness in completing personal narratives in the context of psychotherapeutic consultations rather than observations of actual development. If psychoanalysis is able to meet the challenge that integration with modern cognitive psychology and neurosience represents, then taking psychoanalytical ideas more seriously could have a very beneficial effect on the future of developmental psychopathology. This particularly applies to the central psychoanalytical developmental notion that complex and, at times, conflicting representations of unconscious beliefs and affects created early in life, influence behavior and experience throughout the lifetime.
A widening perspective could, for example, lead to a shift in emphasis from self-report to narrative data. It could also lead to a closer examination of patterns of narration, as opposed to observations of narrative content, and to a greater concern with discordance and conflict among response systems rather than a single-minded search for congruence and consistency. Psychoanalytic theory is alive, and its potential for enriching our understanding of development and psychopathology was not fully exploited in the century that has just closed.