8 the sandwich model: the ‘music and dance’ of therapeutic action

8/12/2019 8 the Sandwich Model: The Music and Dance of Therapeutic Action

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The sandwich model: The music and dance oftherapeutic action

Alexandra M. Harrison

183 Brattle St, Cambridge, MA 02138, USA [email protected]

(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 processesoccurring in three layers although the number of domains in which changeis 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 thesandwich, is explained by theories that are immediately and clinically usefulto a therapist, such as psychoanalytic theories. These are primarily linear the-ories and use language and symbols to tell a story of what happened. Thebottom layer, or bottom slice of bread of the sandwich, is the micro-process;this layer includes the moment-to-moment patterns of coordinated rhythmsthat both communicate meaning and provide the essential scaffold for allhigher-level change processes. The micro-process also requires a non-lineartheory to make sense of its variability and emergent properties. Taking a biteout of the sandwich will include a polysemic bundle of communicative behav-

iors (Harrison and Tronick, 2011). I will illustrate the sandwich model withthe 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 frominfant 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 sametime keeping in mind the frame of reference provided by the general princi-ples of dynamic systems theory. I will demonstrate the micro- process, orwhat 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 canonly help us understand to a limited degree (Sternet al., 1998). I will thenput this level of therapeutic action together with what psychoanalytic theoryis 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 tointegrate 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

e International Journal of


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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. Inaddition to what was described in the earlier paper, the music and dancewill 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 ofthe sandwich model. The second presents the case and illustratesthe micro-process and the narrative level in selected analytic sessions; aftereach sequence of micro-analysis I will integrate the several domains of ther-apeutic activity described, using the sandwich model. The third includessome thoughts about the contribution of this approach to the theory andpractice 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 writersin an effort to find integrative themes linking psychoanalysis and the fieldof infant research, choosing two examples Winnicotts (1941) The observa-tion of infants in a set situation and Loewalds (1960) On the therapeuticaction of psycho-analysis. Among many other classical papers that haveimpressed 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 therapeuticaction. More recently, psychoanalysts who have studied infant research,cognitive science, linguistics or systems theory have brought us further inthe effort to meld these bodies of knowledge. This group includes Beebeand 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 analystsreverie (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 psychoanalystshave 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 interms of behavior is not necessarily what you think you are doing, and it isalso not necessarily what your theory would suggest that you do. The sec-ond thing I have gained from observing myself on video is insights intowhat the theory that guides my clinical work really is. When I watch myselfin 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 interpretthe defense in relation to a conflictual theme, and sometimes I simply pointout the defense in operation: I noticed that when the dinosaur made a big

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high attunement or tight coordination, and it is the type of exchange that Iwill emphasize in the micro-analysis I present in this paper.

In my presentation of the micro-process, I will show diagrams of thevocal turns (VT) and action turns (AT) of my child patient and myself in

sequences of videotape. The diagrams are organized around a horizontalaxis representing time in seconds, with the childs turns above the axis andmy turns below. The VTs are located closer to the axis and the ATs furtherfrom the axis, so that the order of turns in the diagrams is child AT, childVT, axis of time in seconds, my VT, my AT. In the diagrams, I refer tomyself 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 sessionof a 3 year-old girl in. In this sequence of videotape, the child did not vocalizeso above the axis are her ATs, and below the axis are my VTs and ATs. Hadthe child vocalized, her VTs would be found in the open space between herATs and the axis. What does a diagram like this tell us about the music anddance 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, heredemonstrated 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 sessionwith this child, I parse my communication to her an explanation of whatshe 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 toher carries the meaning of no intrusion, no surprises. The verbal content andthe moment-to-moment are consistent in their message of trustworthiness.

It is important to note that whereas most of my behaviors that constitutethe music and dance are out of my awareness, not all of them are. Withstudy 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 ofsettling on the floor.

Turns, gives direct gaze, maintains gaze.Direct

GazeWalks in, turns

to look up, then

down at toys,

not at analyst.

Averts gaze

as orients to

toys.

.

First drops to her knees, then settlesfurther.

Sitting still, hands in lap.

Fig. 1. Microprocess of interaction with 3 year-old girl




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to communicate with my child patients. Although I am convinced that myadult 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 myadult 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 behaviorsthat I track in the videos of my child patients, in the repetitive exchangeswith 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 pervasiveprocess of coordinating implicit rhythms that occurs with my adult patientsout of my awareness, forming the context for linguistic exchange, and I willlook 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 Germanyhas produced a number of important studies and writings. These include Ra-iner Krauses studies of facial interaction, Horst Kaecheles single caseresearch, and Ulrich Streecks studies of unconscious and nonconscious communication between patient and analyst (Frommer, Lagenbach andStreeck, 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 triggereffects 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 inmultiple domains of interaction, and that what is being organized in eachdomain depends for its meaning on what is going on in all the other

domains of the living system that create its context. The somatic andmoment-to-moment exchange forms the context for the symbolic (includingverbal) meaning, and the symbolic meaning forms the context for thesomatic and moment-to-moment. This perspective on the growth process isderived most directly from the work of Tronick, specifically his DyadicExpansion of Consciousness Model (Tronick, 1998). There are two aspectsof this model that make it particularly well suited to my needs as a clinicianand also distinguish it from other models of change. The first is its empha-sis on the multiple simultaneous processes of meaning-making that includephysiological and psychodynamic domains of making meaning as well as

non-verbal behaviors. The second is that the model includes internalprocesses of exchange within the individual. That is, the private inner worldof the individual has a protected place in this model and is not wholly

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subsumed by the relational or dyadic system. The DECM, in my view, isboth more useful to psychoanalysts than other integrations of developmen-tal theory and psychoanalysis, and also more faithful to the hierarchicalorganization 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 organizationof multiple levels in which each level has an organization, or pattern, that isunique, but that also shares important features with patterns belonging toall the other levels in the system (Sander, 2008). I was looking for a way tomake 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 everyday 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 orveggies in between.

The top slice of breadrepresents the macro-process of developmental andpsychotherapeutic change. It uses dynamic systems theory as a meta-theoryand refers to interactive processes that take place in decades and centuries. Itprovides the big picture of how change takes place. The events that occur atthis level are not recognizable in the time we live in, and we cannot predictexactly how and when they will happen. In order to understand evolution andthe creation of mountain ranges and rivers, for example, one must make useof 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 clinicalaccount 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 istold about what happened is only one of many stories that might have playedout 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 verylarge and very long transformations. Change, in the form of new organizationin 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 thegeneral principles of dynamic systems theory and has no direct link to a non-linear mathematical model. One of these general principles is that systemsgrow by increasing in complexity and coherence. Thus, an indication thatchange 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 rigidifiedis 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




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over the course of an analysis. The bottom slice, or micro-level, deals withtime in seconds and split seconds.

So we are talking about putting the story of an analysis together with atleast 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, arespectful narrative together with regular, predictable rhythms tends to gen-erate trust. Also, the micro-process creates a context for the narrative, inthat, 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 ofunpredictability and variability on the process of growth, the linearity ofthe process in the middle is constrained. That is, analyst and patient canattribute the shift in a patients self-understanding to an interpretation, anddoing this might be helpful, but the specificity of the interpretation itselfand the point in time when it was delivered cannot alone be assumed to bethe cause of the effect. In other words, there is no one right way to conductan analysis. There is no one correct interpretation, and there is no oneright time or right way to make it. This is not a new idea but it is a hardone to keep in mind.

This perspective on analytic change has implications for the way we asanalysts discuss or critique our analytic work with colleagues. I am per-suaded that the only sensible way to discuss analytic material is to try tounderstand the way a particular analytic pair is moving forward in the com-plexity and coherence of the meanings they are making together, withoutpresuming that the content or timing of a particular analytic interventioncan be judged as correct or incorrect. That is with two exceptions the firstis that complexity cannot be honored if a particular domain of meaning(usually related to intense negative affect or bodily excitement) is left out ofthe analytic discourse. The second is the main theme of the treatment I willdiscuss 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 separationanxiety. I initially saw Sean and his family together in a family treatment, inwhich Sean and his younger brother had enjoyed rich, symbolic play that Seaninitiated. In one scenario, two boys took the mother dolls house doll, referredto as the girl, to a cemetery, where she was scared by ghosts. In another, theboys 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 factthat Seans mother had explained to him that this time he would be playingwith 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




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and me) who abandoned and bossed him, he refused to play with me andprovocatively 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 atransformational session after seven months of analysis. The two sectionsfrom the first individual session have already been described in detail in aprevious paper (Harrison and Tronick, 2011); here I add the micro-processin order to demonstrate the additional information a second by secondanalysis can offer to even a detailed description of video material. In mydiscussion of the diagrams, I will use the present tense because it seems amore natural way to describe the interactions. At times, I will also refer tomy 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 ashared 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 aninterpretation. Microanalysis of the sequence of the first two minutes of ourtime together reveals that the moments of high attunement between Seanand me are only at points of conflict. One could call this music discordantand the dance one of opposition.

0

20 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 onthe 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



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and walks away as I finish my speech about play being our job, makes itclear that his meaning is a rejection.


Pacing the room, Sean asks me: Wheres the girl? I immediately hand himthe girl doll, exclaiming: Heres the girl! Sean responds: Gonna be a

grownup girl! I think of the transference implications of me as the grown upgirl. He points to the fireplace, pronouncing: The dump! I suggest: Wecould make a dump. He rejects my idea, saying: Make a dump? Ooh, it hasto be dirty! The thin vertical lines at 27 and 36 seconds again indicate tightcoordination. I have initiated the first simultaneous switch, as I enthusiasti-cally respond to Seans apparent invitation to play, by providing the doll thathe was asking for. Sean initiates the second when he rejects my suggestion tocreate a dump in pretend. It is interesting to note that, aside from these hotmoments 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 VTand pause pattern (except for my simultaneous switch at second 27).4060 seconds (see Figure 4)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 hasto 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 ATof walking towards him and in my VT: No. No, were not going to dothat behave in a controlling, prohibitory way towards Sean. After a 1sec 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 ofturn and pause duration in the previous segment is falling apart as I reactto 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

sitting.Walks to right.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




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Then something important happens. Sean abruptly leaves the fireplace,declaring: Oh, I think Im gonna get one of my matchbox, and leaves theroom 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 Ihad felt trapped in, and I am able to reflect on what was going on between usand 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 isregulating 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. Atthis point, I am not provoked by this intentionally naughty behavior because

I am thinking about how to give himand me insight into his behavior.6080 seconds (see Figure 5)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 behaviorsand how that fits into his non-compliance. I say: Yeah, once you get thoseideas 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 mymind about something, it gets done! Even if its something Im not reallysupposed 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, 3sec, 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, especiallyif 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

sitting.Walks to right.

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

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have lots of different ways of doing things instead of only one, is parsedinto 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 amshow-ing him that there are new possibilities in our future together. In myinterpretation, also, I am trying to suggest new ways of helping him under-

stand himself. Although of course my interpretation is consciously thoughtout, the timing of my vocalizations is out of my awareness. However, mysubjective experience is one of greater comfort and interest.

Figure 6 illustrates my interpretation with Seans response of three briefcoughs. 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




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pretation, his pacing indicates an effort at self-regulation, and that effortsuggests 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 higherlevel of organization; he stays in his familiar struggle pattern. I join himthere.

Meat

Sean wants to throw the girl (his mother and me) in the dump (symbolicmeaning 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 fewseconds later I could reinstate the struggle, or I could regain my analyticposition, 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 thelatter. What allows me to do that? I do not know for sure but I have someideas. First, I think that the somatic meanings (for example, the physiologi-cal arousal state) generated in me by the struggle were interrupted by Seansphysical leaving the room. This disorganization allowed me to reorganize somatically, cognitively and affectively at a new level.

Bottom slice of breadThe micro-process shows high attunement only at points of conflict until Iregain my analytic position and show him another kind of dance. At thatpoint, I lead a transition into a more regular vocal rhythm and also greaterconsistency between the verbal content of my interpretation that there arebetter 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 videotapeas the moment when Sean shifted into a collaborative play with me (Harrisonand Tronick, 2011, pp. 1013). It occurs when Sean is dismissively declaringthat what he and his brother had earlier pretended was a sunken treasure shipdoesnt count at all and is just a bunch of dead animals, just a big pile ofskeletons, 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 Seanmust be feeling in the session. I say: Skeletons, huh? That reminds me of thegraveyard, where people go to get lost and scared. As I make this remark, Iplace 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, Seanstarts to move forward, and he places one of the dolls in the car he has beenrolling. He then grins and adds: Where they get tricked.


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In this sequence, I mirror Seans vocalization and pause pattern; my twovocalizations increase progressively from the first VT (Hmm) to a secondVT (Skeletons, huh?) twice the duration of the first ones size, and thepause 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 tosupport the initiative of a child who feels helpless. Whereas I was con-sciously putting the interpretation together in my mind, the vocal rhythmswere 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 whenyou are lost and scared. Sean comes in immediately at the beginning of thisspeech 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 rugand 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




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the sense of constraining Seans initiative as it was at the beginning of the ses-sion. Here, instead, the intention seems to be one ofregulating at a high arousalstatein 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 throughincreasing 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, orenergy here demonstrated in Seans effort at self-regulation required tobring together various elements of meaning to co-create something new.

Meat

In my skeletons reminds me of the graveyard remark, I am bringingforward the sadistic play theme from the family meeting with its implica-tions for the maternal transference. I am communicating my willingness togo there in the play mode. This play offers a more complex alternativethan the enactment of the struggle. Sean adds his bit of meaning, wherethey get tricked, suggesting that he wants to go there with me. This playof tricking has potential for including his aggression, anger but alsointense interest in girls and their hidden treasure (mother and me in the

transference) and Sean seems to recognize it.

Bottom slice of bread

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 levelof coordination of movement and vocalization that Sean and I join intogether. If I had stepped aside from Seans invitation to talk about dead

things, we might have returned to the struggle pattern, or we both mighthave moved into a pleasant rhythm that avoided the deep and dark aspectof 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, anoise monitor, so that she could control the noise. I felt connected with

Sean and appreciative of his capacity for pretend play, and I recommendedintensive play therapy, which became an analysis within a couple ofmonths.

328 A. M. Harrison



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The tricking the girl continued in an enjoyable repetition, with multiplesmall 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 monthof 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 gothim 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 withthe girl in our play. I had heard about the unfortunate incident from hismother prior to our session. When he arrived, I told him: Weve got to getthe girls out, because I dont really understand what the girl did to youthat made you so angry. Sean said: Well, heres what I think. Let me seeif I can make it so you can understand. Well, I wanted a turn, so I shookthe thing (a toy), and she dropped it and so I took her turn. And I dontlike her one bit. I responded: I dont blame you for not liking her,because she had something you wanted, right? Sean averted his gaze andmurmured: Like the girl in the play misses everything she wants because itruns away. I responded: Exactly. Like the girl misses everything shewants because it runs away. In this sequence, we see a coordination char-acterized by respectful, predictable pauses and tight coordination only atmoments of high intensity, to hold it, while we work on the meaning.

0


Note the similarly long VTs (4 and 5 sec) with a 1-second internal pauseby me, followed by the same 4 sec VT by Sean. There is a simultaneousswitch by me at second 18, again intending to maintain the level of intensityof 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




18/28


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 whatthey are discussing.


My interruptive switch, Yeah! at second 48 was intended to recognizethe 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 inthe air so that we can really appreciate it. When I declare: Exactly, I usethe respectful 12 sec pause pattern to extend the time we are engaged withthis important new meaning.


Top slice of breadAs in Figures 7 and 8, Sean demonstrates the intention to make meaningwith 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



19/28

Meat

Sean makes the interpretation linking the girl in the play to his experiencewith a girl on the playground.


Here there is high attunement at moments of our attempts to make sensetogether, and at Seans new meaning.

Seventh month of treatment

By the seventh month of treatment, the tricking play had reached a newdegree of complexity and excitement. In a transformational session, Seanand 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 startedwith a play interruption.

The boys had locked the girl in a plane and were going out to TheSpooky Restaurant, where they were going to eat guts soup. The girl criedout, 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 jinglebells. (Sean had a particularly good singing voice, and this quality mostlikely contributed to my next move.) Straining under my countertransferenceexperience of being over-controlled multiple times a week for seven monthsand now being locked up in a plane and prevented from joining in any ofthis aggressive fun, I spontaneously grabbed up one of the several boys andbegan to sing a verse of the song. Sean instantly declared: That is the worstboys voice I have ever heard! Then he stood up and asked how manymore minutes were left to the session, and: Can we cut it short?


In this sequence, I respond to his question, saying: Weve got 10 moreminutes. He says: Goodies. I respond: Baddies for me, because I loveplaying 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?




20/28

in our actions that we are well coordinated and that we share an implicitwish to be predictable to each other. We restrict ourselves to short (atmost 2 sec until my long lead-up to an interpretation) VTs and our pausedurations 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 delicateground 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 pacingthe room throughout the 100 seconds of this entire sequence; in this motoractivity he is also demonstrating through his energetic self-regulatorybehavior that he desires the relationship and what we are doingtogether.


I continue my preparation for a defense interpretation: But I wanted toknow what made you suddenly say how many more minutes we had.Using the 1-sec VT and pause pattern, Sean retorts: Not telling you! HereI make the first (at second 24) of a number of simultaneous switches. I amaware of Seans intense state of arousal and intend to regulate him andmyself 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 theturn change: I bet I can guess. I am being quite aggressive here, althoughplayfully so, and I imagine that the quality of the rhythmic coordinationallows me the freedom to take this risk. Sean again asserts himself in aspontaneous, interruptive switch: Its personal! I wish to communicatemy 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



21/28

motivation for wishing to interrupt the session, so I wait 1 sec beforeresponding with a question that repeats his assertion: Its personal? But Iam eager to keep the exchange going and sense that it may dissipate, so Imake 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. Hemight indeed have declined to respond. I do not know where we are goingwith this, but I am focusing on the aspect of the discussion having primarilyto do with agency and I want to elaborate as much as possible this subjectthat I consider vital to Seans developmental change. When Sean declares:No! I leave a respectful pause but then move right in with another playfulchallenge: 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 tohave an opinion about what is in his mind, though I will never knowfor sure, as an opportunity to create an understanding together aboutSeans agency and how to allow the exploration of his inner world withouthis having to give way to anothers dominance. I come in with a simulta-neous switch at second 49, declaring: That is, I completely agree withthat. Then, using repetition to keep the idea in the air, allowing multiplechances to consider it, I repeat the bulk of Seans statement. Sean interruptsme 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 knowwhy 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




22/28


Sean might not have responded, or he may have filled in an answer ofthis own, Here, with his Why? he was indicating his interest in what I

had to contribute to the evolving meaning of having an opinion ofanother persons mind. Sean has indicated intensity in his simultaneousswitch with his why (at second 60 simultaneous beginning with my VTof the previous sequence, ending at second 60). I am relaxed and enjoyingthe exchange. I am conscious of building an escalating rhythm with the useof repetition, pauses, and progressing duration of VTs. I feel as if I amdancing. My turns are statements in the form of questions, inviting Sean totake 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 intoyour 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 suggestshe is not quite prepared to claim his agency: Theycan have their opinion.

80100 seconds (see Figure 16)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 ofhis speech expresses anxiety, again as if he were not sure he had a right to amind of his own. I want to support his right to a mind of his own but alsowant 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 yourbusiness, 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



23/28

frame the dilemma in his terms and keep it alive so that hopefully he cantake charge. I repeat, in a simultaneous switch (sec 86): They could bewrong. They could be right. They can have their opinion. They can never,never know for sure. I have added the extra never to emphasize thispoint. 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 levelor organization (a new way of being with Sean) that is more complex, col-laborative. This would not have to preclude the masterslave transferenceparadigm of our previous work, but could just expand our repertoire. Seanis 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 whatmade you suddenly say: How many more minutes? Ill bet it was whenI used a girl-sounding voice.) My spontaneous shift into one of the bossor boy positions in the play upset Seans representation of boys controllingthe girls, an alternative to his life experience of being totally controlled bythe 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 hismind, I can have an opinion. This solution both allows me to be curiousabout 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 willnever, never, know for sure.

Right!

Pacing.

But, They could be wrong!

They could be right!Never!

Fig. 16. Never. . .never




24/28


The high coordination of music and dance achieved over the course of sevenmonths 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 thisprocess 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 anopinion about his internal world without challenging his agency, and a newway 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 toKing 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 behindhim, I was thinking of my own father and the meaning of literature in ourrelationship (Shengold, 1989, p. 233). Within this complex set of feelings, Imade my statement about how those nosy girls could never know for surewhat was inside his mind. I waited for Sean to take a turn. I felt affirmedby these men in my life who helped me value my own mind. Sean waitedfor 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 exchangethrough repeating the most significant word and to give further weight to

his agency by bringing back his initial pronouncement. Thinking of Lear, Irepeated: Never.

Concluding remarks

More important than the interpretation, I think, was the co-creation of anew interpretive or meaning-making process between Sean and me. Whereasin the fourth month of analysis, Sean had made his own interpretation, hehad 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 themicro-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 abouthis 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 beenincreasing our repertoire of meanings and ways of making meaning forexample, in the narratives we were constructing about the girl and also in

the vocal and action rhythms we were coordinating together. Therefore, theprobability that we would create one of these transformative experienceswas growing. In this case, something about Seans innovative use of the

336 A. M. Harrison



25/28

notion of opinion, and a set of connections following a similar theme Iwas making in my own inner world, and crucially supported by one of ournew 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 analystwould have chosen, nor would I have done the same with another child, andSean would not have behaved exactly the same with another analyst. Thesandwich 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 thedance add critical meaning to the words of the analytic dialogue, especiallythrough 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 includebrilliant poetic phrases and descriptions, but that there is in the very eccen-tricity of his writing described very well by Modell an openness, anapparent willingness for his meanings to be guessed at (Modell, 1985).Three examples from Winnicotts papers illustrate the points I have tried tomake in this paper particularly well. The first is his writings about play, thesecond his discussion of the construction of the holding environment inthe early parentchild relationship. The third are his statements about themaking of an interpretation.

In his writing about play, Winnicott acknowledges the unpredictability of

creative process: The thing about playing is always theprecariousness ofthe interplay of personal psychic reality and the experience of the control ofactual 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 withvariation 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 precariousin 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 dailycaregiving activities builds the holding environment reminds me of Tro-nicks concept of thickness and also reminds me of my use of repetition intherapeutic 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 theanalytic process while we continued to work on the symbolic themes.




26/28

Finally, there is Winnicotts admonition about the too smart analyst.Winnicott is talking about the student analyst but he implies that the samecould 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 asthe 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 inthe classic psychoanalytic literature. In the writings of Winnicott, I find notonly brilliance, but also the space to have my own opinion.

Translations of summary

Das Sandwich-Modell: Musik und Tanz der therapeutischen Tatigkeit. Meine Pramisse besagt,dass ein schichtweiser Denkansatz notig ist, um den Prozess des Austauschs zu verstehen, der zu einertherapeutischen Veranderung fuhrt. Ich stelle mir vor, dass diese Prozesse in drei Schichten ablaufen, sowie 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 derUnsicherheit, ein allgemeines Prinzip der dynamischen Systemtheorie. Die mittlere Schicht bzw. der Be-lag des Sandwichs wird erklart durch Theorien, die fur den Therapeuten unmittelbar und klinischnutzlich sind, wie etwa psychoanalytische Theorien. Es handelt sich hierbei hauptsachlich um lineareTheorien, 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 dievon Augenblick zu Augenblick auftretenden Muster koordinierter Rhythmen, die sowohl Bedeutung ver-mitteln als auch das notwendige Gerust fur alle Veranderungsprozesse auf hoherer Ebene bereitstellen.Der Mikro-Prozess erfordert auch eine nicht-lineare Theorie, um den Sinn seiner Veranderlichkeit undder entstehenden Eigenschaften zu verstehen. Wenn man in das Sandwich hineinbeit, umfasst das einpolysemisches Bundel kommunikativer Verhaltensweisen (Harrison und Tronick, 2011). Ich beleuchtedieses Sandwich-Modell anhand des klinischen Falls der analytischen Behandlung eines 5-jahrigen Jun-gen.

El modelo emparedado:

M

usica y baileen la acci

on terap

eutica. Mi premisa es que se necesita unenfoque en capas para entender el proceso de intercambios que llevan al cambio terapeutico. Imaginoque estos intercambios ocurren en tres capas aunque el numero de territorios en los que se producenlos cambios es, en realidad, infinito como las de un emparedado. La capa superior, o la rodaja de panque cubre el emparedado, representa una vision general del proceso de cambio. Es no lineal e incluye elrasgo de incertidumbre: un principio general de la teora de sistemas dinamicos. La capa del medio, o lacarne 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 lossmbolos para contar lo que paso. La capa inferior, o la rodaja de pan de abajo del emparedado, es elmicroproceso. Esta capa incluye los patrones de ritmos coordinados momento a momento que comuni-can sentido y, a la vez, proveen el armazon 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 modele du sandwich: La Musique et la dance de laction therapeutique. Mes premisses sontquune approche en couches est necessaire pour comprendre le processus des echanges qui debouch-

338 A. M. Harrison



27/28

ent sur le changement therapeutique. Je me figure ces processus qui se deroulent sur trois couches bienque le nombre de domaines ou 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 processusde changement; elle est non lineaire et inclut lincertitude, un principe general de la theorie des systemesdynamiques. La couche moyenne, ou la viande du sandwich, se voit expliquee par des theories qui sont

immediatement et cliniquement utiles au th

erapeute, comme en sont les th

eories 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 rythmescoordonnes qui a la fois communiquent le sens et fournissent lechafaudage indispensable a tous leschangements de plus haut niveau. Le micro-processus necessite egalement une theorie non lineaire pourdonner 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). Jillustreraile modele du sandwich par la clinique du traitement analytique dun garcon de 5 ans.

Il modello del sandwich: Musica e Danza dellazione terapeutica. In questo lavoro la premessacentrale 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 chepossono 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-lineareche 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, cheil terapeuta puo 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 dipane, consiste nel micro-processo. Questo strato comprende la descrizione dettagliata, momento permomento, dei vari ritmi coordinati che da una parte comunicano il significato e dallaltra formano lastruttura essenziale su cui si innesteranno livelli piu alti del processo di cambiamento. Anche il micro-processo richiede una teoria non-lineare per spiegare il suo grado di mutabilita e le varie proprietaemergenti. 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 clinicotratto dallanalisi di un bambino di cinque anni.

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