“Meaning making ” is the process of how people make sense of their subjective experiences within the context of their relationships to others. During the first few months of life, an infant’s biopsychosocial development will be constructed from an amalgam of layered and complex meaning-making processes, which will influence how they will make sense of themselves and their experiences with others. Tronick (1989) reminds us that developmental research has expanded the way we understand how infants organize their behaviors in the context of stimulating events, such as emotional expressions of the face, voice, gaze, and the psychophysiology of self and others. He writes:

…these processes include motor activity, emotions, temperamental reactivity, mirror neurons, cortical processes, and processes such as the dampening of the hypothalamic–pituitary–adrenal axis and the kindling effect of trauma on neuronal groups.

Damasio et al. (2000) adds that such internal meanings represent a “core biopsychosocial state of consciousness” for the infant. Such processes can have a profound impact on the developing infant, as it has been proposed that they represent a central mechanism that constructs both typical and pathological outcomes (Tronick and Beeghly 2011). The process of meaning making allows a person to construct mental models that ground their understanding in a deeply personal and unique fashion. Growing evidence suggests that these meaning-making processes continue throughout life (Kegan 1994). That is, a person’s representational models are fine-tuned in perpetuity as they make sense of the meaning, affect, and intentions of others within the intersubjective field . Further, research has documented that infants have an innate bias toward self-regulation and mastery and to create perceptual–experiential coherence and organization of their happenings (Emde 1998). Developmental research demonstrates that during the first few months of life, children rely almost entirely on perceptual clues from others, which can help them identify temporospatial, “amodal ” qualities (Stern 1985), such as rhythm, intensity, sequence, affect, and tone in their interactions with others. Toward the end of the first year of life, verbal–symbolic clues begin to gain ascendancy, leading to the construction of representational models with symbolic qualities.

Developmental researchers Stern and Emde found that the infant’s brain is designed to make meaning of what goes together in reality. Dodd (1979) and Trevarthen (1977) demonstrated that infants as young as 3 months old can experience distress when there is a discrepancy between reality and their mental representation of the event. For example, when an image of their mother’s face is on a television screen and her voice is delayed by a few milliseconds, the infants detect the discrepancy, remaining upset until the discrepancy is corrected. In a review of infant research, Bleiberg (1994) states, “Infants (1) develop fairly realistic spatial-temporal models of reality and use them to anticipate what reality will be like, and (2) present a readiness to activate affective responses of anxiety when reality fails to match their mental model of it.”

More recently, developmental researcher Andrew Meltzoff (2007) has found that infants can represent other people as “like me” and that their imitation of bodily movements is a meaning-making process that establishes a connection between self and other. Meltzoff and Brooks (2007) state, “Imitation shows a sharing of actions. This action, sharing is present at birth and tells us much about the intersubjectivity that infants bring to their first encounters with others.” Further, Meltzoff and Brooks (2007) share that the duplication of the action patterns, mannerisms, and gestures humans use to communicate is part of the fabric of human communication and runs in the background, fostering emotional cohesion in everyday interactions, often times outside of explicit awareness. Thus, Meltzoff’s research experiments in essence define the goals of a two-person relational psychotherapist, “Human parents often act as good therapists, mirroring (and interpreting) the infant’s thoughts, feelings, and behaviors.” We would clarify that the two-person relational psychotherapist’s mirroring and interpreting occur at the implicit nondeclarative level, which allows moving forward the psychotherapeutic process and creating new and more adaptive developmental pathways (Meltzoff 1999).

Ed Tronick , a developmental researcher, who was a member of the Boston Change Process Study Group, designed the “still-face experiment ,” in which mothers would present a “still” face to their infants in the midst of play (2007). Healthy infants, after being presented with their mother’s nonresponsive facial expression, would at first continue to smile and gesture (learned implicitly during the interactions with his mother), attempting to reengage with her. However, when the mother continues with her still face, the infants became upset and would resort to vigorous verbal and motoric attempts to elicit their mother’s response. If not successful, they would become despondent and withdrawn. Tronick (2007) explains the infant’s reaction: “The (in)-action of the still-faced mother precludes the formation of the dyadic state of consciousness because there is no exchange of meaningful affect and action with the infant, no creation of meaning.” The meaning-making process has neural underpinnings and is further discussed in Chap.​ 7.

In this section, we briefly discuss mirror and echo neuron systems, which are believed to play fundamental roles in imitation in infants and in understanding with regard to conspecifics. This system, which is localized in the frontoparietal regions, has been described by Rizzolatti and Craighero as a system responsible for the “neural basis of a mechanism that creates a direct link between the sender of a message and its receiver [and allows] actions done by other individuals become messages that are understood by an observer without any cognitive mediation” (2004). In infant research, infant attachment outcomes at 1 year can be predicted based on the degree of interactive coordination of vocal rhythms between mothers and infants at 4 months (Jaffe et al. 2001).

Literature supports that the mirror neuron system is complex and intertwined in electrophysiological terms with the scaffolding in degrees of functionality (Iacoboni and Dapretto 2006). Mirror neurons are a particular class of visual motor neurons, and it seems natural that an audiovisual neuron system develops to understand object-related actions. This encompasses a visual mirror neuron system and an auditory (echo neuron) system that allows for the understanding of the sound that accompanies the actions as in language; “object-related actions are not sufficient to create an efficient intentional communication system” (Rizzolatti and Craighero 2004).

However, over the last decade, more than a dozen “mirror neuron” areas that involve Brodmann area 9 have been identified, including in the inferior frontal gyrus, premotor cortex, primary visual cortex, cerebellum, and the limbic system, and these structures are functionally connected (Molenberghs et al. 2012). Thus, while the distinction may seem semantic, the extant and accumulating neurostructural and neurofunctional data argue that it is better to consider these “mirror neurons” within larger structures and regions that participate in coordinated reflective functions and reciprocally modulate one another, rather than as isolated, autonomously functioning regions (see Chap.​ 7 for a more comprehensive discussion).

Affective attunement is known as the sharing and alignment of internal states that occur during the interaction between the mother and infant, usually around the eighth month in the domain of intersubjective relatedness to others (Stern 1985, 2005). Stern (1985) gives an example of an infant stretching and extending his fingers to reach a toy. During this moment, a mother may recognize her son’s concentrated facial expression and may begin to utter encouragement, “uuuh…uuuh!” signaling implicit encouragement by the crescendo of her voice. The mother’s accelerating vocal respiratory effort matches the infant’s accelerating physical effort. In a securely attached relationship, affective attunement largely consists of implicit processes and is seemingly automatic. Stern reflects on this process:

It is a matching, more than an imitation, that is cross-modal, each partner using a mode of expression different, unconsciously * the most often. The reference for the match is the internal state and not the external behavioral act. Attunement is felt like an unbroken process in the time and leads to define a new quality of feeling, vitality. The quality of the relation of attunement determines probably the ulterior level of the intersubjective relatedness of the ability to ‘be-with’, to share.

*Stern’s use of the term “unconscious” is not Freud’s conflicted unconscious but rather a dynamic nonconflicted unconscious also referred to by the Boston Change Process Study Group as “nonconscious .”

We would draw the reader’s attention to Stern’s careful delineation that successful affective attunement is based on the internal state and not on an external behavioral act. Stern then ties the quality of this attunement to the level of intersubjective relatedness, which is the ability to be with and implicitly share experiences with others. Emde and Hewitt (2001) consider the affective system as psychobiological dispositions with both organizing and communicative functions. Affective attunement is cross-modal and encompasses both verbal and nonverbal communications. Interactions encompass much more than a shared lexicon; they are strongly influenced by vocal tonality and intensity, and observable movements like touching, laughter, and singing are stored in preverbal amodal understanding, becoming precursors to affective regulation (Barsalou 2010). Ultimately, these various forms of expression should provide a sense of “I get what you need.”

In clinical practice, the two-person relational psychotherapist’s affective attunement refers to the authentic and genuine responses given to the patient. Unlike empathy, the relational psychotherapist is not only reflecting on the patient’s subjective state but also conveying his or her own internal perspective to the patient. Thus, in two-person relational psychodynamic psychotherapy of children and adolescents, there must be concerted attention made to matters of emotional availability and affective attunement, which play a critical role in psychotherapeutic change. Diener and colleague state, “The more therapists facilitate the affective experience/expression of patients in psychodynamic therapy, the more patients exhibit positive changes” (Diener et al. 2007), and concludes, “Research indicates that contemporary psychodynamic therapies place greater emphasis on encouraging experience and expression of feelings compared with cognitive behavior therapies.” According to Safran and Muran, “After approximately a half century of psychotherapy research, one of the most consistent findings is that the quality of the therapeutic alliance is the most robust predictor of treatment success” (2000).

Earlier, we described a typical example of a successful affective attunement between mother and her infant boy reaching for a toy. In contrast, when the primary caregiver does not provide appropriate affective attunement in the early months of life, the infant is at increased risk to develop poor self-regulatory abilities, which become the precursor to a variety of insecure attachment patterns. On one hand, consider an infant boy whose mother is very anxious and has difficulty tolerating the child’s struggle in reaching for a toy. Instead, she reaches and gives the toy to the child and thereby prevents overt signs of distress, which make her anxious. This mother does not provide the emotional availability needed for the child to have a sense of vitality in his exploration and impedes the development of self-regulatory functions. Alternatively, a mother may be dismissive of the child reaching for a toy, and the child will learn that he or she cannot rely on his caregivers, and later others, for appropriate affective attunement. This will also lead to difficulties with self-regulation and interrelatedness. Taking this scenario a step further, if the mother is critical and laughs at the boy when he reaches for the toy, and if this is typical of their mode of interaction, it is reasonable to consider that the child will develop a disorganized attachment style. All of these examples illustrate implicit patterns of relating that will likely over time form internal working models of insecure attachment, which is a considerable risk factor for maladaptive interpersonal behavior and formal psychiatric disorders.

Emotional availability is a comprehensive construct based on the integration of findings from developmental research and attachment theory. This construct is influenced by both caregiver and child. Healthy emotional availability can be evident by mutual interest and openness within the dyad of child and parent. This may include a range of positive and negative emotions.

Social referencing serves to expand emotional availability by introducing a sense of shared meaning about events. Emde (2000) discovered that there is a need for “reciprocity” between caregiver and child for emotional growth and the ability to ultimately enjoy mutually fulfilling and healthy relationships. For Emde (1998), emotional availability referred to the “receptive presence” of the parent to the child’s emotional signals. Emotional availability is a vital aspect of the infant–caregiver relationship before the onset of social referencing (Emde and Easterbrooks 1985). Further, it connotes a type of presence and availability that has a great deal in common with the way a psychotherapist “is there” for a patient (Biringen and Easterbrooks 2012).

Social referencing is a critical milestone in typical child development that refers to the process in which a child looks to a caregiver in an emotionally ambiguous situation in order to obtain clues on how to interpret and resolve the situation. Successful social referencing results in a capacity to self-regulate behavior, gain reassurance, and understand how to proceed (Oppenheim et al. 1997). Bleiberg (1994) in reviewing infant research literature states:

Beginning in the second half of the first year of life, infants respond to a novel or uncertain situation—that is, one for which they lack an internal model—in a predictable fashion: They search the caretaker’s face for clues to resolve the uncertainty. If the caretaker’s face signals encouragement, the infants explore with pleasure. If, however, the caretaker betrays anxiety, they become inhibited and distressed.

The visual cliff experiment is a well-recognized paradigm for studying how social referencing can regulate behavior and was used by Emde and Easterbrooks (1985) to assess the effect of maternal emotional signaling on 1-year-olds. In this experiment, infants were placed on a special table in which a transparent tabletop appeared to end and fall off between the infant and the mother. Remarkably, the majority of infants will cross the cliff in the face of apparent danger if the mother demonstrates a positive facial display. Conversely, when the mothers displayed a fearful face, none of the 17 infants crossed. The observation of social referencing appears to have real-world implications. In a study, Dickstein and Parke (1988) found that when marital satisfaction was stable, infants would equally use their father and mother as social referencing targets. Some research suggests that there is correlation between the security of attachment and maternal referencing (Klinnert et al. 1986). Dickstein et al. (1984) found a strong relationship between infant temperament measures and social referencing capacity, rather than attachment patterns.

As demonstrated by the visual cliff experiment, negative expressions by caregivers can regulate infant behavior similarly to how positive expressions do so. When infants look at parents or caregivers and notice anxious or fearful expressions, they can develop maladaptive, problematic behaviors over time. As an example, starting school is generally an exciting time for parents, even though there may be some difficulty in allowing the child to separate. Though parents may be implicitly anxious, they understand they need to mitigate the child’s inherent anxiety, through facial and emotional expressions that provide reassurance to the child of the new endeavor: “everything will be fine.” However, if parents or caregivers consistently provide fearful or anxious emotional expressions, the child may begin to refuse to go. Additionally, the child may be eager to go to school and rely on school personnel to provide the social referencing needed for reassurance.

Importantly, Emde (1992) also reminds us that social referencing processes have largely been studied from the point of view of the infant and have neglected the caregiver’s side of the process. Observations of caregiver social referencing may help further knowledge and develop programs to promote maternal sensitivity and caregiver emotional response essential for the child’s growth. Additionally, the two-person relational psychotherapist emotional availability is also essential for the patient and family’s growth, as they will implicitly and nonconsciously make use of the psychotherapist’s more adaptive relational knowings.

Several authors have thought of these early referencing patterns in social contexts as initially being dyadic. However, toward the end of the first year, looking behavior becomes increasingly referential—or coordinated between many people—with relationships influencing relationships. The emergence of referential looking is of particular interest because it is a major milestone in the infant’s development of social cognition. It is a marker that the infant has an understanding, however primitive, that other people have intentions directed toward the outside world. These processes will grow increasingly more sophisticated and become the underpinnings of theories of the mind, emerging by the third year (Hala 1997; Striano and Rochat 2000). Up to now, most studies of infant–caregiver interactions suggest that multiple influences are likely to contribute to the emergence of individual differences in social referencing (Table 5.2).

The concept of temperament has traditionally had limited use in the larger mental health community. In contrast, early childhood educators, developmental psychologists, and pediatricians have routinely embraced the concept of temperament. Temperament can be broadly defined as observable and persistent behavior patterns in early childhood that distinguishes one child from another. These patterns remain relatively consistent over situations and time. Many specific patterns of behavior have been identified (McCrae et al. 2000; Windle and Lerner 1986) with several useful classification schemes used across the lifespan. Thomas and Chess are credited with the modern concept of temperament. In Thomas and Chess’ New York Longitudinal Study of 141 youth (Thomas and Chess 1982), they described temperament as having four general styles: 45 % were classified as “easy or flexible,” 15 % “slow-to-warm-up,” 10 % as “difficult or feisty,” and 35 % as “mixed,” a combination of the three, which remained consistent at 22-year follow-up (Thomas and Chess 1999). Though we discuss temperament in greater detail in Chap.​ 8, we will briefly visit this concept as it relates to two-person relational psychology.

Behavioral inhibition is another important temperamental construct that should be clearly assessed prior and during the therapeutic process. In their pioneering work, Kagan and colleagues (1986) characterized behavioral inhibition as the tendency of children, when presented with an unfamiliar circumstance, to restrict speech and play and retreat to an object of attachment. These observations were not restricted to behaviors, but indeed, physiological differences such as higher and more stable heart rates were found in children who were classified with extreme behavioral inhibition. Such temperamental traits in infancy have repercussions later in life. Through a series of studies, Biederman and colleagues found that infants with high levels of behavioral inhibition were at high risk for the later development of childhood anxiety disorders and comorbid psychiatric conditions (Biederman et al.1993, 2001).

Though temperament is presumed to have a biologic basis, environmental influences in a child’s early life may lead the child to selectively develop some traits over others necessary for adaptation. For example, two well-established temperamental traits, emotional reactivity and self-regulation, may be strongly influenced by a child’s early environment (Bronson 2000; McLaughlin et al. 2010). Temperamental traits may also be broadly shaped within a cultural and socioeconomic context (Bornstein and Cote 2009; Paulussen-Hoogeboom et al. 2007). Thus, temperament is a multifactorial process, including contributions from genes, neurobiology, observable behavior patterns of interaction, and culture. Ultimately, temperamental traits play an important role within any therapeutic relationship.

Temperamental differences between individuals, especially within the parent–child and psychotherapist–patient relationships, can play a critical role in the quality of interpersonal interactions. As Roffman and Gerber (2012) state, “Genetics and temperament are two important (and likely related) areas of research that are undoubtedly relevant to the variability of patient outcome in psychodynamic treatment, and ultimately to our understanding of the mechanisms of psychopathology and therapeutic change.” We would encourage psychotherapists to consider not only the child’s or adolescent’s temperament but also that of the primary caregivers. In keeping with the two-person relational perspective, it is also important for the psychotherapist to reflect on his or her own temperamental style, as it will also contribute to the goodness of fit with the patient in the intersubjective field .

The principal tenet of attachment theory is that people have an innate predisposition to form close emotional bonds with others to assure survival. Bowlby (1969) proposed a construct, known as internal working models , to describe the mental representation of the self and others formed by early childhood relational experiences. In typical development, stable internal working models are formed to understand and predict the intent of others within a certain context and environment, conferring a survival benefit to maintain proximity to caregivers and establish a sense of “felt” security (Bretherton 1985; Sroufe and Waters 1977). Bowlby noted that early in life, the infant creates attachment behavioral systems that help assess whether the parent or caregiver is available not only physically but also emotionally. The parent or caregiver strongly influences how the infant develops the capacity for emotional regulation of their feelings, creating an internal working model of attachment (IWMA), which serves as a template when relating to others (Benoit 2004). Further, the quality of the attachment between the infant and the parent or caregiver is a powerful predictor of a child’s later social and emotional abilities (Benoit 2004; Bretherton et al. 1990).

The empirical evidence of the impact of caregivers’ behavior on infants’ behavior and development has steadily accumulated since Bowlby’s original proposition (Cassidy and Shaver 2008). In addition, individual patterns of attachment appear to remain relatively stable and persist over time (Grossmann and Grossmann 2005; Mikulincer and Shaver 2005; Sroufe 2005). In an elegant study, Johnson and colleagues (2010) found evidence of internal working models during a replication of the Strange Situation experiment. The infant participants and their mothers were observed watching an animated presentation involving either a secure or an insecure caregiver. Three unique patterns of expectations emerged: (1) secure infants demonstrated a desire for comfort and had an expectation of caregiver comfort, (2) insecure-resistant infants expected to be comforted but did not expect comfort from the caregiver, and (3) insecure-avoidant infants neither expected comfort for themselves nor expected comfort from the caregiver. Johnson and colleagues came to the following conclusions:

These results constitute direct positive evidence that infants’ own personal attachment experiences are reflected in abstract mental representations of social interactions…. These representations can now be traced as they emerge, well before existing behavioral measures of attachment can be employed.

Their data supports Bowlby’s original claims that infants form internal working models of attachment-relevant behavior, and these models are associated with infants’ own behavior.

In recent years, neurodevelopmental research has begun to uncover the underpinnings of how IWMA are formed (Schore 2005). The attachment quality between a child and caregiver is multifactorial, and the developing IWMA subsequently allows for social referencing, affective attunement, implicit relational knowing, and intersubjectivity.

As we have described previously (Delgado and Strawn 2014), when two people interact with each other, the attachment patterns observed are specific to those two people. It is not necessarily a representation of attachment patterns that may be exhibited when with others. For example, a child may be dismissive of the psychotherapist in his office, and the psychotherapist may feel the need to make extra efforts to connect with the child, although neither behavior is the typical mode of interaction for them. Their interaction has been guided by the here-and-now intersubjective experiences of each other. The child, who may have a history of secure attachment, could still implicitly fear sharing his struggles with the death of a parent to avoid reexperiencing the sadness and anger of the event. In contrast, the relationally informed psychotherapist implicitly is reminded by the child’s anxiety in relating, of his own childhood difficulties tolerating others’ dismissiveness, and nonconsciously and unknowingly attempts to speed up the process by actively encouraging the child to talk about the traumatic event, without recognizing that the child’s reluctance is well founded. Although both the child and psychotherapist typically use a secure form of implicit relational knowing when interacting with others, during the session the child uses dismissive behaviors and the psychotherapist, anxious behaviors, and both cocreate a disruption (i.e., a now moment, see below under Intersubjectivity) that will need to be repaired by the psychotherapist. The psychotherapist will ultimately recognize the child’s subjective anxieties in the here-and-now intersubjective field and may choose to enact and self-disclose (Chap.​ 6) that as a child himself, experiencing negative feelings was difficult and that sometimes playing a game helped create a reprieve from the intensity of the feelings. He may then proceed to invite the child to play to implicitly convey, “I understand that you are uncomfortable in here with me. You do not need to tell me what worries you. Let’s play and cocreate a positive experience for you in the here and now.” Wachtel (2010) eloquently captures this dilemma:

We begin to think that this is the way the person “is,” when it is more accurate to say that this is the way he is with me (and, moreover, how he is with me when I am acting in a particular way, and he may not be that way even with me when I am being different). Thus, a fully contextual or two-person conceptualization of attachment not only attends to how the person varies in the attachment experiences that are evoked with one person or another; it also requires us to ask what is happening that leads the person to relate and to perceive and experience in a secure fashion, in an ambivalent or avoidant fashion, etc. It attends to what each party to the exchange or to the relationship is doing and feeling at any particular moment, and it asks what each person’s participation in the attachment relationship at any given moment is in response to and what it evokes in the other.… What is really being measured is a depiction of the person’s average or modal attachment status, not a measure that is unvarying through the days and weeks and years; our understanding of the person’s “central tendency” must be complemented by an understanding of the exceptions like inpatient, the office of the therapist, the persistence of the child’s attachment behavior contributes to the continuity of the child’s environment just as the continuity of the environment contributes to the persistence of the attachment status.

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