8 The Sandwich Model: The Music and Dance' of Therapeutic Action

The sandwich model: The music and dance of
therapeutic action
Alexandra M. Harrison
183 Brattle St, Cambridge, MA 02138, USA aharrisonmd@comcast.net
(Received 30 April 2013)
My premise is that a layered approach is necessary to understand the pro-
cess of exchanges that result in therapeutic change. I imagine these processes
occurring in three layers although the number of domains in which change
is taking place is actually infinite such as in a sandwich. The top layer, or
top slice of bread of the sandwich, represents a broad view of the change pro-
cess; it is non-linear and includes the feature of uncertainty, a general princi-
ple of dynamic systems theory. The middle layer, or the meat of the
sandwich, is explained by theories that are immediately and clinically useful
to a therapist, such as psychoanalytic theories. These are primarily linear the-
ories and use language and symbols to tell a story of what happened. The
bottom layer, or bottom slice of bread of the sandwich, is the micro-process;
this layer includes the moment-to-moment patterns of coordinated rhythms
that both communicate meaning and provide the essential scaffold for all
higher-level change processes. The micro-process also requires a non-linear
theory to make sense of its variability and emergent properties. Taking a bite
out of the sandwich will include a polysemic bundle of communicative behav-
iors (Harrison and Tronick, 2011). I will illustrate the sandwich model with
the clinical case of the analytic treatment of a 5 year-old boy.
Keywords: microprocess, therapeutic action, polysemic, infant research, integration,
non-linear, simultaneous
Introduction
This paper represents my attempt to integrate what I have learned from
infant research and the study of videotapes of child analytic sessions with
the psychoanalytic theory I use in my daily work. In effect, that means inte-
grating the verbal and symbolic with the micro-process, while at the same
time keeping in mind the frame of reference provided by the general princi-
ples of dynamic systems theory. I will demonstrate the micro- process, or
what I call the music and the dance of what goes on in a therapeutic ses-
sion, with descriptions of videotapes and the microanalysis of these video-
tapes. This is a level of therapeutic activity that psychoanalytic theory can
only help us understand to a limited degree (Stern et al., 1998). I will then
put this level of therapeutic action together with what psychoanalytic theory
is good at explaining, the story of what happened, or what is happening in
a psychoanalysis. To do this, I will introduce a clinical tool I developed to
integrate the multiple domains of therapeutic action, the sandwich model.
In addition to the psychoanalytic narrative, this model includes two addi-
tional domains of therapeutic activity although the actual number of
Int J Psychoanal (2014) 95:313340 doi: 10.1111/1745-8315.12113
Copyright 2013 Institute of Psychoanalysis
Te International Journal of
domains of therapeutic activity is infinite that are not easily explained by
psychoanalytic theory. I will illustrate my points with the clinical case of a
5 year-old boy.
Whereas psychoanalysts primarily focus on the symbolic content of the
analytic session the language and the play current thinking recognizes
the importance of the non-symbolized and the moment-to-moment process
(Beebe, Jaffe and Lachmann, 1992; Beebe et al., 2000; Bucci, 1997; Harri-
son, 2009; Harrison and Tronick, 2007; Stern et al., 1998; Tronick, 2002a).
Psychotherapists come to be attuned to communications made by their
patients in the micro-process, even while it remains out of their awareness
(Heller et al., 2001). In addition, the therapists capacity to communicate
expressively in her facial expression, gestures, and non-verbal speech ele-
ments, is an important asset (Zacki et al., 2008). These movements, or what
I call the dance of psychoanalysis, are easier to visualize in the play of
child analysis than in adult analysis, but the dance occurs in both, in con-
tinual fluctuations in the coordinated patterns of therapists and patients
bodies and voices (Kelso, 2002). For example, as two partners may settle
their bodies into their chairs or to the floor in one synchronous movement,
or as they reach across a play space to take turns in a reciprocal movement,
such as that which I refer to as a do-si-do.
In fact, the level of the micro-process does not just involve making mean-
ing through bodily movements and gestures, or patterns of vocalizations. In
the non-conscious realm of human experience, the nervous system, muscles,
and gut communicate with one another to create neurophysiological mean-
ings related to threat, distress, or wellbeing, for example (Tronick, 2007).
These somatic communications form an essential context within which the
symbolic meanings are interpreted, in an ongoing, constantly evolving pro-
cess. I use the term somatic to signify all those ways of making sense of
our experience that are not directly related to language (Harrison and Tro-
nick, 2011). I prefer this to non-verbal since my essential focus is on how
the system functions as a whole to make meaning, and from that perspec-
tive it is impossible to segregate a non-verbal domain.
According to the general principles of dynamic systems theory, growth in
open systems such as the change that occurs in psychotherapy or in nor-
mal development is manifested in an increase in the complexity and coher-
ence of the system (Van Bertalanffy, 1968). Here, the open system is the
individual, and the growth occurs in the increasing complexity and coher-
ence of the meanings he makes about himself and his relationship to the
world (Sander, 2008; Tronick, 1998).
In this paper I will put together the music and the dance, or the micro-
process, of videotaped sequences from three sessions in the first year of the
analytic treatment of a 5 year-old boy, with the story of what happened,
or the middle layer of the sandwich. A bite of the sandwich will then com-
prise a polysemic bundle of all the different levels at once, including a mix
of language and symbolic meanings as well as somatic meanings. The same
clinical case is discussed in a previous paper in which the first individual
session is explored in detail from the point of view of integrating the verbal
and somatic domains of therapeutic activity (Harrison and Tronick, 2011).
314 A. M. Harrison
Int J Psychoanal (2014) 95 Copyright 2013 Institute of Psychoanalysis
In this paper, two sequences of the first individual session will be included,
as well as sequences from the fourth and the seventh months of analysis. In
addition to what was described in the earlier paper, the music and dance
will be examined in even greater detail through the micro-analysis of those
videotaped sequences of analytic process.
The paper is organized in three parts. The first is a brief section on theo-
retical and research background for the current exploration and then a pre-
sentation of the sandwich model. The second presents the case and illustrates
the micro-process and the narrative level in selected analytic sessions; after
each sequence of micro-analysis I will integrate the several domains of ther-
apeutic activity described, using the sandwich model. The third includes
some thoughts about the contribution of this approach to the theory and
practice of psychoanalysis. I will conclude with some references to the writ-
ings of Winnicott.
Background in theory and research
Psychoanalytic theory
In a previous paper we referred to well-known adult psychoanalytic writers
in an effort to find integrative themes linking psychoanalysis and the field
of infant research, choosing two examples Winnicotts (1941) The observa-
tion of infants in a set situation and Loewalds (1960) On the therapeutic
action of psycho-analysis. Among many other classical papers that have
impressed me with their prescience regarding modern theories of develop-
ment are Waelders (1936) On the principle of multiple function and Valen-
steins (1973) On attachment to painful feelings and the negative therapeutic
action. More recently, psychoanalysts who have studied infant research,
cognitive science, linguistics or systems theory have brought us further in
the effort to meld these bodies of knowledge. This group includes Beebe
and Lachmann, 1994; Bucci, 1997, 2012; Galatzer-Levy, 2004; Harris, 2009;
Knoblauch, 2005; Litowitz, 2011, 2012; Seligman, 2003; Seligman and Har-
rison, 2012. In terms of understanding the way the human mind works,
contributions about the use of metaphor (Modell, 1997) and the analysts
reverie (Ogden, 1997) have increased our understanding of the analytic
process in particularly important ways.
The observation of my videotapes of analytic sessions has taught me two
things about psychoanalytic theory. The first is as many psychoanalysts
have known for a long time the relationship between theory and tech-
nique is hazy at best. In other words, videotape shows that what you do in
terms of behavior is not necessarily what you think you are doing, and it is
also not necessarily what your theory would suggest that you do. The sec-
ond thing I have gained from observing myself on video is insights into
what the theory that guides my clinical work really is. When I watch myself
in video, a frequent type of analytic intervention I can observe is my point-
ing out a defensive operation on the part of the child. Sometimes I interpret
the defense in relation to a conflictual theme, and sometimes I simply point
out the defense in operation: I noticed that when the dinosaur made a big
The sandwich model 315
Copyright 2013 Institute of Psychoanalysis Int J Psychoanal (2014) 95
roar, you moved away and started playing with something else. This, I
believe, is closer to Anna Freuds ego psychology than to many other psy-
choanalytic theories (Freud, 1936). Yet, because of the emphasis I place on
the intersubjective realm in my formulations, I would call my psychoana-
lytic theory, intersubjective ego psychology, as Chodorow (2004) identifies
it, in the American independent tradition.
Another key feature of my clinical theory is the concept of agency. Jer-
ome Bruner (1990) gives the sense of agency, or agentivity, a primary posi-
tion in his considerations about meaning making. The most directly
influential writer in my thinking about agency is Louis Sander:
A first step in our way to integrate the biological, the developmental, and the thera-
peutic would be to see how principles such as organization and primary activity,
essentials at the biological level, might be applied to each of the higher levels. For
example, we now refer to the initiation of self-organizing, self-regulating, self-cor-
recting moves as reflecting the agency of the individual. Achieving a coherent sense
of self-as-agent differentiated, valid, and competent within ones context of life
support brings us to a key goal of both the developmental and the therapeutic
processes. I suggest that the process of achieving a coherent sense of self-as-agent is
an example of the way principles of process in living systems can be applied to the
task of integrating biological, developmental, and therapeutic levels we have been
assigned.
(Sander, 2008, pp. 21819, my italics)
Micro-analytic method
My method of microanalysis of videotape sequences is derived from the
work of Beebe et al. (Jaffe et al., 2001).
1
Using this method, the music of
therapeutic action is demonstrated in the coordination of vocal rhythms as
two partners find a way of being together and communicating with each
other with a particular rhythm of sounds and silences. These vocal rhythms
are specific to each dyad and depend for their meaning on the context of
verbal and non-verbal communications (Harrison, 2013). Beebe, in her
micro-analytic work with mothers and infants, measures the durations and
pauses in the vocalizations of the two partners. To these data I have added
the durations and pauses in the actions of child and analyst engaged in play
together. One important feature of this coordination highlighted by Jaffe
et al. (2001) is the way of exchanging turns. The most common way of
exchanging turns is the switching pause in which the first partner stops
vocalizing and, after a few seconds, the second partner begins her turn. An
interruptive switch occurs when the second partner interrupts the first part-
ner while she is still speaking. Finally, a simultaneous switch, perhaps the
most interesting, is when the second partner begins her turn immediately as
the first partner finishes hers. This last way of exchanging turns requires
1
I am grateful to Beatrice Beebe for her generous help in learning the technique of micro-analysis of vid-
eotapes and for her crucial contribution to my understanding of the micro-process of this specific case.
316 A. M. Harrison
high attunement or tight coordination, and it is the type of exchange that I
will emphasize in the micro-analysis I present in this paper.
In my presentation of the micro-process, I will show diagrams of the
vocal turns (VT) and action turns (AT) of my child patient and myself in
sequences of videotape. The diagrams are organized around a horizontal
axis representing time in seconds, with the childs turns above the axis and
my turns below. The VTs are located closer to the axis and the ATs further
from the axis, so that the order of turns in the diagrams is child AT, child
VT, axis of time in seconds, my VT, my AT. In the diagrams, I refer to
myself as AMH. An example of a diagram is given in Figure 1.
Figure 1 is a diagram of the first 20 seconds of the first individual session
of a 3 year-old girl in. In this sequence of videotape, the child did not vocalize
so above the axis are her ATs, and below the axis are my VTs and ATs. Had
the child vocalized, her VTs would be found in the open space between her
ATs and the axis. What does a diagram like this tell us about the music and
dance in the exchange between us? We can make two main observations. The
first is that of the synchrony of the child and me settling to the floor, here
demonstrated by our two ATs beginning simultaneously at second 4. The sec-
ond is that of the regular rhythm created by my 1-second internal pauses.
From my first utterance in the first 20 seconds of my first individual session
with this child, I parse my communication to her an explanation of what
she and I are going to do with each other before she returns to her mother
into VTs separated by 1-second pauses. After my last vocalization, I sit qui-
etly, with my hands in my lap. The music and dance of this communication to
her carries the meaning of no intrusion, no surprises. The verbal content and
the moment-to-moment are consistent in their message of trustworthiness.
It is important to note that whereas most of my behaviors that constitute
the music and dance are out of my awareness, not all of them are. With
study of videotape and conscious reflection, my consciousness of the micro-
process has grown. This allows me to use my body and voice in new ways
Do you
remember
you were here
before,
playing?
0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
I didnt get a
chance to play
with you
before,
Because you
were just with
your mom and
dad.
Now, I get a
chance to play
with you
before you go
back to your
mommy.
.
Lowers herself to her
knees.
Grasps helicopter and
takes it in hands.
Completes action of
settling on the floor.
Turns, gives direct gaze, maintains gaze.
Direct
Gaze
Walks in, turns
to look up, then
down at toys,
not at analyst.
Averts gaze
as orients to
toys.
.
First drops to her knees, then settles
further.
Sitting still, hands in lap.
Fig. 1. Microprocess of interaction with 3 year-old girl
to communicate with my child patients. Although I am convinced that my
adult patients and I interact so as to create rhythmic patterns that corre-
spond in many ways to what happens with the children I treat, those pro-
cesses are harder for me to identify. One reason for this is that I rarely
videotape my work with adults. Another is that when I try to match my
adult patients I naturally focus my attention on the content of their speech,
on the story. I have noticed some of the small back and forth behaviors
that I track in the videos of my child patients, in the repetitive exchanges
with my adult patients in which I am trying to clarify what he or she is try-
ing to tell me. On the other hand, I do believe that there is a more pervasive
process of coordinating implicit rhythms that occurs with my adult patients
out of my awareness, forming the context for linguistic exchange, and I will
look forward to this being elucidated in future investigations.
It is also important to acknowledge other psychoanalytic writers who
study non-verbal communication. In addition to the classic paper in the Uni-
ted States by Jacobs (1994) on non-verbal communication in the psychoana-
lytic process, research in the area of non-verbal communications in Germany
has produced a number of important studies and writings. These include Ra-
iner Krauses studies of facial interaction, Horst Kaecheles single case
research, and Ulrich Streecks studies of unconscious and nonconscious
communication between patient and analyst (Frommer, Lagenbach and
Streeck, 2004; Krause et al., 1998; Kaechele, Schachter and Thoma, 2008;
Streeck, 1999). Streecks studies of how facial and also bodily communica-
tions relate to the verbal dialogue may be closest to my efforts. In an
interesting paper on action in the analytic process, Streeck identifies micro-
actions on the part of both analysand and analyst that intend to trigger
effects and induce interactions (1999, p. 135).
The sandwich model
Relationship to Tronicks dyadic expansion of consciousness model
My assumption is that meaning is being made simultaneously all the time in
multiple domains of interaction, and that what is being organized in each
domain depends for its meaning on what is going on in all the other
domains of the living system that create its context. The somatic and
moment-to-moment exchange forms the context for the symbolic (including
verbal) meaning, and the symbolic meaning forms the context for the
somatic and moment-to-moment. This perspective on the growth process is
derived most directly from the work of Tronick, specifically his Dyadic
Expansion of Consciousness Model (Tronick, 1998). There are two aspects
of this model that make it particularly well suited to my needs as a clinician
and also distinguish it from other models of change. The first is its empha-
sis on the multiple simultaneous processes of meaning-making that include
physiological and psychodynamic domains of making meaning as well as
non-verbal behaviors. The second is that the model includes internal
processes of exchange within the individual. That is, the private inner world
of the individual has a protected place in this model and is not wholly
318 A. M. Harrison
subsumed by the relational or dyadic system. The DECM, in my view, is
both more useful to psychoanalysts than other integrations of developmen-
tal theory and psychoanalysis, and also more faithful to the hierarchical
organization of a system as described in dynamic systems theory than any
other developmental model of change (Sander, 2008; Tronick, 1998, 2007).
Putting it altogether
How does psychoanalytic theory fit into this picture? The schema of a sand-
wich was suggested to me by one of the general principles of dynamic sys-
tems theory, that a dynamic system consists of a hierarchical organization
of multiple levels in which each level has an organization, or pattern, that is
unique, but that also shares important features with patterns belonging to
all the other levels in the system (Sander, 2008). I was looking for a way to
make use of the insights I had gained from infant research, while still hold-
ing onto the valuable aspects of my psychoanalytic theory that I used every
day in my clinical work, and this seemed to be a way I could do it. I imag-
ined a sandwich consisting of two slices of bread with a filling of meat or
veggies in between.
The top slice of bread represents the macro-process of developmental and
psychotherapeutic change. It uses dynamic systems theory as a meta-theory
and refers to interactive processes that take place in decades and centuries. It
provides the big picture of how change takes place. The events that occur at
this level are not recognizable in the time we live in, and we cannot predict
exactly how and when they will happen. In order to understand evolution and
the creation of mountain ranges and rivers, for example, one must make use
of a non-linear theory that assumes unpredictability (Granic and Patterson,
2006). This layer of the sandwich is necessary in order to maintain an aware-
ness of the non-linear features of change. For example, although a clinical
account tends to take the form of a narrative, the linear coherence of this nar-
rative holds true only in retrospect, thus depending on the top layers over-
arching perspective for its meaning. In other words, the specific story that is
told about what happened is only one of many stories that might have played
out from the beginning of any particular situation.
According to the non-linear meta-theory, change takes place in variable
and unpredictable ways, in very small and very short events, and also in very
large and very long transformations. Change, in the form of new organization
in the system is an emergent phenomenon. Like fractals, it can be recursive,
but the reference to fractals is purely metaphorical. It is important to remem-
ber what I am describing in the sandwich model is a metaphor shaped by the
general principles of dynamic systems theory and has no direct link to a non-
linear mathematical model. One of these general principles is that systems
grow by increasing in complexity and coherence. Thus, an indication that
change has occurred is an increase in complexity and coherence of the system.
By contrast, an indication that change has not occurred that the system is
stuck or rigidified is a lack of increase or even a decrease in these qualities.
The key argument I am making is that there are multiple levels that
are continuously interacting with one another. In the sandwich model, the
particular levels have different functions or aims. The top level serves pri-
marily to conceptualize therapeutic activity as a process of growth and
change in relation to other types of growth and change. In addition to hold-
ing this wide perspective in mind, clinicians need theory to guide them in
making sense of their immediate clinical experience and in choosing inter-
ventions. These clinical goals are served by the middle layer, the symbolic
layer, in which language has a central role.
The middle layer, or the meat of the sandwich, consists of psychoanalytic
theory and provides the story. This level is essentially a linear theory of
change in that it explains change in terms of a causal chain of events. The
analyst and patient interact in such a way that allows the patient to move
forward in his or her personal development. They do this by creating a nar-
rative to explain how the patient got stuck in his life, how he is repeating
this problem pattern with the analyst, and how he might find another way
to think and to live that would bring him more satisfaction. This middle
level does not specify the type of narrative the analytic dyad uses; it may
be that the analyst interprets the patients unconscious conflict, or that the
analyst uses his countertransference experience to understand an enactment
between them, or that the analyst metabolizes the patients beta elements.
The important feature of this level of therapeutic action is that it is at least
partly in the analysts awareness and, because it uses symbols and language
to make sense of clinical experience, it is a useful tool in his or her daily
therapeutic work.
The idea that the conscious process in psychoanalysis is only apparently
coherent and not actually coherent is not new. Important examples of this
idea appear in the work of Lacan, who writes of the disruptive power of
the unconscious, and in discussions of the dialectic inherent in psychoana-
lytic work (Bleger, 2012; Ogden, 1997). Galatzer-Levy continues to be a lea-
der in his innovative application of the principles of non-linear theory to
psychoanalysis (Galatzer-Levy, 1978, 2004, 2009). What I am calling atten-
tion to is that, although, as clinicians, we need to be able to construct
coherent linear narratives as we do our work because our cognitive pro-
cesses are categorical and time-bound, it is also helpful to complement these
narratives with the perspectives represented by the other two layers of the
sandwich, both of which constructively challenge our linear narratives.
The bottom slice of bread of the sandwich, or the music and dance of
therapeutic action, represents interactive events that occur in seconds and
split seconds. Because these events occur in time that is too short to form
language and symbols, they are not available to the analysts conscious
mind. To make sense of these tiny events, given the variability that charac-
terizes their organization, it is necessary to use a non-linear model. Again,
the top slice of bread and the bottom slice of bread refer to non-linear pro-
cesses of change, and the middle layer of the sandwich is linear. Another
way of looking at it is to see the sandwich model as dealing with different
temporal levels. The top slice, or macro-level, deals with time over decades
and centuries. The meat of the sandwich deals with time over minutes,
hours, and years change that takes place during an analytic session and
320 A. M. Harrison
over the course of an analysis. The bottom slice, or micro-level, deals with
time in seconds and split seconds.
So we are talking about putting the story of an analysis together with at
least part of its context. According to a dynamic systems theory model, the
meaning of the story depends on its context. Here, we assume that the nar-
rative creates a context for the micro-process, in that, for example, a
respectful narrative together with regular, predictable rhythms tends to gen-
erate trust. Also, the micro-process creates a context for the narrative, in
that, for example, a poorly coordinated micro-process together with a nar-
rative about trust might generate a meaning of wary anticipation.
The dilemma of unpredictability
Unpredictability presents the proponents of various psychoanalytic theo-
ries with a dilemma. If the non-linear meta-theory imposes principles of
unpredictability and variability on the process of growth, the linearity of
the process in the middle is constrained. That is, analyst and patient can
attribute the shift in a patients self-understanding to an interpretation, and
doing this might be helpful, but the specificity of the interpretation itself
and the point in time when it was delivered cannot alone be assumed to be
the cause of the effect. In other words, there is no one right way to conduct
an analysis. There is no one correct interpretation, and there is no one
right time or right way to make it. This is not a new idea but it is a hard
one to keep in mind.
This perspective on analytic change has implications for the way we as
analysts discuss or critique our analytic work with colleagues. I am per-
suaded that the only sensible way to discuss analytic material is to try to
understand the way a particular analytic pair is moving forward in the com-
plexity and coherence of the meanings they are making together, without
presuming that the content or timing of a particular analytic intervention
can be judged as correct or incorrect. That is with two exceptions the first
is that complexity cannot be honored if a particular domain of meaning
(usually related to intense negative affect or bodily excitement) is left out of
the analytic discourse. The second is the main theme of the treatment I will
discuss in this paper the essential need to respect the agency of the patient.
Clinical case: 5 year-old Sean
Sean was referred to me because of disruptive behavior and severe separation
anxiety. I initially saw Sean and his family together in a family treatment, in
which Sean and his younger brother had enjoyed rich, symbolic play that Sean
initiated. In one scenario, two boys took the mother dolls house doll, referred
to as the girl, to a cemetery, where she was scared by ghosts. In another, the
boys searched for hidden treasure in a sunken ship (my barn with farm ani-
mals). However, when Seans symptoms did not improve with the family
work, his parents and I decided to try individual treatment. In spite of the fact
that Seans mother had explained to him that this time he would be playing
with me alone, when she left him at the threshold of my office, he felt fright-
ened and betrayed (Harrison and Tronick, 2011). Angry with girls (mother
and me) who abandoned and bossed him, he refused to play with me and
provocatively insisted on throwing the girl doll into the fireplace.
In my presentation of the case, I will discuss diagrams of 20-second incre-
ments of videotape material that include both the narrative and the micro-
process taken from four videotapes two from the first individual session,
one from a session following four months of analytic work, and one from a
transformational session after seven months of analysis. The two sections
from the first individual session have already been described in detail in a
previous paper (Harrison and Tronick, 2011); here I add the micro-process
in order to demonstrate the additional information a second by second
analysis can offer to even a detailed description of video material. In my
discussion of the diagrams, I will use the present tense because it seems a
more natural way to describe the interactions. At times, I will also refer to
my subjective experience as I can remember it and as I imagine it through
review of the videotapes.
First two minutes of the first individual session
In this first individual session, Sean and I could not initially negotiate a
shared agenda and instead created a struggle pattern that was all too famil-
iar to him. Then, at a certain point, I was able to regroup and make an
interpretation. Microanalysis of the sequence of the first two minutes of our
time together reveals that the moments of high attunement between Sean
and me are only at points of conflict. One could call this music discordant
and the dance one of opposition.
020 seconds (see Figure 2)
Sean rises from sitting and walks to the right, gazing at the fireplace:
Waa! Im lookin at it. Lookin awful interesting! He begins swinging on
the arm of a chair. I say: Weve got to play. Remember? Thats our job.
Sean walks away, and then exclaims: Ooh! In there! pointing to the fire-
place. The tight coordination at 14 seconds, when Sean immediately gets up
0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
Waaa! Im lookin at it. Lookin awful
interesting!
Gets up from
sitting.Walks to right.
Weve got to
play.
Remember,
thats our job!
.Swinging on chair. walks back towards left.
Ooh. In there!
Walks back to left and sits
down.
Fig. 2. First 20 seconds with Sean
322 A. M. Harrison
and walks away as I finish my speech about play being our job, makes it
clear that his meaning is a rejection.
Pacing the room, Sean asks me: Wheres the girl? I immediately hand him
the girl doll, exclaiming: Heres the girl! Sean responds: Gonna be a
grownup girl! I think of the transference implications of me as the grown up
girl. He points to the fireplace, pronouncing: The dump! I suggest: We
could make a dump. He rejects my idea, saying: Make a dump? Ooh, it has
to be dirty! The thin vertical lines at 27 and 36 seconds again indicate tight
coordination. I have initiated the first simultaneous switch, as I enthusiasti-
cally respond to Seans apparent invitation to play, by providing the doll that
he was asking for. Sean initiates the second when he rejects my suggestion to
create a dump in pretend. It is interesting to note that, aside from these hot
moments of conflict, Sean and I have not established a coordinated rhythm.
Sean takes VTs of 1 sec, 2 sec, 0.5 sec, and 3 sec, and he allows a pause of 1 sec
and then a 2.5 sec internal pause. I, on the other hand, offer a regular 1 sec VT
and pause pattern (except for my simultaneous switch at second 27).
Sean stands beside the fireplace, rubbing his hand along the screen and
gazing provocatively at me, declaring: No. It has to look dirty. So it has
to look dirty. So thats why its really a dump! The thin vertical line at sec-
ond 46 indicates another moment of tight coordination, when I in my AT
of walking towards him and in my VT: No. No, were not going to do
that behave in a controlling, prohibitory way towards Sean. After a 1
sec pause, I suggest to him that we build one (a dump) over here. Again,
with the exception of the high attunement at a moment of conflict, no coor-
dinated rhythms are apparent. Even my attempt at a 1-second regularity of
turn and pause duration in the previous segment is falling apart as I react
to Seans provocation.
20 21 22 03 04 05 06 07 08 09 30 11 12 13 14 15 16 17 18 19 40
We could make
a dump.
Wheres the girl?
Pacing, first walks to left near A, then moves to
right.
Gets up from
Hands him the girl
doll..
Theres the
girl!
The dumpl!
Gonna be a
grownup girl!
walks back towards left, then towards A, pacing, then away.
Make a dump?
OOh. It has to
be dirty!
Fig. 3. The Dump
Then something important happens. Sean abruptly leaves the fireplace,
declaring: Oh, I think Im gonna get one of my matchbox, and leaves the
room to enter the adjoining playroom. By matchbox, he is referring to toy
cars, though of course there is also within the name a reference to the fire-
place. His action of leaving the room releases me from the struggle pattern I
had felt trapped in, and I am able to reflect on what was going on between us
and to relate it to the struggles Sean and his mother made together. I recog-
nize the transference (and countertransference) pattern and, in doing that, cre-
ate a more complex meaning about our relationship. This understanding is
regulating to me, and I am able to resume my analytic stance and begin to pre-
pare an interpretation. Sean returns from the playroom after 5 seconds, hold-
ing two matchbox cars. He throws one car on the rug and then the other. At
this point, I am not provoked by this intentionally naughty behavior because
I am thinking about how to give him and me insight into his behavior.
Sean returns to the fireplace and places his hand on the screen. I am
thinking of what his mother has told me about his perseverative behaviors
and how that fits into his non-compliance. I say: Yeah, once you get those
ideas into your head, its hard to get them out, huh? Sean makes a simul-
taneous switch at second 67, when he pronounces: Once I make up my
mind about something, it gets done! Even if its something Im not really
supposed to do! Something interesting is happening in my turn patterns.
Coincident with my shift into a more reflective and analytic state, my VTs
become more rhythmic within my own framework. They are 5 sec, 3 sec, 3
sec, and 5 sec (in the next sequence), with pauses of 1 sec, 1 sec, and 1 sec.
My interpretive remark: Oh, that could be a problem, you know, especially
if thats the way you think it has to be, because kids are stronger if they
Throws one car down,
then the other.
40 01 02 03 04 05 06 07 08 09 50 11 12 13 14 00 01 02 03 04 05
Oh, I think Im gonna !
Lets build one
over here.
Standing by fireplace, rubbing hand along fire screen.
No, it has to look dirty!So it has to
look dirty so thats why its a really
dump.
Gets up from
No
No, were
not gonna
use that.
Walks out of
room to play
room.
Interruption of
time line of 5
seconds.
Fig. 4. The Analysts Transformation
324 A. M. Harrison
have lots of different ways of doing things instead of only one, is parsed
into this pattern of regular VT durations and pauses. Even though my part-
ner has not yet joined me in this new, more collaborative dance, I am show-
ing him that there are new possibilities in our future together. In my
interpretation, also, I am trying to suggest new ways of helping him under-
stand himself. Although of course my interpretation is consciously thought
out, the timing of my vocalizations is out of my awareness. However, my
subjective experience is one of greater comfort and interest.
Figure 6 illustrates my interpretation with Seans response of three brief
coughs. Although the coughs could be apprehended as rejecting the inter-
60 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 80
Pacing
The
dump!
Yeah, once those ideas get into your
head, its hard to get them out, huh?!
Gets up from sitting.
Once I make up my mind about
something, it gets done! Even its not
something Im supposed to do!
Oh, that could be kind of
a problem, you know.
Averts gaze and starts to pick up and put down toys.
Especially if
thats the way
you think it has
to be!
Fig. 5. First Interpretation
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Because kids are stronger if they have lots of different ways of doing
things instead of only one!
Cough
Pacing
Fig. 6. Kids are Stronger
pretation, his pacing indicates an effort at self-regulation, and that effort
suggests the desire to hear what I have to say.
Insights from The sandwich
The top slice of bread
Sean cannot risk (does not have the energy for) an interaction at a higher
level of organization; he stays in his familiar struggle pattern. I join him
there.
Meat
Sean wants to throw the girl (his mother and me) in the dump (symbolic
meaning of dump). Then, he declares that he wants to get a matchbox
and physically exits the struggle. It is now my move. When he returns a few
seconds later I could reinstate the struggle, or I could regain my analytic
position, reflect on what was going on between us, and then make an interpre-
tation that offered a new and more complex meaning. Luckily, I choose the
latter. What allows me to do that? I do not know for sure but I have some
ideas. First, I think that the somatic meanings (for example, the physiologi-
cal arousal state) generated in me by the struggle were interrupted by Seans
physical leaving the room. This disorganization allowed me to reorganize
somatically, cognitively and affectively at a new level.
Bottom slice of bread
The micro-process shows high attunement only at points of conflict until I
regain my analytic position and show him another kind of dance. At that
point, I lead a transition into a more regular vocal rhythm and also greater
consistency between the verbal content of my interpretation that there are
better possibilities in the future and a rhythm that offers more opportuni-
ties for collaborations.
Mid-way in the first individual session
Mid-way into the session is a point that I identified in review of the videotape
as the moment when Sean shifted into a collaborative play with me (Harrison
and Tronick, 2011, pp. 1013). It occurs when Sean is dismissively declaring
that what he and his brother had earlier pretended was a sunken treasure ship
doesnt count at all and is just a bunch of dead animals, just a big pile of
skeletons, referring to the farm animals in the barn. I remember the grave-
yard play from the family meetings and connect it with how I imagine Sean
must be feeling in the session. I say: Skeletons, huh? That reminds me of the
graveyard, where people go to get lost and scared. As I make this remark, I
place two dolls on the floor in the space between us. After I complete my VT,
I sit back and fold my arms against my chest. Just as I begin to sit back, Sean
starts to move forward, and he places one of the dolls in the car he has been
rolling. He then grins and adds: Where they get tricked.
326 A. M. Harrison
In this sequence, I mirror Seans vocalization and pause pattern; my two
vocalizations increase progressively from the first VT (Hmm) to a second
VT (Skeletons, huh?) twice the duration of the first ones size, and the
pause is roughly twice the size of Seans pause, implicitly indicting an invi-
tation for Sean to take over the turn. My micro-process is attempting to
support the initiative of a child who feels helpless. Whereas I was con-
sciously putting the interpretation together in my mind, the vocal rhythms
were of course out of my awareness.
In this sequence, my first VT is That reminds me of the graveyard. After a
1-sec pause, I resume my turn, saying: The graveyards the place you go when
you are lost and scared. Sean comes in immediately at the beginning of this
speech in a move that requires high attunement: Heh! (second 24). At sec-
ond 36, I make a similar simultaneous switch; this is controlling, but not in
Hmm.
0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
Running car along the rug with right hand, then leans down to barn, takes one barn door at
a time, closes them.
Sits still, moving car in left hand back
& forth small distance.
This cow and
this sheep dont
count at all.
Just a big bunch of, just a big pile of
skeletons, and another big pile of
skeletons!
Skeleton
s, huh?
Skeletons
of the dead
animals!
Leaning forward on palms of
hands.
Fig. 7. The Transition: Skeletons, huh?
Then moves vehicle
towards village.
20 21 22 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Heh! Where they get
tricked!
Slowly crosses arms and
sits way back.
Oh, that reminds me
of the graveyard.
The graveyards the place
where you have to go when
you are lost and scared
Picks up doll A had placed on rug
and places it in vehicle.
Starts to place dolls one at a time in space
between them.
Moves vehicle back and forth
across the rug.
Where they get tricked
by some bossy guy!
Fig. 8. The Transition: A Graveyard
the sense of constraining Seans initiative as it was at the beginning of the ses-
sion. Here, instead, the intention seems to be one of regulating at a high arousal
state in order to maintain the intensity of the affect and the play theme.
Top slice of bread
Sean shows the intention to negotiate a shared agenda, to grow through
increasing complexity by collaborating instead of struggling. In this sequence,
the verbal and symbolic content move into the forefront of our engagement.
This perspective on the process of meaning-making underscores the work, or
energy here demonstrated in Seans effort at self-regulation required to
bring together various elements of meaning to co-create something new.
Meat
In my skeletons reminds me of the graveyard remark, I am bringing
forward the sadistic play theme from the family meeting with its implica-
tions for the maternal transference. I am communicating my willingness to
go there in the play mode. This play offers a more complex alternative
than the enactment of the struggle. Sean adds his bit of meaning, where
they get tricked, suggesting that he wants to go there with me. This play
of tricking has potential for including his aggression, anger but also
intense interest in girls and their hidden treasure (mother and me in the
transference) and Sean seems to recognize it.
Music I begin mirroring Sean, as we move towards greater coordination.
Dance Frame by frame analysis of the video reveals the do-si-do pat-
tern, as I sit back and cross my arms against my chest and Sean in a reci-
procal movement leans forward and places one of the dolls in his vehicle.
The deepening of the analytic play theme creates a context for the new level
of coordination of movement and vocalization that Sean and I join in
together. If I had stepped aside from Seans invitation to talk about dead
things, we might have returned to the struggle pattern, or we both might
have moved into a pleasant rhythm that avoided the deep and dark aspect
of the transference.
Tricking the girl: The beginning of the analysis
Following this transition in the first session, Sean and I moved into an ani-
mated play of tricking the girl with a siren noise. At the end of the ses-
sion, Sean offered the girl an imaginative solution to her distress, a
noise monitor, so that she could control the noise. I felt connected with
Sean and appreciative of his capacity for pretend play, and I recommended
intensive play therapy, which became an analysis within a couple of
months.
328 A. M. Harrison
The tricking the girl continued in an enjoyable repetition, with multiple
small variations on the theme, for months. Variations included medieval war-
riors or the boys whisking delicious pies and cakes away from the girl.
Other times they prevented her from snuggling baby animals by tempting her
with statues (not real) or pygmied animals (not babies). In the fourth month
of treatment, Sean had an encounter with a real girl on the playground.
Fourth month of analysis
Sean intimidated a girl on the playground and she told a teacher and got
him into a lot of trouble. In his session that afternoon, Sean made an inter-
pretation that linked his behavior with the real girl on the playground with
the girl in our play. I had heard about the unfortunate incident from his
mother prior to our session. When he arrived, I told him: Weve got to get
the girls out, because I dont really understand what the girl did to you
that made you so angry. Sean said: Well, heres what I think. Let me see
if I can make it so you can understand. Well, I wanted a turn, so I shook
the thing (a toy), and she dropped it and so I took her turn. And I dont
like her one bit. I responded: I dont blame you for not liking her,
because she had something you wanted, right? Sean averted his gaze and
murmured: Like the girl in the play misses everything she wants because it
runs away. I responded: Exactly. Like the girl misses everything she
wants because it runs away. In this sequence, we see a coordination char-
acterized by respectful, predictable pauses and tight coordination only at
moments of high intensity, to hold it, while we work on the meaning.
Note the similarly long VTs (4 and 5 sec) with a 1-second internal pause
by me, followed by the same 4 sec VT by Sean. There is a simultaneous
switch by me at second 18, again intending to maintain the level of intensity
of the meaning we are working on.
0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
Well, heres what I think, like let me
see if I can make it so you can
understand.
Rubs
nose
on L arm
Weve gotta get some
girls out, because you
were so upset with that
girl today!
Rubs
nose on
arm R arm
I dont understand what she
did to you to make you so
terribly mad at her.
Pulls shirt neck
over nose.
Reaches in basket and sifts
through army stuff.
Well, I wanted a turn,
and I shook the thing,
O.K,
Fig. 9. Four Months into Analysis: The Stupid Girl
At seconds 3031 is what I call a nesting sequence, or an intensive com-
munication pattern, in which the two partners enter into a tightly coordi-
nated back and forth in order to make more precise the meaning of what
they are discussing.
My interruptive switch, Yeah! at second 48 was intended to recognize
the importance of Seans idea. The simultaneous switch at second 50 indi-
cates my delight at Seans insight, and my wish to capture it and keep it in
the air so that we can really appreciate it. When I declare: Exactly, I use
the respectful 12 sec pause pattern to extend the time we are engaged with
this important new meaning.
Top slice of bread
As in Figures 7 and 8, Sean demonstrates the intention to make meaning
with me, in other words, grow, and increase in complexity.
20 21 22 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Turn! Then I took her
turn.
Returns to sifting through army toys.
Sifting through army toys.
I dont blame you for not
liking her!
Out of range of camera,
sittiing still.
Then you took her
what?
Rubs nose
on arm. And it scared her, and she thought she was going to
get hit, so she walked away, and I took her turn.
Oh, I see. I
see.
So
...
And I dont like
her.
One
bit.
Fig. 10. I took her turn
40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 19 20
Continuing sifting through army toys.
.Because she had
something that you
wanted, right?
Yeah!
Like the girl misses everything that she wants
because it runs away.
Yeah, like the girl misses
everything she wants because it
runs away.
Exactly!
Fig. 11. Like the girl misses everything she wants
330 A. M. Harrison
Meat
Sean makes the interpretation linking the girl in the play to his experience
with a girl on the playground.
Here there is high attunement at moments of our attempts to make sense
together, and at Seans new meaning.
Seventh month of treatment
By the seventh month of treatment, the tricking play had reached a new
degree of complexity and excitement. In a transformational session, Sean
and I co-created a way of my making an interpretation having an opin-
ion about what was in his mind without challenging his agency. It started
with a play interruption.
The boys had locked the girl in a plane and were going out to The
Spooky Restaurant, where they were going to eat guts soup. The girl cried
out, but to no avail. I played the role of the girl, micromanaged by Sean.
The boys were singing a rollicking song about guts soup to the tune of jingle
bells. (Sean had a particularly good singing voice, and this quality most
likely contributed to my next move.) Straining under my countertransference
experience of being over-controlled multiple times a week for seven months
and now being locked up in a plane and prevented from joining in any of
this aggressive fun, I spontaneously grabbed up one of the several boys and
began to sing a verse of the song. Sean instantly declared: That is the worst
boys voice I have ever heard! Then he stood up and asked how many
more minutes were left to the session, and: Can we cut it short?
In this sequence, I respond to his question, saying: Weve got 10 more
minutes. He says: Goodies. I respond: Baddies for me, because I love
playing with you. From the beginning of this exchange, we demonstrate
0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20
Baddies for
me because I
love playing
with you.
How many more
minutes?
Yep .
Goodies..
Can I make
him say
that?
Weve got 10
more minutes.
Hey! Goodies?
lava!
Fig. 12. Seventh month: How many more minutes?
in our actions that we are well coordinated and that we share an implicit
wish to be predictable to each other. We restrict ourselves to short (at
most 2 sec until my long lead-up to an interpretation) VTs and our pause
durations are mainly 1 or 1.5 sec. It seems as if we sense that we are on
delicate ground yet we wish to maintain the connection. The delicate
ground is related to our openness to a perturbation to our system. We are
(out of conscious awareness) preparing for the possibility of an innovation.
Despite Seans stated wish to end the session, he indicates through his rep-
etition of my pause and VT pattern that he is with me. Sean is pacing
the room throughout the 100 seconds of this entire sequence; in this motor
activity he is also demonstrating through his energetic self-regulatory
behavior that he desires the relationship and what we are doing
together.
I continue my preparation for a defense interpretation: But I wanted to
know what made you suddenly say how many more minutes we had.
Using the 1-sec VT and pause pattern, Sean retorts: Not telling you! Here
I make the first (at second 24) of a number of simultaneous switches. I am
aware of Seans intense state of arousal and intend to regulate him and
myself at this high level of intensity rather than allow the intensity to dimin-
ish. The verbal content of my VT carries the same level of intensity as the
turn change: I bet I can guess. I am being quite aggressive here, although
playfully so, and I imagine that the quality of the rhythmic coordination
allows me the freedom to take this risk. Sean again asserts himself in a
spontaneous, interruptive switch: Its personal! I wish to communicate
my respect for Seans agency, especially while I pursue his unconscious
But I wanted to
know what
made you
suddenly say
how many
more minutes
we had.
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
I bet I
can
guess.
Its personal?
I bet it was when I
made a girl
sounding voice.
You can have your opinion. Any
opinion you like. Not telling
you!
I bet I
can
guess,
though.
Are you sure?
No!
Its personal!
Pacing around the room.
Fig. 13. A girl-sounding voice
332 A. M. Harrison
motivation for wishing to interrupt the session, so I wait 1 sec before
responding with a question that repeats his assertion: Its personal? But I
am eager to keep the exchange going and sense that it may dissipate, so I
make a defense interpretation: I bet I can guess, though. I bet it was when
I made a girl sounding voice. Sean waits a full 2 sec before responding. He
might indeed have declined to respond. I do not know where we are going
with this, but I am focusing on the aspect of the discussion having primarily
to do with agency and I want to elaborate as much as possible this subject
that I consider vital to Seans developmental change. When Sean declares:
No! I leave a respectful pause but then move right in with another playful
challenge: Are you sure? Sean then responds with a simultaneous switch,
a hot moment exchange, with his long and eloquent speech that begins:
You can have your opinion. Any opinion you like.
At the beginning of this sequence, Sean concludes his speech: Youll
never have. You could have your opinion, but you you could be right,
but youll never know for sure. I see Ss speech about my being able to
have an opinion about what is in his mind, though I will never know
for sure, as an opportunity to create an understanding together about
Seans agency and how to allow the exploration of his inner world without
his having to give way to anothers dominance. I come in with a simulta-
neous switch at second 49, declaring: That is, I completely agree with
that. Then, using repetition to keep the idea in the air, allowing multiple
chances to consider it, I repeat the bulk of Seans statement. Sean interrupts
me when I say: And I may be right (repeating his phrase), insisting: And
you may be wrong! I leave a short pause for emphasis, and then I repeat,
to emphasize the verbal meaning: And I may be wrong. Then I ask a
question that leads towards an elaboration of Seans theme: Do you know
why Ill never know for sure?
Pacing.
40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
That is, I completely agree with that! ! I can have
my opinion, and I may be right, but I will never
know for sure!
And I may be wrong. Do you
know why Ill never know for
sure?
Youll never have.. You
could have your opinion,
but you you could be
right, but youll never
know for sure .
And you may be wrong.
Fig. 14. You can have your opinion
Sean might not have responded, or he may have filled in an answer of
this own, Here, with his Why? he was indicating his interest in what I
had to contribute to the evolving meaning of having an opinion of
another persons mind. Sean has indicated intensity in his simultaneous
switch with his why (at second 60 simultaneous beginning with my VT
of the previous sequence, ending at second 60). I am relaxed and enjoying
the exchange. I am conscious of building an escalating rhythm with the use
of repetition, pauses, and progressing duration of VTs. I feel as if I am
dancing. My turns are statements in the form of questions, inviting Sean to
take a turn to validate or invalidate the content of the speech. I first state:
Because Ill never know whats inside your head, right? Sean responds:
Yep. In a simultaneous switch, I ask: Because your head is your own
private property, right? Sean responds: Yep. I make another simulta-
neous switch: And even though girls can be very nosy and try to butt into
your business, they can never know for sure, right? After this longest turn,
Sean takes his customary 1-sec pause and responds in a way that suggests
he is not quite prepared to claim his agency: They can have their opinion.
I, perhaps concerned that we may lose the intensity and therefore the
associated vital meaning of our exchange, make another almost simulta-
neous switch (sec 80), declaring: Right! Sean seems to match me here,
making another simultaneous switch as he initiates an expression of this
dilemma: But they could be wrong, they could be right. The tonality of
his speech expresses anxiety, again as if he were not sure he had a right to a
mind of his own. I want to support his right to a mind of his own but also
want him to keep the initiative, to claim it. With that in mind, I try to
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
Because your head is
your own private
property, right?
.Because Ill never
know whats inside
your head, right?
Pacing.
And even though girls
can be very nosy and
try to butt into your
business, they can
never know for sure,
right?!
Yep!
They can have their
opinion!
Yep!
Why?
Fig. 15. Ill never know inside your head
334 A. M. Harrison
frame the dilemma in his terms and keep it alive so that hopefully he can
take charge. I repeat, in a simultaneous switch (sec 86): They could be
wrong. They could be right. They can have their opinion. They can never,
never know for sure. I have added the extra never to emphasize this
point. After his characteristic 1-sec pause, Sean repeats: Never. After a
quarter of a second, I repeat: Never.
The top slice of bread
I feel constrained, stuck, in my role as the girl and reach for a new level
or organization (a new way of being with Sean) that is more complex, col-
laborative. This would not have to preclude the masterslave transference
paradigm of our previous work, but could just expand our repertoire. Sean
is afraid to let go of the old way in which he is the boss.
Meat
I make a relatively standard defense interpretation (I want to know what
made you suddenly say: How many more minutes? Ill bet it was when
I used a girl-sounding voice.) My spontaneous shift into one of the boss
or boy positions in the play upset Seans representation of boys controlling
the girls, an alternative to his life experience of being totally controlled by
the women in his life and also most likely challenging his masculine identity.
Sean initially rejects my wish to know his personal thoughts. However, he
proposes an innovative solution. Even if I cannot know what is on his
mind, I can have an opinion. This solution both allows me to be curious
about his inner world and protects him from threatening intrusion. I enthu-
siastically join him in this new proposal.
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Never.
They could be wrong. They
could be right. They can have
their opinion. But they will
never, never, know for sure.
Right!
Pacing.
But, They could be wrong!
They could be right!
Never!
Fig. 16. Never. . .never
The high coordination of music and dance achieved over the course of seven
months of analytic work together is apparent in this sequence. This level of
coordination allows us to manage the stress of trying something new, mutu-
ally regulating at a high level of intensity. The micro-process is crucial to this
process of change. The co-creative activity involves an internal disorganiza-
tion of the meaning in each of us, resulting in a new way of my having an
opinion about his internal world without challenging his agency, and a new
way of each of us valuing our own thoughts and opinions.
Within the mind of the analyst
As I built the rhythm of my discourse with Sean, I had an association to
King Lear, and the iterative use of the negative to elaborate increasing com-
plexity of meaning. Behind Lear I was thinking of the valued senior col-
league whose writing about Lear brought this to my attention, and behind
him, I was thinking of my own father and the meaning of literature in our
relationship (Shengold, 1989, p. 233). Within this complex set of feelings, I
made my statement about how those nosy girls could never know for sure
what was inside his mind. I waited for Sean to take a turn. I felt affirmed
by these men in my life who helped me value my own mind. Sean waited
for 1 second and then repeated never. I wanted the moment to last a cou-
ple of seconds longer to underscore the importance of the verbal exchange
through repeating the most significant word and to give further weight to
his agency by bringing back his initial pronouncement. Thinking of Lear, I
repeated: Never.
Concluding remarks
More important than the interpretation, I think, was the co-creation of a
new interpretive or meaning-making process between Sean and me. Whereas
in the fourth month of analysis, Sean had made his own interpretation, he
had never before allowed me to wonder out loud about what he was think-
ing and feeling. I think it is clear in the micro-analysis presented that the
micro-level interaction was crucial in communicating my respect for Seans
agency. Through implicit as well as explicit means, in a step-by-step process,
Sean and I created a new way for me to give my opinion to Sean about
his inner world without undermining his initiative, without controlling him.
At the same time, I was actively reorganizing my own sense of agency.
Experiences like this are not common in analytic work, though they hap-
pen to all of us. Most likely they occur when a corresponding pattern simul-
taneously emerges in multiple domains of making meaning (Tronick, 2012,
personal communication), and this is not predictable. Sean and I had been
increasing our repertoire of meanings and ways of making meaning for
example, in the narratives we were constructing about the girl and also in
the vocal and action rhythms we were coordinating together. Therefore, the
probability that we would create one of these transformative experiences
was growing. In this case, something about Seans innovative use of the
336 A. M. Harrison
notion of opinion, and a set of connections following a similar theme I
was making in my own inner world, and crucially supported by one of our
new patterns of highly coordinated micro-rhythms, came together to pro-
duce a new understanding between us.
It is clear from my description that this is not the way another analyst
would have chosen, nor would I have done the same with another child, and
Sean would not have behaved exactly the same with another analyst. The
sandwich model of therapeutic action highlights the interaction of meaning-
making activities in many different domains of interaction and at many differ-
ent temporal levels occurring simultaneously, although it explicitly describes
just three. The clinical illustration demonstrates how the music and the
dance add critical meaning to the words of the analytic dialogue, especially
through the examination of the second by second exchange.
Of all the psychoanalytic authors, I at this time find Winnicott the most
sympathetic to my train of thought. It is not just that his writings include
brilliant poetic phrases and descriptions, but that there is in the very eccen-
tricity of his writing described very well by Modell an openness, an
apparent willingness for his meanings to be guessed at (Modell, 1985).
Three examples from Winnicotts papers illustrate the points I have tried to
make in this paper particularly well. The first is his writings about play, the
second his discussion of the construction of the holding environment in
the early parentchild relationship. The third are his statements about the
making of an interpretation.
In his writing about play, Winnicott acknowledges the unpredictability of
creative process: The thing about playing is always the precariousness of
the interplay of personal psychic reality and the experience of the control of
actual objects (Winnicott, 1971, p. 47, my italics). The term precarious-
ness implies to me a process always in transition or evolution, never reach-
ing equilibrium. It fits the way non-linear systems grow and change with
variation and unpredictability and is an essential quality of creativity.
One could call the micro-process precarious in its relationship to the sym-
bolic content that forms its context, as is the symbolic content precarious
in its relationship to the micro-process that forms its context.
In his paper on the parentchild relationships, I find an echo of the bit-
by-bit, repetitive, interactive process I consider basic to therapeutic change
(Winnicott, 1960). Winnicotts description of the way the repetition of daily
caregiving activities builds the holding environment reminds me of Tro-
nicks concept of thickness and also reminds me of my use of repetition in
therapeutic technique (Tronick, 2002b, p. 4). Winnicott states:
It includes the whole routine of care throughout the day and night, and it is not
the same with any two infants because it is part of the infant, and no two infants
are alike. Also it follows the minute day-to-day changes belonging to the infants
growth and development, both physical and psychological.
(Winnicott, 1960, p. 592)
I recall the way Sean and I used repetition to hold the intensity of the
analytic process while we continued to work on the symbolic themes.
Finally, there is Winnicotts admonition about the too smart analyst.
Winnicott is talking about the student analyst but he implies that the same
could be said for an analyst of any age or stage of training:
When he has had several patients he begins to find it irksome to go as slowly as
the patient is going, and he begins to make interpretations based not on material
supplied on that particular day by the patient but on his own accumulated knowl-
edge or his adherence for the time being to a particular group of ideas. This is of
no use to the patient. The analyst may appear to be very clever, and the patient
may express admiration, but in the end the correct interpretation is a trauma,
which the patient has to reject, because it is not his.
(Winnicott, 1971, p. 593, my italics)
In this, the reader will of course recognize my emphasis on Seans agency.
The longer I study psychoanalysis, the more I see that is new and helpful in
the classic psychoanalytic literature. In the writings of Winnicott, I find not
only brilliance, but also the space to have my own opinion.
Translations of summary
Das Sandwich-Modell: Musik und Tanz der therapeutischen T
atigkeit. Meine Pramisse besagt,

dass ein schichtweiser Denkansatz n otig ist, um den Prozess des Austauschs zu verstehen, der zu einer
therapeutischen Veranderung f uhrt. Ich stelle mir vor, dass diese Prozesse in drei Schichten ablaufen, so
wie in einem Sandwich obwohl die Anzahl der Bereiche, in denen Veranderungen stattfinden, tatsa-
chlich unendlich ist. Die oberste Schicht bzw. die obere Brotscheibe des Sandwichs stellt eine breitgefas-
ste Sichtweise des Veranderungsprozesses dar; sie ist nicht-linear und umfasst das Merkmal der
Unsicherheit, ein allgemeines Prinzip der dynamischen Systemtheorie. Die mittlere Schicht bzw. der Be-
lag des Sandwichs wird erklart durch Theorien, die f ur den Therapeuten unmittelbar und klinisch
n utzlich sind, wie etwa psychoanalytische Theorien. Es handelt sich hierbei hauptsachlich um lineare
Theorien, und sie verwenden eine Sprache und Symbole um zu berichten, was geschehen ist. Die unter-
ste Schicht bzw. die untere Brotscheibe des Sandwichs ist der Mikro-Prozess; diese Schicht umfasst die
von Augenblick zu Augenblick auftretenden Muster koordinierter Rhythmen, die sowohl Bedeutung ver-
mitteln als auch das notwendige Ger ust f ur alle Veranderungsprozesse auf h oherer Ebene bereitstellen.
Der Mikro-Prozess erfordert auch eine nicht-lineare Theorie, um den Sinn seiner Veranderlichkeit und
der entstehenden Eigenschaften zu verstehen. Wenn man in das Sandwich hineinbeit, umfasst das ein
polysemisches B undel kommunikativer Verhaltensweisen (Harrison und Tronick, 2011). Ich beleuchte
dieses Sandwich-Modell anhand des klinischen Falls der analytischen Behandlung eines 5-jahrigen Jun-
gen.
El modelo emparedado: M
usica y baile en la acci
on terap
eutica. Mi premisa es que se necesita un

enfoque en capas para entender el proceso de intercambios que llevan al cambio terapeutico. Imagino
que estos intercambios ocurren en tres capas aunque el n umero de territorios en los que se producen
los cambios es, en realidad, infinito como las de un emparedado. La capa superior, o la rodaja de pan
que cubre el emparedado, representa una visi on general del proceso de cambio. Es no lineal e incluye el
rasgo de incertidumbre: un principio general de la teora de sistemas dinamicos. La capa del medio, o la
carne del emparedado, se explica con teoras que son de utilidad clnica inmediata para los terapeutas,
como las teoras psicoanalticas. Estas son primordialmente teoras lineales, y utilizan el lenguaje y los
smbolos para contar lo que pas o. La capa inferior, o la rodaja de pan de abajo del emparedado, es el
microproceso. Esta capa incluye los patrones de ritmos coordinados momento a momento que comuni-
can sentido y, a la vez, proveen el armaz on esencial para todos los procesos de cambio de mayor nivel.
El microproceso tambien requiere de una teora no lineal para dar sentido a su variabilidad y sus pro-
piedades emergentes. Morder el emparedado incluira un paquete polisemico de comportamientos comu-
nicativos (Harrison y Tronick, 2011). Ilustrare el modelo del emparedado con el caso clnico de un
tratamiento analtico de un ni~ no de 5 a~ nos
Le mod
ele du sandwich: La Musique et la dance de laction th
erapeutique. Mes premisses sont

quune approche en couches est necessaire pour comprendre le processus des echanges qui debouch-
338 A. M. Harrison
ent sur le changement therapeutique. Je me figure ces processus qui se deroulent sur trois couches bien
que le nombre de domaines o u le changement seffectue soit en fait infini- comme un sandwich. La cou-
che superieure, ou la tranche de pain du haut du sandwich, correspond a une vue elargie du processus
de changement; elle est non lineaire et inclut lincertitude, un principe general de la theorie des systemes
dynamiques. La couche moyenne, ou la viande du sandwich, se voit expliquee par des theories qui sont
immediatement et cliniquement utiles au therapeute, comme en sont les theories psychanalytiques.
Celles-ci sont en premier lieu des theories lineaires et elles utilisent le langage et des symboles pour ra-
conter une histoire de ce qui sest passe . La couche du bas, ou la tranche inferieure de pain du sand-
wich, est celle du micro-processus; cette couche inclut les patterns moment-apres-moment des rythmes
coordonnes qui a la fois communiquent le sens et fournissent lechafaudage indispensable a tous les
changements de plus haut niveau. Le micro-processus necessite egalement une theorie non lineaire pour
donner sens a sa variabilite et a ses proprietes emergentes. Prendre une bouchee du sandwich incluera
un faisceau polysemique de comportements communicatifs (Harrison et Tronick, 2011). Jillustrerai
le modele du sandwich par la clinique du traitement analytique dun garc on de 5 ans.
Il modello del sandwich: Musica e Danza dellazione terapeutica. In questo lavoro la premessa
centrale e che per la comprensione dei vari processi dellazione terapeutica che portano alla trasformazi-
one sia necessario un approccio stratificato. Immagino che questi processi si verifichino in sequenze che
possono essere rappresentate in tre strati, proprio come in un sandwich (anche se il numero di livelli in
cui avviene il cambiamento e praticamente infinito). Lo strato superiore, nel nostro modello la prima fet-
ta di pane, rappresenta la vista globale del processo di trasformazione; si tratta di uno stadio non-lineare
che implica il principio dellincerto, come proposto nella teoria dei sistemi dinamici. Lo strato intermedi-
o, nel nostro modello il companatico, rappresenta la teoria, un modello psicoanalitico per esempio, che
il terapeuta pu o usare nellimmediato della prassi clinica. Si tratta soprattutto di teorie lineari, che ricorr-
ono al linguaggio e ai simboli per narrare laccaduto. Infine lo strato inferiore, ovvero laltra fetta di
pane, consiste nel micro-processo. Questo strato comprende la descrizione dettagliata, momento per
momento, dei vari ritmi coordinati che da una parte comunicano il significato e dallaltra formano la
struttura essenziale su cui si innesteranno livelli pi u alti del processo di cambiamento. Anche il micro-
processo richiede una teoria non-lineare per spiegare il suo grado di mutabilita e le varie proprieta
emergenti. Un morso del panino rappresentera dunque un insieme polisemico di comportamenti comu-
nicativi (Harrison e Tronick, 2011). Illustro quindi il modello che propongo con un esempio clinico
tratto dallanalisi di un bambino di cinque anni.
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340 A. M. Harrison

8 The Sandwich Model: The Music and Dance' of Therapeutic Action

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The sandwich model: The music and dance of

atigkeit. Meine Pramisse besagt,

usica y baile en la acci

eutica. Mi premisa es que se necesita un

ele du sandwich: La Musique et la dance de laction th

erapeutique. Mes premisses sont

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