Basseches: You have always been closely associated with infant research. Can you tell us how you came to that field?
Greenspan: I was trained in both adult and child psychiatry. As I was finishing my child psychiatric training, I started psychoanalytic training and did both the adult and child programs. Now I'm a supervising child analyst at the Washington Psychoanalytic Institute. Around the time I was in analytic training, I also started doing research at NIMH. That is where we initiated the research on infants and young children's emotional development, as well as clinical problems and intervention strategies. That research program went on for around fifteen years at NIMH and now continues in a number of other settings, including the Reginald Lourie Infant Center in Rockville, Maryland, and the University of Maryland at College Park. During this time I was also involved in clinical practice, including child and adult psychoanalysis, as well as work with infants and very young children and their families. For most of my career I have been involved in both research and clinical practice, learning about development from both perspectives.
Basseches: Do you recall what spurred your interest in this area?
Greenspan: Well, it grew out of curiosity about how adults become the way they are. So I did some child training. But even older children had earlier roots, so I went back still further to infants. But I suspect that the real reason, or another reason, was that I was getting ready to be a parent. I was about to have my first child when we started the baby research. Earlier, when I was an undergraduate at Harvard, I became interested in depth psychology from reading Erikson and Freud. My parents, having gone through the depression, had always emphasized my doing something like medicine, which would be “secure.” My brother was already in medical school. In my sophomore year in college, I was interested in science and was thinking about becoming a doctor. I became fascinated with depth psychology and at that point the idea of becoming a psychiatrist started taking shape. Then I went on to medical school at Yale.
Basseches: Did you have a mentor or someone who particularly influenced your thinking?
Greenspan: Well, Reginald Lourie, a psychoanalyst and the director of child psychiatry at Children's Hospital during my child psychiatry residency, was a very important influence, in terms both of his interest in infants and young children and of his overall broad-based clinical perspective. He was an important teacher and mentor to many. He retired from Children's Hospital right around the time I was beginning the NIMH Clinical Infant Development research program, and Reg was able to join me in developing it. We worked together for many years, studying infants and young children in multi-risk families, developing preventive intervention strategies, and starting the Zero to Three National Center for Clinical Infant Programs and the Reginald Lourie Center I mentioned earlier.
Basseches: Of the many books and articles you have published—I counted over a hundred articles and chapters and twenty monographs and books either authored or edited—are there some you would mention that would best show the direction of your thinking?
Greenspan: An early book, one that serves as a theoretical foundation for much of the later work, is Intelligence and Adaptation: An Integration of Psychoanalytic and Piagetian Developmental Psychology (1979). The monographs Psychopathology and Adaptation in Infancy and Early Childhood (1981) and Infants in Multi-Risk Families (1987) describe some of the findings from the NIMH research. More recent books that further refine and apply this general theoretical structure to clinical problems include Infancy and Early Childhood: The Practice of Clinical Assessment and Intervention with Emotional and Developmental Challenges (1992) and The Development of the Ego (1989). The latter explores the implications of this work for psychoanalytic theory and technique. Books for parents and educators include a very recent one, Playground Politics: The Emotional Life of the School-Aged Child (1993), as well as two that I wrote with my wife, Nancy T Greenspan—First Feelings: Milestones in the Emotional Development of Your Infant and Child from Birth to Age Four (1985) and The Essential Partnership: How Parents and Children Can Meet the Emotional Challenges of Infancy and Childhood (1989). Many of the ideas we will be talking about are discussed in a book due out from International Universities Press in a few months entitled Developmentally Based Psychotherapy. It discusses new psychotherapeutic strategies that build on an understanding of early development.
While the major part of my writing has been directed to scientific and professional groups, including pediatricians and educators, about a quarter of my effort has been toward communicating directly with the general public. The goal is to create a greater awareness of in-depth emotional development throughout all the developmental stages, from infancy up through adulthood, to facilitate healthier child rearing, and to encourage preventively oriented interventions. In that regard, I might mention that our work on the milestones of early emotional development was incorporated into the American Academy of Pediatrics' guidelines for the well baby exam. It was also featured in a PBS Nova documentary entitled “Life's First Feelings,” which has been shown yearly on public television. A videotape based on the milestones was made by the Institute for Mental Health Initiatives, a nonprofit foundation.
Called “Exploring First Feelings,” it is being shown to new mothers in over two hundred hospitals. Another videotape, made for both educators and parents, is called “Floor Time.” Produced by Scholastic Inc. of New York, it presents both the emotional milestones and various strategies for promoting healthy emotional and intellectual growth in young children. In addition, a number of books based on this work have been written for educators and parents.
Basseches: I know you have received many awards. Could you highlight a few?
Greenspan: I am especially proud of the American Psychiatric Association's Ittleson Prize for Contributions to Child Psychiatry Research, and of the Edward A. Strecker Award for Contributions to American Psychiatry. They indicate a recognition of the importance of early emotional development and preventive approaches.
Basseches: There is so much more to discuss in terms of your theoretical ideas and research. Perhaps we can begin by discussing your belief that psychoanalysis needs an improved developmental model for understanding normal and pathological patterns, as well as the therapeutic process.
Greenspan: Our current developmental model has provided unique insights. The work of pioneers like Mahler, Anna Freud, Spitz, Erikson, and Hartmann, Kris, and Loewenstein has focused on early experience contributing to intrapsychic phenomena. However, the focus has for the most part been on the content of intrapsychic phenomena. By content I mean the nature of wishes, conflicts, prohibitions, and various aspects of the ego mechanisms.
Yet there is another very important aspect of intrapsychic phenomena that has been relatively neglected in our current developmental perspectives. It's hinted at by Anna Freud's work on the nature of ego mechanisms of defense, Mahler's
work on object constancy, and some of Spitz's observations, as well as some of Hartmann, Kris, and Loewenstein's work on psychic structure formation. But overall we haven't had a detailed road map of how intrapsychic structure builds up. For example, we haven't had a complete understanding of how the ego develops and how its different mechanisms develop and come to play their particular functional roles. To use an analogy, we have had a relatively good understanding of the drama that is enacted, but an insufficient understanding of the structure of the stage that supports that drama.
There are two aspects of intrapsychic structure formation that clinical work with infants and young children, as well as psychoanalytic work with children and adults, has begun to reveal. One of these has to do with the sequence of intrapsychic organizations that characterize early structure formation, including the organization of experience that precedes the ability to represent it. The second builds on Freud's goal for psychoanalysis regarding an understanding of the biological aspects of ego development, especially the biological aspects of defenses. Emerging is an understanding of how individual differences, in terms of biological aspects of constitutional and maturational phenomena, contribute to the structure of the ego. We are beginning, then, to understand the individual biological differences that contribute to the differences in ego structure and organizational levels of experience that characterize early ego development.
Basseches: Can you give some examples of these organizational levels and biological differences?
Greenspan: In The Development of the Ego I describe in some detail a total of six such levels, as well as the types of problems that are related to each: (1) self-regulation, where perceptual differences in sensory-affective reactivity and processing contribute to the development of personality or character structure; (2) forming and maintaining relationships as a basis for the capacity for object relatedness; (3) self/object boundary-defining pre-representational interactions; (4) self- and object pre-representational “personhood,” characterizing interactions; (5) representational elaboration as a basis for internal self- and object representational elaborations; and (6) representational differentiation as a basis for internal self- and object differentiations and integration.
The biologically based constitutional and maturational differences we describe are based on differences we have observed in infants and young children, as well as older children and adults, and appear to contribute significantly to character formation and pathology. In each sensory pathway, sensory and affective experience can be characterized as hypo- or hyperreactive. In addition, each sensory channel can have differences in the way interpersonal and affective information is processed (e.g., auditory/verbal, visual/spatial). Further, motor tone and motor planning abilities can vary significantly. What Hartmann described as the autonomous ego functions can actually vary quite a bit from person to person, and contribute to both character and pathology.
Basseches: Can you give an example?
Greenspan: When certain biological patterns are coupled with certain environmental patterns, they can intensify each other. We see what Freud had anticipated, a biological basis for character structure and selection of defenses. For example, individuals who are overreactive to touch or sound, and have stronger auditory processing abilities and relatively weaker visual/spatial powers, tend toward the hysterical, depressive, and anxiety disorders. Those who have difficulty with movement in space tend toward phobic disorders.
It should be emphasized that when environmental conditions enhance flexibility rather than
“When certain biological patterns are coupled with certain environmental patterns, they can intensify each other. We see what Freud had anticipated, a biological basis for character structure and selection of defenses.”
pathology, we tend to see healthy character formation, but with a tendency toward one or another of these characteristics. For example, instead of panic and/or anxiety or depression, we see a reactive, sensitive person who is very alert to others' moods and tendencies to be reactive themselves.
Basseches: Do you see an antithesis between this structural perspective and dynamic perspectives that focus on unconscious wishes and conflicts?
Greenspan: Not at all. Each is an essential aspect of the multiple perspective psychoanalysis has traditionally employed in understanding the mind. It's easy to focus on only one perspective, say the dynamic, and to lose sight of the fact that every dynamic drama must take place in the context of a particular structure or set of structures. In addition, when focusing on structural perspectives it's easy to lose sight of the fact that structures provide the foundation—the housing, so to speak—for different dynamic dramas, each with its own content or meanings.
Basseches: From a practical clinical point of view, why is it important to have a structural perspective?
Greenspan: It's especially important clinically to understand the structure of the ego, in addition to the particular dynamic phenomenon the ego is struggling with at any moment. Many individuals who come for psychoanalytic or psychodynamic treatment, or who could benefit from such treatment, have important structural limitations. It is rare that individuals who come into treatment already have highly differentiated ego structures whereby, for example, they could observe their own wishes and abstracted feeling states, make connections between different wishes and feelings (as well as different sides of a conflict), and understand these in historical, current, and future contexts.
The “ideal” neurotic patient allegedly has all these capacities working for him, and needs only the therapeutic process, including a transference relationship and the skillful guidance of a seasoned therapist, to avail himself of opportunities for new insight and growth. But in fact relatively few patients come into the treatment situation with highly differentiated ego structures. The majority come in with significant compromises in one or another aspect of their basic ego structure. That is why having a road map of the structural components of ego development, to go alongside our road map of intrapsychic content (e.g., wishes, fears, conflicts), could increase our understanding of the mind and improve the efficacy of our therapeutic strategies.
Basseches: What does the developmental-structural perspective alert us to clinically that dynamic considerations don't?
Greenspan: The dynamic perspective has been elucidated over many years by skillful analytic inquiry. For the most part, however, this work provides a rich description of the various dramas played out in our intrapsychic life. By contrast, understanding the structural development of the mind provides us a way of comprehending how an individual learns to regulate the intensity of sensations and, later, the intensity of internal wishes and affects. It also provides us a way of understanding how individuals process—that is, comprehend and organize—sensations, wishes, and affects, and how they organize both motor and communication patterns.
Further, the structural perspective explores how individuals learn such fundamental capacities as how to become part of a relationship and share a sense of humanity with others. It demarcates the processes involved in early pre-representational self- and object interactions and differentiations. Beginning with part-internal object interactions and partial differentiations, it describes how we progress to pre-representational (presymbolic) whole self- and object patterns and further pre-representational differentiations. It demarcates how these prerepresentational patterns serve as a foundation for the construction of a representational system, that is, the ability to abstract wishes and affects in a representational form. Most important, it helps us to understand
biologically based constitutional and maturational differences.
The structural perspective seeks to understand how early representational capacities coalesce into internal self- and object organizations, and how constitutional and maturational deficiencies contribute to these early structural capacities—how, for example, overreactivity to sound and touch will lead to one type of organization, while underreactivity will lead to another. It also helps us identify specific interactive patterns that support or undermine particular structural capacities. In addition, it helps us understand how representational, internalized self- and object organizations become further differentiated as a foundation for the development of basic ego functions, including reality testing, impulse control, stable mood, stable internal representations of self and object, and stable differentiations between those representations. It also outlines how a differentiated ego structure leads to further growth and development, in terms of shifts from dyadic to triadic structures, and then to structures dealing with group phenomena, as well as more advanced, internalized phenomena.
Basseches: Could you give an example?
Greenspan: Consider a conflict over aggression, having to do with a wish to hurt the object and, in turn, a fear of being annihilated by the object. There are enormous differences in one's approach, depending on whether this conflict is operating at one level of structural organization or another. Consider that it is operating at a representational level. We may see it reflected in the play of a child, who has one doll hit another doll, followed by a hurricane, where the first doll gets submerged under crumbling buildings. There may be affects of fear and anxiety. While playing this out, however, the child is using words, maintains a descriptive or reflective attitude, and, when getting anxious about the hurricane, can put into words aspects of the anxiety and say, perhaps, “Mommy, I need a hug.”
The same conflict played out at a pre-representational level, where experience can't be represented, might have the child yelling and screaming at the real object, not the pretend toys, or biting, kicking, or hitting the real object. Following this, in anticipation of severe punishment, the child might experience diffuse anxiety in a more bodily and behavioral sense (increased diffuse aggressive activity, changes in heart rate and muscle tone, etc.).
A child at the pre-representational level can't represent the expected retaliation. It's more like a person in a fight who throws a punch and, simply from the other persons behavioral pattern, anticipates a punch back. Our pre-representational, conflicted individual may therefore pinch, bite, or throw a tantrum and then up the stakes, increasing his own aggression because of the anticipation of counteraggression. Or he may withdraw into a state of unrelatedness. In either case, he doesn't have the capacity to represent (i.e., create) a multisensory, affective picture of the pattern. The pattern is simply acted out, including expectations of the other's behavior.
What we see here is a drama that is not represented, but that rather is played out in the actual reality of a relationship. The content of the drama is not representational elements symbolized in pretending or elaborated in words (as in free association), but instead is behaviorally enacted, directly and viscerally. The drama is perceived as real, not as a set of feelings or wishes, as “He is going to hurt me” rather than “I feel as though I will be hurt.” One may further speculate that a drama acted out behaviorally and viscerally might be associated with more primitive and overwhelming fears.
“… one must always meet patients at the developmental level of their ego structure. Some of the strategies I propose are no different from what many therapists have been doing for years. But these approaches are too often viewed as intuitive rather than systematic or central to therapeutic growth.”
In this sense, the structure of the ego affects the content and vice versa. But it would be a mistake to think of these fears as having representational forms. Rather, they are experienced in a visceral and behavioral sense (“My muscles were exploding as I was hitting him”).
Using traditional diagnostic thinking, one would see the more representational individual as having a more mature personality structure, capable of more traditional therapeutic exploration, whether it's a child using pretend play or an adult using words and descriptions or reporting associations or dreams. The individual who expresses the conflict in terms of direct behavioral phenomena we would view as a more primitive character disorder. Such individuals might come in having been involved in barroom brawls or severe, acting-out marital problems. We might feel less optimistic about their ability to participate in a dynamic therapeutic exploration.
But, regardless of our prognostic thinking about such persons, the structure of the personality and the ego is obviously critical in understanding the nature of their conflicts and anticipating the type of therapeutic work to come. Helping individuals shift from the level of acting out conflicts to the level of representing them might be seen, in fact, as the first order of business. Without this step, little growth could occur in their overall personality.
Basseches: How would these concepts play out in the treatment of patients?
Greenspan: Simply clarifying and interpreting these patterns would not be sufficient, and in fact might be counterproductive. First, one must always meet patients at the developmental level of their ego structure. Some of the strategies I propose are no different from what many therapists have been doing for years. But these approaches are too often viewed as intuitive rather than systematic or central to therapeutic growth. The developmental perspective can help systematize them and open up new areas for inclusion, such as constitutional and maturational differences, and the various developmental levels, that are not always grasped intuitively. Some, of course, will argue that these developmentally guided clinical strategies are preparatory to analysis, a preanalytic or analytic psychology phase of the work. To those who take this point of view, I would suggest that many more patients have these early difficulties than is often recognized, and that some of the limitations of analytic treatment relate to too narrow a view of the developmental levels in need of reworking.
Basseches: You seem to be saying that psychoanalysis should not define itself simply as a treatment for neurotic patients already capable of representing, differentiating, and observing their own experience. Instead, in order to deal with the issues you raise about early ego structure, it must define itself more broadly.
Greenspan: Psychoanalysis, as an approach to understanding the mind, has no choice. To remain vigorous and grow, it must embrace new findings. As a clinical treatment, it must continually bring in new discoveries to strengthen its clinical strategies. It must be careful, however, to build on its foundation systematically. As a discipline, psychoanalysis should be defined most broadly by its general principles and refrain from becoming too rigidly tied to one or another set of procedures.
Psychoanalysis has the opportunity to integrate findings about the mind, biological as well as psychodynamic and psychosocial. The developmental perspective can be especially useful in understanding how the different factors that influence development work together throughout the course of life. In this sense, the developmental perspective can guide the growth of psychoanalysis.
Basseches: Thank you for sharing your views so generously, and for giving our readers this opportunity to think about the important issues you raise.