PSYCHOTHERAPEUTIC APPROACHES

2005 The Medicine Publishing Company Ltd 21 PSYCHIATRY 4:5

Developmental psychopathology is a relatively modern term for
a discipline with a long heritage. Pre-eminent among its early
proponents was Sigmund Freud. Freud realized that what others
chose to sideline as abnormal in the sense of being beyond
comprehension according to the usual principles of psychological
functioning might instead have great value in revealing some
profound and remarkable things about the workings of the human
mind. It was not simply that he exhorted us to attend to disguised
expressions of personal meaning in neurotic or psychotic clini-
cal features, nor simply that he introduced radical new ways to
detect and analyse such meanings through free association and
the analysis of patterns of interpersonal relation (transference)
between patient and therapist. It was also that he set his clinical
observations in developmental perspective, giving us a fresh view
of the development of mental disorder and, beyond this, the nature
of psychological development itself.
What is developmental psychopathology?
The principles of developmental psychopathology are simple.
In order to identify the processes of typical development and
to trace the trajectory of normal mental growth, one needs to
encompass a picture of how those processes and that trajectory
can go awry. And in order to understand how psychopathology
arises, one needs to see how development normally unfolds and
pinpoint where and how the course of psychological integration
and growth has been derailed.
This approach presents a fundamental challenge to anyone who
studies the human mind. The problem is to decide how narrow
or how broad a domain of psychological functioning one needs
to encompass within a given explanation. It certainly makes life
simpler if one chooses to exclude such phenomena as perversions
or persecutory experiences as beyond the pale of psychological
explanation. Freud made a different choice.
Meaning in madness
Freuds investigative stance was to try to find meaning in mad-
ness and to seek a coherent psychological story of development
for abnormal functioning. This approach promises to show us new
things, precisely because certain goings-on in the mind that are too
subtle or too familiar to attract notice in typically developing indi-
viduals may be writ large in cases of psychopathology. In Mourning
and Melancholia,
1
for example, Freud suggested that if one listens
to the melancholic person (or, as he insisted, a particular class of
melancholic person), what one hears is not merely someone who
feels worthless and despicable, but in effect two figures in relation
to one another. One of these is indeed downcast and oppressed,
the object of scathing criticism and scorn; but then there is the
other figure, a disguised but insistent tyrant, a berating internal
object who occupies a platform within the mind from which to
unleash a condemning, hateful tirade upon the self. The patient
is both implicated in, and subject to, each of these figures and the
sado-masochistic exchanges in which they are embroiled.
As if this were not revolutionary enough as a picture of severe
depression, Freud took us further in offering a developmental
account of how this unhappy relation of oneself at war with oneself
comes into being. It does so through identification, a process by
means of which highly conflictual and ambivalent relations with
someone become interiorized (as the developmental psycholo-
gist Vygotsky would have expressed it) in such a way that a part
of the personality assumes the role of the attacked, and another
part assumes the role of the attacker.
How an internal world develops
What Freud gives us in this scenario is a vision of how pathology
is the lived-out expression of human relationships instantiated
within an individuals mind. He also shows how the development
of personality proceeds through the internalization of patterns of
relations with others, coloured and distorted by ones own feelings
and experiences feelings and experiences that depend upon the
time in an individuals life when the internalizations are taking
place. The foundations of personality are laid in early childhood,
and the experiences of infants and young children are not like those
of adults, perhaps especially because young children do not have
the same framework of reality within which to adjust and correct
their perceptions and experiences.
Largely on the basis of her work with very young children who
were free to play, Melanie Klein elaborated a picture of develop-
ment in which a young child is prone to experience the world in
terms of fairy-tale or nightmarish transactions among people.
2

Sometimes the people are less than fully human figures (known
as part-objects) that embody functions of people such as feeding
or withholding or satisfying or invading. Young children might
identify with such figures, experiencing themselves to have their
characteristics (as in play), or they might need to establish defen-
sive relations towards them. Klein delineated two positions, or
stances, that young children can occupy in relation to the world-
as-experienced:
the paranoidschizoid position is characterized by black-and-
white, beatific or threatening relations of a kind that induce
feelings of bliss, or of persecution and threat of annihilation
in the depressive position, by contrast, the world seems more
Psychodynamics
and developmental
psychopathology
Peter Hobson
Peter Hobson is Tavistock Professor of Developmental Psychopathology
in the University of London, London, UK, based at the Tavistock Clinic
and the Institute of Child Health, University College London. He trained in
psychiatry at the Maudsley Hospital, London, has a PhD in experimental
psychology from the University of Cambridge and is an Associate
Member of the British Psychoanalytical Society. His research interests are
focused on the pivotal importance of interpersonal relations for human
psychological development, with special reference to autism.
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2005 The Medicine Publishing Company Ltd 22 PSYCHIATRY 4:5
coherent and forgiving, and figures are more like whole people
towards whom the child feels yearning and concern, and in
relation to whom the predominant anxiety is that of harming
or losing a valued and depended-upon person.
From a developmental perspective, concern and caring towards
others, as well as stability in the way that others are experienced,
are developmental achievements. They occur only if the young
child receives the sensitive attention and containment of at least
one caregiver. When this is not available, abnormality may arise
as the expression of maldeveloped offshoots of a developmental
process that we all share. In other words, the potential for abnor-
mality including the paranoidschizoid or perverse is within
all of us.
Contemporary research
This contribution will now consider how such perspectives on
mental and interpersonal functioning, for so long caricatured and
derided by scientists, are being elaborated through systematic con-
trolled studies of attachment, the transgenerational transmission
of pathology through interpersonal relations, and autism.
The case of borderline personality disorder
Although formally recognized as a syndrome according to a set
of co-occurring clinical features (Figure 1), borderline personality
disorder may have a variety of manifestations both across and
within individuals. No wonder that the condition attracts a range
of psychiatric diagnoses, including depression and even atypical
psychosis. There is little evidence that it has a genetic or other
constitutional basis, but substantially more evidence that factors
such as childhood separations and maltreatment play an aetiologi-
cal role. Yet, until recently, the scientific evidence for this being a
disorder rooted in adverse early experiences in essence a disorder
of interpersonal relations has been circumstantial.
That situation is changing. Take the issue of attachment, for
example. In recent years, research has extended from studies of
children to investigation of the mental representation of attach-
ment in adults. In the Adult Attachment Interview developed in
the USA by Dr Mary Main, individuals are interviewed about their
own childhoods and give descriptions of their relationships with
caregivers and experiences when they suffered illness, separation
or trauma. Transcripts are coded not so much for what partici-
pants say, but the ways in which they organize their thoughts and
feelings effectively, their defensive strategies towards painful
memories. Some people are Free to Evaluate their attachments,
talking coherently even when they report unhappy events. Others
are Dismissing and terse, for example describing how things were
just normal, even when there are indications that they were very
difficult or traumatic.
It has emerged that a third category, that of Enmeshed Pre-
occupied, where participants are unable to give a coherent account
of their experiences of childhood and instead tend to vacillate in
viewpoint, is especially characteristic of women with borderline
personality disorder. In one study, for example, borderline women
contrasted with matched depressed women in being fearful, con-
fused and overwhelmed in relation to attachment experiences,
and moreover unable to integrate memories of trauma and loss
without becoming disorientated.
3

In a further study of similar groups of adult women, Hobson
1
The syndrome of borderline personality disorder
Five or more of the following:
Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships
Identity disturbance
Impulsiveness in at least two areas that are potentially self-
damaging
Recurrent suicidal behaviour, gestures or threats, or self-
mutilating behaviour
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger
Transient, stress-related paranoid ideation or severe
dissociative symptoms
et al.
4
videotaped psychotherapy assessment interviews and asked
blind raters to evaluate participants ways of experiencing the
psychotherapist and/or other people (as reported) by scoring a set
of descriptors that reflected features of Kleins paranoidschizoid
and depressive positions. For example, excerpts of the videotape
were rated for whether the patient experienced others (including
the therapist) as persecutory, self-preoccupied, and/or unavailable,
or as more benign and helpful. The results showed not only that
such clinical features clustered in the way that Klein had described,
but also that paranoidschizoid features were significantly more
characteristic of the women with borderline personality disorder
than those with depression.
Borderline personality disorder is thus characterized both by
what attachment theorists call Enmeshed Preoccupied forms of
mental representation, and by many features of what Klein called
paranoidschizoid functioning. These fragmented and conflictual
patterns of thinking and feeling can be evaluated within affected
individuals minds, and as they are lived out in their relationships.
Not only this, but one can observe what appear to be the effects of
such relations on the infant offspring of mothers with the disorder.
In a recent study,
5
a large majority of 1-year-old infants of mothers
with borderline personality disorder were found to be disorgan-
ized in their attachments, a pattern of relatedness that often leads
to untoward relationships and sometimes psychopathology later in
life.
6
Here we see how interpersonal relations are not only shaped
by, but potentially shape, internal workings of the mind that may
become manifest in psychiatric disorder.
The case of autism
There is a danger that psychotherapists who study autism will be
tarred by the brush of those such as Bettelheim (an Austrian-born
psychoanalyst) who have claimed that the disorder is psychogenic.
In fact, a substantial number of child psychotherapists and ana-
lysts who have devoted time to studying the condition highlight
the childrens constitutional abnormalities. For example, Mahler
7

made prescient observations of how children with autism are
unable to use their mothers as beacons of emotional orientation,
a description that has found ample confirmation in recent quasi-
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2005 The Medicine Publishing Company Ltd 23 PSYCHIATRY 4:5
experimental studies of the childrens limited propensity to perceive
and learn from adults ways of reacting to objects and events in
the world.
8
One of the most powerful insights that autism can
give us is what happens to development when certain processes
basic to human functioning across the lifespan processes that
have been documented and explored by dynamic psychotherapists
are missing or weak from early in life. In other words, autism
may draw attention to the nature and implications of foundational
interpersonal processes, not only for social but also for cognitive
development.
On the one hand, autism is like borderline personality disor-
der in being a syndrome, a constellation of clinical features. In
autism, the most important are impairments in social relatedness
and communication, and in creative flexible thinking (Figure 2).
Kanner
9
suggested that the children have an inborn disturbance
of affective contact with others. But is it possible that even such
striking impairments in thinking and flexibility might stem from
primary interpersonal disorder and moreover from disturbances
in affective contact? It is indeed the case that autism may not
only enable us to see how interpersonal engagement is vital for
the development of a broad range of cognitive as well as social
abilities, but also that a specific mechanism of social engagement
the mechanism of identification described in the writings of
Freud plays a critical role.
Identification: how might evidence about identification, or the
lack of it, emerge from experimental studies of children with
autism? Hobson and Lee
10
tested matched groups of 919-year-
old children with and without autism for their ability to imitate a
person demonstrating four novel goal-directed actions on objects
in two contrasting styles. In one condition, the demonstrator
made a toy policeman-on-wheels move along by pressing down
on its head either with his wrist cocked or with extended index
and middle fingers.
The results were as follows: the children with autism were
perfectly able to copy the demonstrators actions, for example in
pressing down the policemans head to make him move. How-
ever, they contrasted with control participants insofar as very few
adopted the demonstrators style of acting upon the objects. Instead
2
The syndrome of autism
Qualitative impairment in social interaction
Impaired eye gaze, gestures, facial expressions
Failure to share experiences, or develop relationships with
peers
Qualitative impairment in communication
Delayed and idiosyncratic language development
Inability to sustain conversation
Restricted patterns of interests and activities
Inflexible adherence to routines and rituals
Repetitive motor mannerisms
of adopting the wrist or two-finger approach to activating the toy,
for example, most of them pressed down on the policemans head
with the palm of a hand. Therefore, there seemed to be a contrast
between childrens ability to observe and copy intended actions
per se relatively intact in autism and the propensity to identify
with and thereby imitate a persons expressive mode of relating
to objects and events in the world.
Another feature of the results distinguished between participants
with and without autism. One condition involved the demonstrator
holding a pipe-rack against his own shoulder in order to strum
it with a stick, either harshly or gently. A substantial majority of
the control participants identified with the demonstrator and posi-
tioned the pipe-rack against their own shoulders before strumming
it. By contrast, most of the children with autism positioned it at a
distance in front of them, on the table. They failed to imitate the
other persons self-orientated action in such a way that the action
became orientated to their own (rather than the copied persons)
self. Moreover, participants who copy the self/other-orientation
of actions are also more likely to direct sharing looks (but not
checking or orientating looks) to the tester. It seems there is a
quality of interpersonal engagement that entails being moved into
the position of the person-related-to, and in which one identifies
with the others subjective state and makes this ones own, that
is relatively lacking in children with autism.
Intersubjective engagement is pivotal for development
Autism is revealing what psychotherapists have long claimed to
be the case. In order to be able to think, one needs to be able to
relate to other people as whole, independent sources of attitude.
Both self-reflective awareness and creative symbolic thinking are
intimately tied up with interpersonal processes, and in particular,
being able to relate to other peoples relations with oneself and
the world. When such processes are impaired, a relative lack of
self-consciousness and concrete, inflexible thinking may result.
Children with autism are often oblivious to the effect they have on
others, and relatively empty when it comes to seeing themselves
in relation to other people. They are often unable to symbolize
in play, and what symbolic play they do produce is mostly sterile
and repetitive, just as their language is often restricted in flexibility
and sensitivity to context. The developmental psychopathology of
autism is thus far more relevant to psychotherapy than one might
suppose: it is showing us the pivotal role of truly intersubjective
relations, and the role of identification within those relations, in
human cognitive as well as social development.
Conclusion
From the outset, psychodynamic psychotherapy has been at the
cutting edge of an approach that now enjoys the rather grand title
of developmental psychopathology. More recently, research that
employs investigative techniques quite different from those of
psychoanalysis, but that follows the tradition of drawing typical
and atypical development into close relation with one another,
has begun to provide new evidence for certain specifically psy-
chodynamic concepts (such as identification) and claims about
the patterning of mental life in cases of psychopathology. In this
domain there is mutual enrichment between psychotherapy and
developmental research.
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REFERENCES
1 Freud S. Mourning and Melancholia (1917). In: Strachey J, ed.
Standard Edition of the Works of Sigmund Freud. London: Hogarth,
1957.
2 Klein M. Notes on some schizoid mechanisms. Int J Psychoanal 1946;
27: 99110.
3 Patrick M, Hobson R P, Castle D, Howard R, Maughan B. Personality
disorder and the representation of early social experience. Dev
Psychopathol 1994; 6: 37588.
4 Hobson R P, Patrick M P H, Valentine J D. Objectivity in psychoanalytic
judgements. Br J Psychiatry 1998; 173: 1727.
5 Hobson R P, Patrick M P H, Crandell L, Garcia-Perez R, Lee A. Personal
relatedness and attachment in infants of mothers with borderline
personality disorder. Dev Psychopathol; in press.
6 van Ijzendoorn M H, Schuengel C, Bakermans-Kranenburg M J.
Disorganized attachment in early childhood: meta-analysis of
precursors, concomitants, and sequelae. Dev Psychopathol 1999;
11: 22549.
7 Mahler M S. On Human Symbiosis and the Vicissitudes of
Individuation. Madison, CT: International Universities Press, 1968.
8 Sigman M D, Kasari C, Kwon J H, Yirmiya N. Responses to the negative
emotions of others by autistic, mentally retarded and normal
children. Child Dev 1992; 63: 796807.
9 Kanner L. Autistic disturbances of affective contact. Nerv Child 1943;
2: 21749.
10 Hobson R P, Lee A. Imitation and identification in autism. J Child
Psychol Psychiatry 1999; 40: 64959.
FURTHER READING
Hobson P. The Cradle of Thought. London: Pan Macmillan, 2002.
(A book that fills out the arguments and evidence of this
contribution.)
Practice points
A great deal can be learnt about the origins of
psychopathology from considering typical and atypical
development in relation to one another
There are new sources of evidence for psychodynamic
processes that characterize certain forms of personality
disorder
The study of autism sheds light on how development of the
mind depends on interpersonal experiences, and identification
between young children and other people
Research on the transmission of psychological difficulties
from parents to their infants promises to elucidate sources of
psychopathology early in life