Forms of Intersubjectivity in Infant Research and Adult Treatment (Book Review)

Author:  Beebe, Beatrice, Steven Knoblauch, Judith Rustin and Dorienne Sorter
Publisher:  Susan DeMattos, PhD
Reviewed By:  Other Press, 2005, Vol 26 (2), pp. 42-45

Early in Forms of Intersubjectivity, the authors tell the following story:

One hot summer day the Italian researcher Rizzolatti, who was studying the premotor cortex in monkeys, took an ice-cream cone. A monkey nearby was watching. As Rizzolatti moved the cone to his mouth and began to lick it, the electrodes implanted in the monkey’s premotor cortex, which are active when a monkey performs a goal-directed action himself (such as reaching for an ice-cream cone) are also active when this monkey simply observes this same action in someone else (the researcher reaching for an ice-cream cone). (Beebe, et al, p. 52).

The story is told as an introduction to the concept of mirror neurons that provides an insight into action-recognition and empathy. But I found myself thinking about that hot summer day and the monkey and the researcher and the ice-cream cone. How hot was it, I wondered. Was it hot even for a monkey? And do neuroscience research programs in Italy provide ice-cream cones for their staff? And what flavor ice cream? Lemon, I hoped if it was really hot, or raspberry.

What had happened to me after reading fifty pages of this book was that I was thinking of sensations and movements as well as words and concepts. The authors of the book had helped me to focus on the presymbolic and somatic. I was also interested in what relationship this monkey had to this researcher and this book had helped me to see that an interaction was going on, that there was something occurring between two minds and a bidirectional influence: the monkey watches the researcher move the cone to his mouth and the monkey’s electrodes are active; the researcher sees the active electrodes and begins to wonder. Monkey and researcher have influenced each other.

So the story about Rizzolatti and his monkey is about more than mirror neurons; it is also about different forms of interactions, the pivotal construct of intersubjectivity.

For Beebe and her colleagues, theories of intersubjectivity are theories of interaction and the most useful theory of intersubjectivity for psychoanalysis must address both verbal and nonverbal forms of intersubjectivity. Building on a ten year collaborative study of nonverbal and verbal forms of interaction in the therapeutic encounter, Beebe and her colleagues use a dyadic systems view of communication to compare theories of intersubjectivity proposed by both infant researchers (Meltzoff, Trevarthen, and Stern) and adult psychoanalytic theorists (Benjamin, Ehrenberg, Jacobs, Ogden, and Stolorow and colleagues). There is enough variability in all these theories of intersubjectivity for Beebe and her colleagues to suggest that we need to throw out the word intersubjectivity and instead discuss forms of intersubjectivity.

But beyond comparing these theories, Beebe and her colleagues first review the forms of intersubjectivity in the adult psychoanalytic theorists, then offer an integration and extension of the work of the three infant researchers and then apply this integrative understanding to a clinical case.

Using visual models of interaction that chart both interactive regulation and self-regulation, Beebe and her colleague note that Jacobs emphasizes the impact of the patient on the analyst and the analyst’s history of self-regulation, Ehrenberg pays equal attention to the patient’s impact on the analyst and the analyst’s impact on the patient while attending more to the analyst’s self-regulation in present, Ogden emphasizes the patient’s impact on the analyst and the analyst’s own self-regulation process, Benjamin emphasizes the analyst’s impact on the patient and changes in the patient’s self-regulation based on the analyst’s impact, and Stolorow and colleagues emphasize the patient’s impact on the analyst and the analyst’s current self-regulation process. But all of these analysts are working “primarily with the analyst’s and patient’s capacity to symbolize and verbalize experience” (p. 23).

In reviewing the work of Meltzoff, Trevarthen, and Stern, Beebe and her colleagues note that all three conceptualize mind as beginning as shared mind (a dialogic origin theory of mind) and that the infant’s capacity for crossmodal perception is key in detecting nonverbal, implicit correspondences that help the infant sense the state of the other.

All three conceptualize a highly complex presymbolic representational intelligence, a motivated and intentional (rather than reflective) infant, capable of distinguishing self vs. environment at a perceptual level. And all three emphasize positive emotion, playfulness, intimacy, and bonding as an essential function of intersubjectivity (pp.49-50).

Beebe and her colleagues extend the work of these three infant researchers by using a more neutral definition of intersubjectivity as what is occurring between two minds (not implying mutuality) and looking beyond correspondence to five other critical patterns of self- and interactive regulation: the place of interactive regulation, a full dialectic between similarity and difference, problems with the concept of matching, the role of self-regulation, and the balance model of self- and interactive regulation.

Beebe and her colleagues (p. 88) point out that infant research has documented the forms of intersubjectivity/interaction that are implicit and track how infant and caregiver impact each other, regulate themselves and perceive and align themselves “with the moment-by-moment process of the other.” In this way infant researchers have described the co-construction of the intersubjective field. But while this co-construction of the intersubjective field is of great interest to psychoanalysis, there has been little published clinical illustration of the nonverbal and implicit dimension of this process. Beebe skillfully addresses this area in chapter four of this book.

Chapter four is the description of the work done by Beebe and her patient Delores, a woman who experienced a good foster mother for two years before being returned to her impaired biological mother who physically, sexually, and emotionally abused her for two years, and then spent a year in a hospital before being adopted by a loving family. Delores sought out Beebe in part because of Beebe’s videotaped work with infants. There is the strong sense that Delores knows what she needs – someone who will see her and hear her into speech and be with her and attune to her self-states that are prereflective and presymbolic.

Beebe (p. 95) states that Delores is preoccupied with faces, but Beebe and her colleagues (p. 6) had already alerted us to the importance of faces and videotapes in the first chapter of the book when they illustrated procedural and emotional implicit knowledge with a paper by Heller and Haynal (1997) entitled “The Doctor’s Face: A Mirror of His Patient’s Suicidal Projects” which documented that while a psychiatrist’s written predictions of which of 59 suicide attempting patients would re-attempt suicide were random, “fine-grained microanalyses of the videotapes of the psychiatrist’s face identified 81 percent of the re-attempters.” Beebe and her colleagues this early in their book enumerate the nonverbal implicit procedural action-sequences of head, eye, face, and voice and the implicit emotional reactions that will play such an important role in understanding self- and interactive regulation in the work Beebe does with Delores. Beebe’s chapter also guides clinicians in tracking these implicit moments in their own work.

In a course that I teach on clinical applications of attachment theory, Beebe’s description of her work with Delores is the graduate students’ favorite reading assignment. Beebe and her colleagues have taken on the enormous challenge of using a written manuscript to convey the nonverbal and the implicit. They succeed by using vivid illustrations (like Rizzolatti and his monkey), diagrams, case description, descriptions of videotaped sessions, and verbal excerpts from clinical sessions. My students were able to feel that they were in the room with Delores and Beebe and they were appreciative of Beebe’s generosity in sharing her verbal and nonverbal interventions and feelings about the treatment. Beebe movingly describes the course of this ten-year treatment, the introduction of videotaping, and the dance of rupture and repair.

Generosity is a word that comes up often as I think about this book. It is clear that Delores was generous in allowing her work to be published. But there is generosity throughout this book. Beebe and her colleagues acknowledge the work done by Stephen Mitchell in unpacking what intersubjectivity meant to Ehrenberg, Jacobs, and Ogden. They also acknowledge the similarities they share with Beebe, Lachmann, & Jaffe; Mitchell and Aron; the Boston Change Process Study Group, Lichtenberg, Lachmann, and Fosshage; and Fonagy, Gergely, Jurist, and Target. In addition, they include in this volume contributions from Theodore Jacobs who reviews analytic contributions to the understanding of nonverbal behavior, comments on Beebe’s case study, describes how he has utilized patient and analyst nonverbal behavior to enhance his understanding of the analytic process, and reflects on the ongoing neglect of nonverbal phenomena in contemporary analysis and from Regina Pally (p. 227) who beyond adding a neuroscience perspective further elaborates the new type of interaction Beebe utilizes with Delores:

What facilitates the development of new, more flexible ways of responding in the patient’s current repertoire? Dr. Beebe provided a new type of interaction, one that was contingently responsive to slight shifts in Delores’ nonverbal behavior, although this responsiveness often occurred out of awareness of both partners. This form of responsiveness enhanced emotional regulation and feelings of trust, safety, and control in the patient. Delores learned these new ways of relating at the implicit level. She came to feel safer, before she could express this in words.

However, to maximize the likelihood that a patient will be able to apply this new learning to other relationships, or during periods of stress such as separation even within the therapeutic relationship, it is also important to explicitly recognize, in words, what is going on. Conscious explicit mechanisms differ significantly from nonconscious implicit ones, in ways that allow for a greater likelihood of flexible and deliberate choice. With explicit processing, despite similarities between a current situation and a prior traumatic one, old responses developed for coping with trauma can be inhibited, and newly learned more adaptive ones can be activated.

Pally emphasizes the nonconscious (as opposed to unconscious or conscious), nonverbal aspects of learning and interaction. I would love to hear the authors of this book in dialogue with psychoanalyst Donnel Stern (1997) who has conceptualized some unconscious experience as unformulated.

The first four chapters of this book were originally published in two issues of Psychoanalytic Dialogues with commentaries on Beebe’s case study by Michael Heller, Carolyn Clement, and Judith Edwards. Heller is one of the authors of the article on the analysis of the doctor’s face to predict suicide re-attempters; and in his commentary on Beebe’s case study, he describes a postural dynamics model to better understand bodily dynamics. Beebe (2004, p. 89) states that

Heller understands and has elaborated my fundamental message: Delores had to do more than ‘restructure her ideas,’ change her representations or fantasies or even her relationship with me. She had to reconstruct her entire ‘bodily communicative behavior.’

Carolyn Clement, who had invited the papers by Beebe and her colleagues for publication in Psychoanalytic Dialogues, brings a relational psychoanalytic focus to Delores’s creative and active search for self-initiating agentic experience in the videotapes and in the sessions. Judith Edwards, brings a Kleinian perspective and wonders if similar results could not have been achieved without the videotape (because Delores might have used it in an autistic fashion rather than as a transitional object) and through the here-and-now relationship between analyst and patient. In her response to Edwards’ critique, Beebe (2004, p. 97) again highlights the important ideas in this book and offers the final words of this review:

By discussing primarily the verbal content of the treatment, Edwards overlooks the main point: how nonverbal, implicit, or out-of-awareness transactions are a potent source of therapeutic action. In addition, she does not see Delores’s creative and determined struggle to register these implicit communications and to translate her understanding of them into explicit language. Edwards does not discuss the new ideas about what representations are, and how they may be transformed in the implicit mode. Representations are organized as much through action sequences, Downing’s (2003) ‘bodily micropractices,’ such as Delores’s ‘making your faces on my face,’ as through verbalized thoughts and feelings and their interpretations.

Beebe, B. (2004). Reply to commentaries. Psychoanalytic Dialogues, 14 (1), 89-98.
Clement, C. (2004). Self communion in the intersubjective field: Commentary on case study by Beatrice Beebe. Psychoanalytic Dialogues, 14 (1), 65-71.
Edwards, J. (2004). Making the music visible: Commentary on case study by Beatrice Beebe. Psychoanalytic Dialogues, 14 (1), 73-87.
Heller, M. (2004). Behind the stage of interacting faces: Commentary on case study by Beatrice Beebe. Psychoanalytic Dialogues, 14 (1), 53-63.
Heller, M., & Haynal, V. (1997). A doctor’s face: mirror of his patient’s suicidal projects. In J. Guimon, Ed., The body in psychotherapy (pp.46-51). Basel, Switzerland: Karger.
Stern, D.B. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillsdale, NJ: Analytic Press.

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