Embedding Co-Regulation Within Therapeutic Process: Lessons from Development Response to...

Embedding Co-Regulation WithinTherapeutic Process: Lessons from

DevelopmentResponse to “Co-Regulated Interactions:

Implications for Psychotherapy …,”paper by Stanley Greenspan

K. Mark Sossin, Ph.D.Jan Charone-Sossin, Ph.D.

Considerations Regarding Greenspan’sPast Contributions

APANORAMIC VIEW OF STANLEY GREENSPAN’S CONTRIBUTIONS TO

psychiatry, psychology, and psychoanalysis captures work of excep-tional breadth, depth, and remarkable utility to clinicians treating

individuals of all ages. Over years of dedicated observation and synthesis, anotable continuity flows through his work. He joined others in attemptingto expand the usefulness of Anna Freud’s metapsychological profile(Greenspan, Hatleberg, and Cullander, 1976) by both narrowing its scope,updating its developmental constructs, and incorporating interview-basedscales of personality functioning. Ingredients of the functional emotionalgrowth he stresses in later contributions are evident here. From an initial

259 © 2007 The Analytic Press, Inc.

Journal of Infant, Child, and Adolescent Psychotherapy, 6(3): 259–279, 2007

K. Mark Sossin, Ph.D., is Professor of Psychology, Pace University, New York City. He is aclinical psychologist and psychoanalyst, on the faculties of the Anni Bergman Program inParent-Infant Psychotherapy (NYFS/IPTAR) and the Postdoctoral Programs in Psychother-apy and Psychoanalysis of Adelphi University. Jan Charone-Sossin, Ph.D., M.S.Ed., is Assis-tant Professor of Education, Pace University, New York City. She is an educator, clinical psy-chologist, and psychoanalyst. Both have private practices with infants, children,adolescents, and adults in New Hyde Park, New York.

integration of Piagetian and psychoanalytic developmental theories(Greenspan, 1979), in which he conceptualized the emotional underpin-nings of cognition, and from his tri-tiered view of learning—linking bodilyexperience, consequence (cause/effect), and representational processes(Greenspan, 1982)—Greenspan sustained his focus on psychoanalytic psy-chotherapy from a developmentalist’s perspective. Within his framework,therapeutic progress requires the patient to have the capacity for assimila-tion and integration. The reworking of affective and cognitive meanings ona complex, representational level requires the processing of prerepresenta-tional somatic experience as well. Greenspan appreciates the need for syn-chrony and a fit between therapist and patient, and he has shared ideasabout how the therapist and therapeutic process need to correspond to thepatient’s developmental level at any given phase of the treatment.

For Greenspan (1989), ego development became framed against thebackdrop of six stages of experiential organization.1 As such, Greenspannot only offered a significant developmental model, but also clearly ele-vated discussion among psychoanalysts about the integration of constitu-tional factors (including sensory-affective processing) and caregiver-childinteraction patterns. In this model, a vulnerable sensory pathway wouldheighten the risk factor for later thought and/or affect disorders. A lim-ited deficit in auditory affective processing, for instance, would heightenthe chance of disorganized thinking or feeling, especially if exacerbatedby environmental stresses. In an interdisciplinary, multi-dimensional, andsystems-laden manner, Greenspan viewed how early vulnerabilities canlead to future breakdowns. Specific hypotheses were: “(1) auditory-ver-bal-affective vulnerabilities may be associated with disorders of thoughtand obsessive-compulsive patterns, (2) visual-spatial-affective vulnerabil-ities may be associated with disorders of affect regulation and hystericalpatterns, and (3) spatial, motor movement (vestibular) vulnerabilitiesmay be associated with phobic and/or counterphobic tendencies” (p.625). A deficit in auditory-verbal symbolic sequencing can underlie frag-

260 K. Mark Sossin and Jan Charone-Sossin

1Specifically (as originally framed and labeled, followed by more current and elaboratedterms, as per Greenspan, DeGangi, and Wieder, 2001), these stages are: homeostasis (0-3months) [later termed “self-regulation and interest in the world”], attachment (2-7 months)[“forming relationships, attachment, and engagement”], somatopsychological differentia-tion (3-10 months) [“two-way, purposeful communication”], behavioral organiza-tion-emergence of a complex self (10-18 months) [“behavioral organization, problem-solv-ing, and internalization”], representational capacity and elaboration (1 -3 years) [same], andrepresentational differentiation (2-4 years) [same, described as “building bridges betweenideas and emotional thinking”].

ile representational processes, manifested in poor organization of self,nonself, and other.

Such model-making led to hypotheses for research and to principles thatcould guide primary prevention as well as intervention work. Greenspan(1989) elaborated upon the therapeutic manner in which intact sensorypathways could be used specifically so as to not overwhelm the more vul-nerable pathways. He also linked developmental and therapeutic progressto an environment able to offer reciprocal cause-and-effect actions andtherapeutic experiences that promoted representational differentiation.

Years of honing his ideas and perspectives finds Greenspan overseeingthe further development and implementation of the Developmental Indi-vidual Relationship (DIR)-based model, exemplified in the establishedmethod of “Floortime,” as well as the reframing of infant and early child-hood diagnostic categories, especially reflected in the Diagnositc Manual forInfancy and Early Childhood (ICDL-DMIC) published by the Interdisciplin-ary Council on Developmental and Learning Disorders (2005). AlongsideZero-to-Three and the World Association for Infant Mental Health, ICDLhas been a notable forum for advancements in understanding infants andyoung children and in applying effective interventions on their behalf.ICDL has also become a conduit for evolving ideas and methods consonantwith DIR. In the ICDL-DMIC, we see the influence of Greenspan in therecognition of body-mind confluence, as in the rubric of regulatory-sensoryprocessing disorders. This perspective was further extended to the diagnos-tic and therapeutic puzzles pertaining to early-evident Bipolar Disorder(Greenspan and Glovinsky, 2002).

Through more accessible writing, Greenspan has become an integralmember of the support system for many families with children with specialneeds (Greenspan, Wieder, and Simons, 1998), and even for parents ofwell-developing children reflecting on their parenting (Greenspan andLewis, 2000; Brazelton and Greenspan, 2001). With varied colleagues,Greenspan has given cogent thought to essential childcare challenges of ourtime. Some of his other work has a very professional audience. He has care-fully considered the sensory and thematic-affective organizations alongsideclinical features linked to difficulties in each of the developmental phases, sothat relativedegreesofmaladaptiveoradaptivepatterns linkedtoeachphasecanbecoded.TheresultingFunctionalEmotionalAssessmentScale (FEAS;Greenspan, DeGangi, and Wieder, 2001), which provides a remarkable toolfor coding developmental attainments from videotape, is especially valuablein planning interventions for children in the autism spectrum (with currentnorms extending to age four, though the applicable age range may be broad-

Embedding Co-Regulation Within Therapeutic Process 261

ened) and for charting progress in the context of intervention. Heco-authoreda lucid textonTheClinical Interviewof theChild (GreenspanandGreenspan, 2003), which is an excellent training guide for child clinicians.Together with Serena Wieder, he has crystallized the DIR approach to inter-vention with children with autism (Greenspan and Wieder, 2006), and theyhave also written a state-of-the-art text on Infant and Early Childhood MentalHealth (Greenspan and Wieder, 2005).

One of Greenspan’s defining achievements is his recent collaborativetome The First Idea (Greenspan and Shanker, 2004), wherein he and Stu-art Shanker, a philosopher and Wittgenstein scholar, explore neuro-scientific and anthropological sources (as well as drawing upon work withindividuals with autism and work with nonhuman primates) in re-think-ing communicative development and the emergence of language andsymbolic thought in human evolution. Emotions and interaction pro-cesses are schematized as central elements moving evolution forward.From the vantage point of Greenspan and Shanker, caregiving practices,and other basics of social and emotional communication, pertain to there-learning of symbol formation abilities, and the sharpening of reflectivefunction skills. Greenspan and Shanker offer sobering consideration to anincreasing global interdependency imposing an increasing “morality of in-terdependency” and “ethic of survival;” these demand greater empathyand a greater integration of emotional and intellectual capacities throughgreater reflective thinking. These considerations fall against the backdropof 16 articulated stages of functional-emotional development. In this way,Greenspan and Shanker promote a rich accounting of lifespan develop-mental psychology, while they also enter the political arena. They con-sider “…the kinds of family and educational practices necessary to createa reflective citizenry and the reflective institutions that can rise to thechallenge of global interdependency” (p. 449). One can see in this recentwork that Greenspan himself enters a deeply reflective and moral modein extrapolating from clinical work, parent-child observation, and hisrichly articulated developmental model to envision and promote a furtherstep in human social evolution.

Psychotherapeutic Model Built uponDevelopmental Anchors

These prefatory comments about Greenspan’s accomplishments and over-arching viewpoints seem necessary to place the current paper on co-regula-


tion in context. This paper by Greenspan is an updated but highly con-densed paper, articulating a psychotherapeutic stance that is far morethoroughly mapped out in a savvy, engaging, and often-luminous text, De-velopment Based Psychotherapy, which is abounding with explicatory clinicalexamples (Greenspan, 1997). In addition, it outlines a psychoanalyti-cally-informed, DIR-consistent, developmental psychopathology schemethat highlights some of the key biologic- and relationship-sourced risk-fac-tors manifested in distinct clinical outcomes.

Originally, psychoanalytic technique emerged hand-in-hand with whatwas at the time a newly cast theory of mind and corresponding theory of de-velopment. However, newer understandings have led to the re-casting ofthe infant as a far more active agent, and we now know far more about ex-perience-dependent neurodevelopment and the nature of infant-caregiverinteractive processes. Hence, ideas regarding psychopathology as well aspsychotherapeutic technique understandably need to be revised, a task towhich Greenspan has assiduously devoted himself. Greenspan’s view offunctional emotional developmental capacities is portrayed by the DIRmodel, which reframes developmental pathways—always interfacing bio-logic processing, family relationships, and patterns of interaction—leadingto perspectives pertaining to a broad range of disorders, which in turn sup-port advances in psychotherapeutic technique.

When focused on young children, or on children in the autism spectrum,Greenspan’s developmental model stresses the founding of shared atten-tion, engagement, increasingly complex gestures and problem-solving to-ward the development of more abstract thinking (Wieder and Greenspan,2003). Greenspan truly describes a manner of climbing the symbolic ladderwith a patient. Regarding the child with autism, he enjoins therapists to en-gage the children on the level they can engage on; his developmental modeloffers a reference point to substantiate the value of creating interactions fortheir own sake, and to establish a basis from which to move developmen-tally upward. Notably, these same principles apply to adult psychoanalyticpsychotherapy as well. Greenspan’s work challenges psychoanalytic psy-chotherapists to truly consider their patient’s developmental status (ofthinking, feeling, and relating), as well as somatopsychic integrations, andaccommodate technique accordingly.

The functional assessment inherent in the DIR model not only applies tothe framing of interventions for the young atypical child, but also for olderchild, adolescent, and adult patients. Within Greenspan’s unified develop-mental model, behaviors and affects emerging from sensory under- orover-reactivity are viewed from the perspective of how they evolve in con-


texts in which manners of caregiving vary qualities of availability andresponsivity. Hence, as evident in the present paper, dynamic contents areviewed alongside presymbolic structures. More than other psychodynamicmodels, competencies and constrictions across motor, sensory, cognitive,and language capacities are viewed as integral to the thematic and affectivecomponents (Wieder and Greenspan, 2005). Some might consider that thisis how DIR steps aside from being a psychodynamic model. Rather, wemight argue this integration, much like current attention to neuro-psychoanalysis, links body and mind in a way that fits more closely with de-velopmental research, broadens the therapist’s awareness of interrelatedbody-mind-relational domains, and may, historically and theoretically,have roots in the work of early body-mind psychoanalytic explorers such asSchilder (1935).

Across diagnostic categories, Greenspan stresses the importance of thetherapist’s offering of co-regulating “soothing” emotional interactions; ina parallel way, the supported parent is encouraged to offer such soothingfor the challenged child. Greenspan’s clinical perspicacity builds upon theaffect diathesis hypothesis, incorporating the insight that each sen-sory-motor pattern is inextricably linked to affect, the identification of apatient’s progress upward within the multifaceted developmental modelproffered, the appraisal of one’s complex interactive patterns, and the in-dividual’s meaningful use of symbols. Greenspan’s 11 therapeutic princi-ples are valuable guides for the clinician, and they reflect a colossal syn-thesis of developmental and clinical thinking. They underscore thecoherence of the developmental theory Greenspan articulates and its di-rect relevance to a mutative therapeutic stance. The principles remindthe clinician of the importance of a developmental profile and of thetherapist’s need to observe changes in this profile over the course of ther-apy, directly inviting modifications in therapeutic interventions in termsof therapeutic engagement, the patient’s level of processing, readiness forsymbolic-levels of communication, nonverbal patterns, specificity of af-fect-experience, and progress toward self-observation (reflectivity). Thetherapist is reminded to buttress the patient’s own assertion and initia-tive, and to appreciate the developmental steps of action, affect, andthought, as progressing in representational experience. Greenspan quitecorrectly notes that therapists often introduce and continue with symbols(and interpretations) beyond the reach of patients, underscoring the im-portance of employing the developmental model through the course oftherapy, linking chosen interventions to the patient’s climb up the evolv-ing developmental ladder.


Gesture and the Importance of the Nonverbal

Greenspan has a remarkable eye for the nonverbal, as exemplified in nu-merous case examples throughout his clinical writing, and he incorporatesconsiderations of the therapist’s gesture as focal in clinical technique. Inthe current paper, he links a woman’s depression to her lacking internal rep-resentational experience at a “presymbolic affective interactive” level aswell as the symbolic level. In addition to considerations of transference andreflective/explorative work, Greenspan noted that it was “necessary to cre-ate a different type of affective interaction and rhythm as well,” leading himto communicate with her in specifically animated affective gestures.

In this regard, Greenspan has encouraged therapists to be aware of theimportance of the nonverbal channel in psychotherapy. It remains ques-tionable, however, whether Greenspan, whose knack for utilizing nonver-bal channels appears to be a finely honed amalgam of intuition and analyticresonance crafted through experience, is able to communicate effectivelyto other therapists what to look for nonverbally, and how to encode re-sponses to amplify efficacy. Similarly, it may be that the lack of a system forrecognizing and understanding nonverbal patterns may somewhat limit thetherapist’s ability to cue parents via coaching toward more developmentallyadvantageous use of the nonverbal channel as a tool in “co-regulating” thechild of concern while in interaction.

Greenspan offers examples of down-regulating, as when the caregiver ofa toddler evidencing risk for bipolar patterns (sensation and vestibu-lar-stimulation seeking, risk-taking, and essentially acting upon over-sensitivity through stimulatory overload) is encouraged to use a calm voiceinstead of more excited tones, and “…the caregiver works on soothing andslowing down the affective rhythm until the child is calm.” Greenspan fur-ther underscores the therapist’s need, in an analogous situation, todown-regulate the overexcited child patient, by which he primarily means“…calm down first at the affective, experiential level” before reformulatingexperience on the more symbolic level.

These are important caveats, correct in a fashion, and yet at the sametime problematic. Because they don’t address the complexity of co-regula-tion or the multifaceted nature of movement and paralinguistic patterns,such ideas are not easily employed. In fact, a caregiver or therapist greetinga child’s excitability or high-intensity of affect with low-intensity may verywell break the empathic bond, no longer serve as a suitable container, andamplify a sense of disjuncture in the relationship. Affect-sharing in thenonverbal channel is intricate and multi-modal. While Greenspan himself


may clinically manage such a moment with remarkable finesse and efficacy,the principle itself is stated in terms that are two-dimensional and readilymisapplied. In Greenspan’s own body-mind synthesis, incorporating wel-come consideration of sensory processing, it currently remains that a truemodel of nonverbal patterns, and of their own embodied, communicative,and representational meanings, is missing. This is generally true in writingon psychotherapy.

The therapist’s use of specific nonverbal patterns, in conjunction with apatient’s psychological and affective status, and the patient’s awareness ofhis or her own body in the context of therapy, have been addressed by many(e.g., La Barre, 2001; Davis and Hadicks, 1994; Balamuth, 1998;Kestenberg-Amighi, Loman, Lewis, and Sossin, 1999; Beebe, 2004, 2005).Interesting considerations abound as to the degree of conscious awarenessthe therapist has about nonverbal behavior. Beebe (2004), who elaboratedupon her knowledge of nonverbal processes (e.g., gaze, vocal rhythms,tone) in an innovative treatment endeavor, comments that upon examin-ing videotape of the therapy process, she concluded that most of her non-verbal behavior was nonetheless out of her awareness. Beebe’s remarkablecase description highlights the degree to which early trauma can disruptintersubjectivity, and also how early implicit relational knowing influencesand continues to enter nonverbal exchanges years later.

Trevarthen, among others, while not employing a “language of move-ment,” has paid scrupulous attention to the rhythmic, intensity, and tem-poral features of movement in normal development (Trevarthen, 2005b;Trevarthen and Aitken, 2001) and has linked their neurobiologically weak-ened status in the infant at risk for autism with “asynchronous social behav-ior” and deficient “sympathetic motivation,” collaboration in learning andcompanionship (Trevarthen and Daniel, 2005). Notions of what is co-reg-ulated, what subjectivities are shared, and what nonverbal patterns aremeaningful, can be made clearer in Greenspan’s work, especially whereinaffective co-regulation is an important clinical construct that remains un-defined.

While Greenspan’s perceptivity regarding nonverbal processes is sharp,he does not utilize the tools offered by those directly studying such realms.At the same time, Greenspan is both exquisitely attentive and attuned tothe movements, gestures, and sounds of his patients, and yet lacks a lan-guage to describe these nonverbal patterns. Such refinements in nonverbaldiscriminations can be derived from evolutionary and discrete-emotionsperspectives, mostly focusing on facial-expression, or from process-focusedlanguages of movement (perhaps more readily linked to psychodynamic


psychotherapy), such as those derived from Laban (e.g., Laban and Law-rence, 1974; Lamb, 1965). Researchers using Ekman & Friesen’s Facial Ac-tion Coding System (FACS) found evidence suggesting that facial affectmeasures could distinguish among patients across diagnostic classifications,and even between those fitting subgroups within the same general diagnosis(Ekman, Matsumoto, and Friesen, 2005). The FACS methodology has fur-ther been extended to the objective coding of infant facial expressions uti-lizing the Baby FACS (Oster, 2005), as well as to the analysis of affectivemicrosequences within the psychotherapeutic process (Bänninger-Huber,1992). A similar AFFEX coding system (Izard and Dougherty, 1980) identi-fies facial expressions and their blends.

Tortora (2006) has explicated a Laban-derived approach to movementbehavior she calls “Ways of Seeing,” especially discriminating the elementsof Body, Effort, Shape, Space, and Phrasing, delineating an important con-tribution of dance-movement therapy, and theories that have evolvedwithin it, to therapeutic implementations of movement observation. Ob-servation finds that individuals characteristically vary in terms of their per-sonal styles of entering and of maintaining interactive engagements. Thera-pists, following Tortora, distinguish between the roles of witnessing,kinesthetic seeing, and kinesthetic empathy in observing, feeling and,through their own emobodied experiences, reflecting upon the patient’s in-ner states.

Over many years, Kestenberg (1975) and colleagues (Kestenberg-Amighi et al., 1999) have advanced a Laban-derived model of movementbehavior, integrated with psychoanalytic developmental perspectives, fol-lowing the ways in which shape-flow patterns could lend structure to ten-sion-flow, and shaping in space (horizontal, vertical, and sagittal) couldlend structure to attitudes toward and within the environment (space,weight, and time); a careful appraisal of an individual’s patterns could offerimportant clues regarding personal harmonies and conflicts. Similarly, pat-terns used by interactants within a dyad, such as a parent and child, couldbe assessed regarding the degrees and nature of specific concordant and dis-cordant patterns, each of which is linked to specific psychological experi-ence. This has been further described regarding the employment of suchmethods and insights in parent-infant psychotherapy (Sossin, 2002), aswell as in research applications in which parental transmission of stresscould be seen in the child and in dyadic processes (Sossin and Birklein,2006).

Such theoretical and observational modeling regarding nonverbal be-havior becomes crucial in attempts to explicate the observation of clinical


features expressed through the body, and the utilization of gesture in psy-chotherapy. Relative degrees and specific dimensions of concordance anddiscordance in rhythmic, synchronous, and/or sequenced dyadic behaviorsare meaningful in the co-regulation in the dyad, and in what Greenspan re-fers to as the therapist’s counterbalancing of the patient’s affect. Thedown-regulating Greenspan refers to may only succeed (between parentand child or between therapist and patient) if, for example, a shift in inten-sity of tension-flow by the down-regulating partner is done while concor-dant shape-flow patterns are sustained, or while a consonant (developmen-tally affined) set of patterns maintains the connection (Loman and Foley,1996; Sossin, 2007). Children in the autism spectrum often appear to lackcentralization of their own bodily movement patterns, manifested in multi-ple patterns evident in different body parts (excessive localization of ges-ture), which, in addition to an atypical and heightened degree of neu-tral-flow (in both tension and body-shape) challenges the interactingpartner to maintain interaction via confluent or resonant patterns.

Development and Psychopathology

Greenspan’s model incorporates true contributions to our understanding ofchild and adult psychopathology, making specific linkages among biologi-cal, experiential, and relational phenomena, which unfold through the de-velopmental phases outlined in the DIR model. In this integrative way,Greenspan makes a special contribution to developmental psycho-pathology. High emotional reactivity is a risk factor for child (and later) de-pression, as are interactive factors that lead to rupture in the care-giver-child pattern of co-regulation; “up” or “down” regulating may bereplaced by withdrawal. Since internalized representations evolve from theaffects imbued in co-regulated prerepresentational experiences, thedysphoric affects that result derail the construction of a nurturant, soothingimage. Greenspan’s notion of an internal, representational “security blan-ket”—both presymbolic/interactive and symbolic—evolving from success-ful co-regulation is an important developmental reference, as is his obser-vation that individuals prone to depression are often stronger in verbalthan visual-spatial processing, also contributing to challenges in represent-ing nurturant interactions. His case vignette clearly highlights that in thecontext of complex clinical work with a depressed individual, the role ofco-regulation, rhythm, and nonverbal processes in affective interaction arepivotal, as they address core developmental deficits. As written, Greenspan


is clear that such treatment methods involving the therapist’s attentivenessto the co-regulated flow of interaction are not substitutive for work withmemory and narrative-building, but rather serve as the crux upon whichself-exploration can build.

Fraiberg, Adelson, and Shapiro (1975) heightened our focus on the pri-macy of affect and relationship in infant mental health and, of course, onthe role of the parent’s internalized world of self and other, and the readymade way in which those internalizations carry consequence for the baby.Remnants of a parent’s traumatic past may, via “ghosts in the nursery,”manifest in parental misattributions regarding the child’s feelings and/ormotives (Kalmanson and Seligman, 2006). Similarly, Greenspan under-scores the risk for attachment disturbances in such situations, as well as theimportant role of relationship building between parent and therapist as anessential building block upon which the parent can form an improved rela-tionship with the infant.

The child in the autism spectrum is deemed to be impeded in enteringinteractions involving co-regulated affect signaling due to biological fac-tors. Greenspan reflects on the success he and colleagues experienced intherapeutically connecting sensation, affect, and motor action, leading tomore purposeful affective behavior, always linking capacities for affectivecueing with symbolization. The overall DIR framework has served as aguidepost to much important clinical intervention with children with au-tism spectrum disorders and their families, clearly with some success, butthorough outcome research is needed.

One can see tremendous potential for primary prevention and earlyidentification derived from Greenspan’s developmental mapping. The linkamong motor planning, sequencing challenges and sensory modulation dif-ficulties and risk for schizophrenia is a fascinating observation, alongsidethe differentiation among schizophrenic types based upon over- or un-der-reactivity. Greenspan notes differences within this severe psycho-pathologic realm based upon when along the developmental pathway in-side and outside, self and nonself get organized. The differentiations arecrucial in developing beneficial environmental provisions and therapeuticinterventions. Similarly, his denotation of pathways toward the fragmentedthinking of borderline pathology or the avoidance of affective experience insevere personality disorders is also important, but again it seems incongru-ously detached from highly considered developmental ideas elsewhere inthe current literature, such as those implicating problematic attachmentrelationships and trauma impeding mentalization and reflective capacitiesin borderline pathology (Fonagy et al., 2003).


Need for Clarity of Concepts

The DIR model is impressive, and clearly it has its own strong foundation,evidenced in the many contributions cited above. Though in this paperDIR is seen as informing psychodynamic psychotherapy, it has developed asan interdisciplinary model and a thoughtfully designed DIR CertificateProgram (Wieder and Greenspan, 2005), which incorporates reflectivementorship and pertains to infant mental health and developmental andlearning disorders, extends to the training of interventionists from variednonmental health-based disciplines (e.g., educators, speech pathologists,occupational therapists). Though this reflects the rich cross fertilization ofknowledge and ideas about language, sensory-experience (e.g., proprio-ceptive and auditory processing), motor skills, cognition, affect, and relat-edness that Greenspan and others have interwoven (Costa, 2006;Shahmoon-Shanok, Henderson, Grellong, and Foley, 2006), the border-land between psychotherapeutic and nonpsychotherapeutic interventions,in both infant mental health, and later appraisal and intervention, becomessomewhat blurred. It would appear that the DIR clinician from anonmental-health specialization is expected to work through the compli-cated transferences and countertransferences, as well as reciprocal uncon-scious processes that are likely to enter the consultation contexts, and yet itis the analytically trained psychotherapist who would be able to incorporatethat skill set into DIR-informed treatment approaches.

Greenspan lends great import to the role of co-regulated affective ex-changes and links them to the developmental attainment of connectingperceptions to emotions, and to the ability to organize affective experiencerepresentationally. Hence, they are crucial in caregiver-child developmentand in therapist-patient process. Within current psychoanalytic thinkingthat reframes early development and consequent therapeutic strategies,utilizing constructs such as co-regulation, intersubjectivity, mentalization,and the reflective function, Greenspan’s work resonates but does not suffi-ciently plant itself within the landscape of corresponding work, bearingupon similar theoretical, developmental, and applied concepts. There areas yet too few bridges between his developmental and clinical ideas andthose developed in parallel by others. Even when cited, the works of signifi-cant model-builders (e.g., Stern, Emde, Beebe, Tronick, Trevarthen,Fonagy), though touching on crucially shared ideas of co-regulation andintersubjectivity, don’t seem adequately recognized. Greenspan stresses theimportance of heightened affects in promoting purposeful affective interac-tions, yet he doesn’t seem to consider earlier explications of this observa-


tion by Emde (1991) or Beebe and Lachmann (1994). The question arisesas to whether there is a disinclination to enter into dialogic and studiedcomparisons of both theory and findings. Such critical interchange is andwill be necessary for theoretical paradigms and clinical insights to evolvealongside underlying science.

For example, Trevarthen (2000, 2005a) also has closely consideredneurostructural vulnerabilities and the intricacies of infant-parent interac-tion, as well as their implications for neurodevelopmental disorders such asautism. He argues, analogous to Greenspan, that cognition is not usefullystudied in isolation and that emotional and motivational factors are focal,and he too underscores the atypical regulatory needs of the child with au-tism. Trevarthen states: “…instructive training of an autistic child in ac-ceptable habits and cognitive and practical skills is not enough to developtheir human potential. The child’s motives have to be supported directly,and difficulties with physiological self-regulation compensated…. Psycho-social or interpersonal techniques that ‘meet the child where they are,’picking up on his or her interests, purposes and sensitivities, can help physi-ological regulation, emotions and learning” (Trevarthen, 2000, p. 42).While Greenspan has supported sensory-integration therapy and auditorytraining, acknowledging the buoying of regulation of such psychophysio-logical processes, Trevarthen has pointed to the efficacy of music therapy inheightening rhythmicity that, in turn, establishes a basis for the attainmentof early intersubjectivity. This fits with the point of view that the child’s fa-vored mode of sensory contact needs to be respected in facilitating experi-ences in which the child’s behaviors are geared toward rhythmic emotionalinteraction (Trevarthen and Daniel, 2005). Developmental and psycholog-ical studies of rhythms, as they are manifest across modalities of physical ex-perience and perception will further inform therapists interested in theintrapersonal and relational regulatory processes these rhythms serve.

In the current paper, Greenspan generally captures the co-constructednature of dyadic experience, and identifies patterns of “co-regulated, recip-rocal, emotional interaction” that prove pivotal in generating vulnerabilityfor certain pathologies. Ruptures in co-regulation, experienced as with-drawal, or sometimes as intrusions, lay the ground for dysphoric affects.Such ruptures disrupt the development of an internal representation thatincorporates nurturing qualities. Given Greenspan’s interest in presymbolicexperience, it may be that ideas developed about early temporal experi-ence, such as those Stern (2000) has expounded regarding vitality contoursas feeling flow patterns in consideration of how the infant’s mind imposesform upon experience (analogous to musicality), will likely prove relevant.


In atypical development it may very well be that both biologic and interac-tive factors can lead to compromised abilities to represent such presymbolicoccurrences, hence profoundly altering temporal and affective experiencelater in development as well.

Greenspan is at once the penultimate theoretic integrationist, and yet healso stands in a certain way as an outsider. He is simultaneously wideningand sharpening the lens of the psychodynamic psychotherapist, and he isstepping into related domains, perhaps bringing some of the riches ofpsychodynamic thinking to other disciplines. Yet Greenspan may not be ad-equately linking some core concepts to the ongoing work of other psycho-analytic researchers and authors. A close reading of other developmentalmodel-builders also looking at co-regulation and self-development findsnotable differences. Beatrice Beebe and colleagues exemplify how carefulcomparisons among researchers and theorists help clarify complex develop-mental concepts. For instance, Beebe, Sorter, and Rustin (2003) carefullyexamined the works of Meltzoff, Trevarthen, and Stern, finding that along-side parallels in their examination of infant representation and crossmodalcorrespondence, and in their modeling of the ways in which infants attaintheory of mind, each has a distinct set of ideas about intersubjectivity. Sucha considered reading illuminates the fact that Stern’s notion of inter-subjectivity bears upon the emergence of a symbolic mind in which the in-fant’s sense of separate minds is essential, whereas Meltzoff (working out-side a mutual regulation model) and Trevarthen (working within one)evolved intersubjectivity concepts that bear on the origins of a presymbolicmind. Beebe et al. further summarize that while Meltzoff, from his experi-mental paradigm, “…privileges the infant’s mind, at the moment of match-ing the other” (p. 82), Trevarthen “…privileges the moment of immediatesympathetic contact between two minds” (p. 82), and Stern “…privilegesthe moment in which the parent attunes to the infant” (p. 83). Thethoughtful manner in which Beebe and colleagues consider differences inmeanings of core concepts such as matching, self-regulation, and contin-gency bear on the overall coherence of theory, the furthering of research,and the honing of clinical techniques derived from this research.

Co-regulation is a complicated process, and observers/authors havechallenged themselves to discern definitions and operationalizations con-forming to their particular propositions. Generally, self- and other-monitor-ing are involved as are abilities to transition among inner-states. Co- or in-teractive-regulation has been defined as the predictability of each partner’sbehavior from that of the other over time (Beebe et al., 2000; Jaffe et al.,2001), an operationalization built upon the observation and measurement


of contingencies. An important finding of the Beebe and Jaffe researchteam is that vocal rhythm contingency at four months can predict later at-tachment status. Contingency, however, is not predictive in a linear fash-ion. High interactive contingency (deemed vigilant) and low interactivecontingency (linked more with withdrawal and inhibition) can both beproblematic; a more midrange contingency seems optimal. Stressors canpotentially influence the dyad toward higher or lower co-regulation. How-ever, optimal contingencies vary as a function of context, developmentalfunction, and partner, demanding even more caution in generalizing aboutco-regulatory patterns.

Reading Greenspan against the backdrop of the current literature findsgeneral parallels with those noting the significance of interactive errors,amplified in circumstances of maternal depression, lending risk for disorga-nized attachment (Lyons-Ruth, 2006), as well as for the role of interactiverepairs following disrupted interactive-regulation (Tronick and Weinberg,1997). In applying Tronick’s Face-to-Face Still-Face paradigm alongsidethe Mutual Regulation Model (MRM), researchers have carefully craftedtheir operationalizations of key concepts (Weinberg, Olson, Beeghly, andTronick, 2006), such as matching, mismatching, synchrony, andbi-directionality. Within this model, matching involves a parent and infantsharing joint affective states within the same moment, and synchrony in-volves a time-series analysis finding a parent and child changing their affectin temporal coordination with respect to each other. The extent to whicheach partner’s affect influences the other partner’s affect constitutes theirdyadic bi-directionality. Utilizing such methodology, Weinberg et al. foundthat male infants appear more vulnerable than female infants in interactionwith mothers with depressive symptoms, especially when social contextswere challenging.

This type of specificity is understandably more likely to emerge in the re-search lab than in Greenspan’s clinical writing, yet a lack of such specificityoften leaves key concepts too wooly; hence, they are not as clearly applica-ble in the therapeutic situation as would be ideal. Co-regulation, then, be-comes more a principle than a measureable or more clearly definable phe-nomenon. While DIR appears to have developed into its own school ofthought and, in fact, shared principles of focus and practice guide the workof those identifying themselves as DIR practitioners, there is nonetheless aflipside to employing a patented-like model, as it runs the risk of discourag-ing new integrations. It will become increasingly important for those articu-lating the DIR perspective to clarify concepts and to amplify creativity, newsyntheses, objective research, and academic discourse. New models inher-


ently bring with them the risk of becoming embedded in rigidity. The newwave, generative and fresh, can become the old guard quickly.

Overview

Stanley Greenspan has provided a cogent and clinically thoughtful paperunderscoring DIR principles, diagnostic implications, and therapeuticstrategies that simultaneously appreciate an individual’s distinct mannersof processing (physical, sensory, and cognitive) experience and the role ofco-constructed experience, all against a backdrop of a sophisticated and in-tegrative developmental model. A psychodynamic psychotherapist iswell-served in considering the profound implications of the developmentalpathways to specific psychopathology as outlined, underscoring both thequalitative aspects of relationships and processing modes. The paper is es-pecially helpful in articulating the manner in which the therapist can ad-dress prerepresentational levels of experience and can meet a patient asneeded given distinctive processing modes across sensory, cognitive, andaffective domains. Greenspan’s model of the therapist as collaborator in theconstruction of experience is not simply a metaphor but an explicated rolein helping the patient succeed in progressing through the functional emo-tional developmental levels described.

A seeming paradox is that Greenspan serves as such a remarkable inte-grative thinker, creating and utilizing a model that interlaces biological fac-tors so inextricably with relational experience, yet he does not sufficientlyintegrate other highly relevant work (conceptual, research, and clinicalwork) with his own. This pertains especially to concepts such as co-regula-tion and gestural patterns, but extends to autism spectrum disorders as well.As exemplified in this paper, his work is presented as if it stands apart from afield in which Greenspan’s very questions are central and ardently dis-cussed. While keynote thinkers are referenced by Greenspan, there are nocritical thinking comparisons, as might have been described between DIRand other leading approaches directly applicable to children with autismspectrum disorders. There are no sufficient comparisons with the self-psy-chological, relational, interpersonal, or more traditional psychoanalysts re-garding the large range of disorders considered here, nor are there criticalappraisals of research particulars that nurture dialogue regarding develop-ment, theory, and approaches to prevention and intervention. Such omis-sions can, of course, be forgiven, especially in the case of an abbreviated,clear, and compelling paper. However, it may be that these omissions are


more reflective of a pattern: it becomes important that the level of dis-course is not its own impediment. Specifically, a clarified operationalizationof co-regulation, incorporation of a more differentiated and meaning-re-lated language of nonverbal patterns and processes, and an enhanced re-search orientation, bearing upon the core developmental constructs of DIRunderlying the therapist’s stance, would be welcome.

Perhaps when placed on a relative dimension, Greenspan’s work is some-what more deductive. Other contributors tend to be more inductive, espe-cially as lab and research results are so carefully considered before moreuniversal principles are derived. With his developmental model honed andin place, certain inferences follow for Greenspan. Much to his credit,though, his clinical examples are especially incisive, and they exemplify theprinciples integral to the DIR model with clarity.

The cautions expressed above do not diminish the hardly paralleledachievements reflected by Greenspan’s theoretical and clinical contribu-tions, evidenced in the paper eliciting this response. As we commonlybrand psychoanalytic and psychotherapeutic approaches (e.g., Freudian,Relational, Interpersonal), and as therapists we often build our own profes-sional identities around a chosen model, we are reminded of the option toconsider ourselves developmentalists. The idea of considering how andwhen development was interrupted is not a new clinical concept, of course.Greenspan, however, has evolved a developmental model that more thor-oughly integrates the body (including sensory experiences), affect, thought,and relationships, and has more clearly explicated therapeutic principlesguiding the therapist’s conceptual understanding and the type (i.e., the de-velopmentally-consonant level) of verbal (and/or nonverbal) interven-tions, heightening affinity between the therapist’s responses and the pa-tient’s readiness to benefit from them.

Greenspan brings clarity to his developmental psychotherapeutic ap-proach through his 11 principles, which correspond to the developmentalmodel espoused. This developmental model promotes understanding (andpossibly earlier identification) of the diagnostic manifestations that takeform, and it frames intervention strategies. One of many key contributionsto child and adult psychotherapy is Greenspan’s prompt to carefully ap-praise the individual’s ability to represent feelings and to consider whetherparticular themes are especially precluded from being shared in interaction.The process of experiencing, tolerating, knowing, and describing feelingsfollows a developmental trajectory that needs to be respected in thepsychotherapeutic process. Along this path, Greenspan’s “Principle V”—involving the role of assisting in the transformation of more “global emo-


tional experiences” into more differentiated ones through “co-regulated af-fect exchanges”—reflects an especially astute appreciation for thenuanced, developmentally anchored steps the therapist need take to scaf-fold the patient’s own progression toward an organized and affective repre-sentational level of functioning. Throughout his road map and principles,Greenspan enhances our view of the importance and multi-component na-ture of early, preverbal affect states, and their crucial place in therapeuticprocess. The value of these principles cannot be underestimated.

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