On: Miss A

Dear Sirs,

On the basis of our research over many years, we propose alternative hypotheses for understanding the patient described in the Fonagy et al. (2004) ‘Analyst at work’ article. We believe that he and the commentators have overlooked crucial aspects of the early caregiving Miss A received which underlie the development

of her personality. Fonagy's patient, the eldest of four daughters close to one another in age, was reared primarily by a nanny and a housekeeper. In three papers (Hardin, 1985; Hardin and Hardin, 2000, 2004), we note that children reared by nannies or other primary caregivers experience them as de facto mothers. Almost invariably these children suffer losses of their caregivers, and often, in turn, of their replacements. We observe that these traumatic events lead to the development of inordinate fear of loss, separation anxiety and the inability to become intimate with others. These patients have difficulty trusting others; they are uncertain about their own perceptions and, in treatment as in life, need constant validation. They are disposed to depression and to restricted affective and social lives.

In all likelihood Miss A experienced such losses that became deeply repressed. She remembers others, designated as ‘catastrophes’, because of sharing of nanny and housekeeper with interminable newborn siblings. We believe that losses were major traumas in her infancy and childhood; their developmental consequences may be discerned throughout Fonagy's report. Understandably, in denying that their children's primary caregivers become de facto mothers, biological parents are unable to validate the significance of caregiver losses. In treatment the same neglect and lack of validation is often recapitulated. Thus, though he describes her as ‘hardly a part of Miss A's early life’, Fonagy continues to refer to the biological mother, providing no information about the surrogate-mother care, its quality, the number of turnovers or the times of their oc