Tag Archives: psychoanalysis

Stress Regulation: From Theory to Practice


Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Stress Regulation: “From Theory to Practice”

Perry’s ideas about stress regulation are particularly important to me in my clinical work. In contrast to the negative cascade stress can cause in a sensitized child, helping a child grow his stress regulation system may initiate a healthy “cascade” effect.

In my practice, if a child gets better at calming herself, she can pay more attention to my ideas about the motivations for some of her problem behavior and consider trying more adaptive ways of behaving. For example, if a child is poorly regulated, she will not be receptive to my observations that when she starts out with “loser feelings” she cannot bear to play competitive games with her peers. She is more likely to use psychological defenses such as denial and avoidance to protect herself from the stress of acknowledging her painful feelings. If, however, we begin by my giving her a “handicap” that makes it easier for her to win, and then emphasize the rhythmic, repetitive turn taking patterns of the game with my actions and with my voice, she may be able to establish and maintain a receptive, alert position in relation to my communications and even allow me to scaffold some self reflection. In play sessions with one child, I would ask her at the beginning of the session whether it was a “bad guys in” or “bad guys out” day for her before we settled into a game of Candyland. If it had been a hard day for her, we would take all the cards that send you backwards out of the pile. If it had been a good day, we would leave them in. This small ritual allowed us to play the game together, while also helping her begin to reflect on and identify her feelings, and eventually appreciate the link between her temper tantrums and her sense of herself as a “bad girl”.

In psychology and psychoanalysis we refer to “respecting the child’s defenses”, something that Anna Freud talked about. That means not overwhelming a child, usually by avoiding confronting him with information he is not ready to receive. Perry’s idea of “dosing” and “spacing” adds a new dimension to the concept of “defense”. It brings the body into the equation in an important way. Thinking in these terms helps us organize our interactions with a child in time and space. It helps us put the music and dance into our clinical work. Because I study videotapes of my work with children, I see the nonverbal communication, what I call the “music and dance” of psychotherapy, both in a standard time frame and in a microprocess, second by second, time frame. In the microprocess, you can see this dosing and spacing even better than in real time. For example, in one session with a 4-yo boy, you see me introduce an idea about something scary to him; I deliver my communication in short (2 sec) vocal turns defined by short internal pauses (“dosing”) and then, right after I finish, I sit back and fold my arms across my chest. This is “spacing”. When you look at the film in slow motion, you can infer my (out of my awareness) intention of giving him space, giving him a turn.

“Dosing” adds the factor of measurement, of size, which I think is very useful to keep in mind. I remember playing with a little boy who felt the need to exert extreme control over me in the session. In order to help him grow, move him towards reciprocity, I had to stress him by interrupting him sometimes, declining to jump to comply with an order, or by adding a detail of my own to the narrative that he was spinning, any of which could make him mad. Sometimes I “dosed” my contributions by adding humor, sometimes I made them very short, and other times I acted a little confused. Slowly, using dosing in that way, he began to give me a turn now and then.

Spacing is another very helpful perspective. “Spacing” is even closer to the theory of psychological defenses than “dosing”. I was observing the need for “spacing” when I sat back and folded my arms across my chest in the previous example. Another example is my work with a child who lost a parent. When he saw me in the preschool classroom, he would “pretend” reject me by playfully pushing me away or telling me in a loud voice to go away. I would play along, sometimes moving back a few inches, but not going away until it was time for me to say goodbye. When you think about it, there is a lot of communication in our behavior. He is telling me he needs to know if his behavior can cause me to disappear forever, and I am telling him that his behavior is unrelated to when I come and go. My leaving the classroom was a dosing experience for this child. One day after many months of this daily play (“spacing”), I stood to leave, and the boy approached me sideways, without giving me a direct gaze, and leaned against me. I stroked his hair and he didn’t move.

In addition to dosing and spacing, Perry’s thoughts about “distributed caregiving” have also been helpful to me. Actually, what has happened is that my own clinical experience has been moving me further and further from thinking in terms of categorical diagnoses and “clinical” interventions. Instead, I think about children’s problems more often in dimensional terms and tend to move to support the child’s caregiving environment before immediately beginning an individual psychotherapy. Supporting the child’s caregiving environment means working with the child’s parents and teachers. One of my favorite ways of intervening is to work in the preschool. Then, I not only have a chance to offer the very capable teachers an insight now and then about a particular child. I also have the chance to “be there” for certain children when and how they need me. This is what Perry means by “distributed caregiving” – allowing a child to initiate a particular kind of interaction with each caregiver in a group available to him. This kind of thinking moves away from formulations about pathology and towards developmental goals. For example, Perry talks about how after the Waco disaster, the traumatized children seemed to identify particular caregivers for specific needs of the child – one for help with schoolwork, another for rough housing, another for snuggling. I have seen the same kind of distributed caregiving activity in the preschool classroom with healthy children.

I realize that psychotherapists and even psychoanalysts like me sometimes consult to teachers in schools by sitting down with them and listening to them talk about the children and answering their questions, and even by entering the classroom to observe certain children pointed out by the teachers. What I prefer to do is “live” in the classroom so that I can see the children in action and sometimes engage directly with them, while at the same time trying from time to time to identify what the teachers can do even better. For example, I might see a little boy who seems more fearful than average and begins tentatively to play with a toy car. I might suggest to the teacher that she encourage some gentle crashing games if the child initiates them.

In closing, I would like to emphasize the importance of rhythmic patterned activity that is repeated over and over again in helping people grow. This is very different from what I learned in psychiatric and psychoanalytic training. It is not that I have not engaged in that kind of activity in my clinical work; I have. On the other hand, now that I have integrated it into my theory, I do it more, and I do it better.

What Does Psychoanalysis Have to Offer the Treatment of an ASD Child?


What does psychoanalysis have to offer models of intervention? There are several features of psychoanalytic theory and technique that can benefit the treatment of ASD children and their parents.

First, the training and experience of psychoanalysts is unique in that it involves developing an intimate, dependent relationship with a person in need, with the focus of attention on that individual’s inner world and also in the interaction between the two analytic partners.  This attention to what is going on in the relationship, in the moment, contributed to by both partners, and understood at a deep level – both symbolically and in the implicit and nonverbal – allows for a different kind of co-creative meaning making. I would consider this to be a unique competence of the psychoanalyst.

Second, psychoanalytic training and experience includes a high degree of “pattern recognition”, for example, an ability to recognize symbolic representations of strong emotions within relationships, and combinations and sequences of emotion and psychological efforts at self-protection or defense. Illustrations of these patterns might include a child’s remark about a tornado followed by an association to the child’s younger brother. Another example might be a child’s attempt to protect him or herself from threatening aggression coming from within by turning away from what is provoking the sense of threat or by retaliating against an imaginary external threat. Refined pattern recognition allows the psychoanalytic clinician to take a less linear approach to the treatment of ASD children in that partial or relatively incoherent symbolic representations are easier to spot and to use in understanding the child’s experience and communicated to the child. This often can be helpful even if the child is not considered to be at a level capable of apprehending such a communication according to other models.

Third, psychoanalytic training and experience requires learning a great deal about yourself, that is, about the clinician him or herself. This self-knowledge might include the clinician’s personal organizing fantasies, for example, to rescue a suffering child. It might include the stressors that challenge the clinician’s sense of him or herself, such as making a mistake or causing pain in another person.  It might also include the individual’s particular reactions to emotional challenges and the characteristic means he or she uses to deal with intense affect – to withdraw, for example, or to try to undo some perceived injury.

Psychoanalytic training also allows for a deeper and more comprehensive understanding of parents – how adults cope with stress, how they transmit early relational patterns from one generation to the other, how they grow. Psychoanalysts learn how to tolerate anguished attacks without taking them personally, how to help a suffering person move from the perception of being a victim to that of taking an active role in recovery, and how to move into a collaborative role with another in the context of threat.

Psychoanalysis “off the couch” is valuable not only to the psychoanalytically trained clinician, but to the team that treats these children. I believe that a team that includes specialists in psychoanalysis or psychodynamic psychotherapy, occupational therapy, speech, and education should treat all children with autistic spectrum disorders. Pediatricians or pediatric specialties are also sometimes needed. It is very challenging to organize a team into a collaborative partnership in which roles are clear and compatible and in which there is adequate communication, but it is possible. It is also challenging – though I also believe possible – to plan such a treatment that is affordable and not an unbearable burden for parents.

Read this blog in Spanish. 

Photograph by Ginger Gregory