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Book Forum   |    
Beyond the Reflection: The Role of the Mirror Paradigm in Clinical Practice
Reviewed by LEON HOFFMAN
Am J Psychiatry 2009;166:241-243. doi:10.1176/appi.ajp.2008.08071092

by Paulina Kernberg, M.D., in collaboration with Bernadette Buhl-Nielsen, M.D., and Lina Normandin, Ph.D. New York, Other Press, 2007, 232 pp., $26.00.

Paulina Kernberg’s final book, published after her untimely death and with an afterword by her daughter, reflects her expertise as a clinician, her knowledge of development, and her abiding interest in the integration of clinical observations with systematic studies. Kernberg describes the utilization of the mirror as a diagnostic tool as well as a therapeutic tool.

Although not extremely familiar with the mirror paradigm, my reading of Kernberg’s clinical vignettes and theoretical ideas prompted me to reflect on my own experiences and my own forays into developmental and psychoanalytical literature. In my review of the book, I have digested its contents as best I could and will reflect them back to those who will read the present review.

The word “reflect” has at least two usages in the book (see page xv). One usage of the word refers to how a mirror gives back or exhibits an image. Another usage refers to one’s own mental process as one gives consideration to a variety of input, thoughts, and feelings. As Kernberg perceptively discusses, a mother does not simply reflect her child’s raw emotions back to him or her; rather, she digests and processes these emotions, particularly negative emotions, and then reflects them back to the child. This helps the child develop his or her own capacity to master unpleasant emotions as well as self-reflection.

The book is divided into four parts: 1) Self-Development, Mirror Behaviors, and Attachment; 2) Clinical Applications: Mirror as a Clinical Tool; 3) Mapping and Measuring Mirror Behavior; and 4) Considerations About Future Developments. The amount of information in this volume demonstrates Kernberg’s prodigious knowledge. She discusses and integrates her clinical and systematic observations with the work of many authorities in the field, such as Mary Ainsworth, John Bowlby, György Gergely, John S. Watson, Margaret Mahler, Mary Main, and Daniel Stern. Additionally, she gives reference to the pathbreaking observations of Beulah Kramer Amsterdam, who, dating back to 1968, studied the reactions of infants and toddlers to their reflections in the mirror (1–3). Throughout the volume, Kernberg provides many clinical examples illustrating the ideas explicated in the book. One key chapter includes transcripts of mirror interviews with normal and disturbed adolescents.

Kernberg’s unique contribution lies in her conceptualization of the following:

Behaviors of the infant, child, and adult toward the mirror are related to actual behaviors toward the mother. The human mirror (that is the actual mother) interprets, integrates, and reflects back to the child the image received. The processed image then is introjected and contributes to the sense of self. The actual mirror becomes a symbolic representative of the mother, and the individual’s behavior in front of the mirror parallels the behavior of the mother and the relationship to the mother at different points of the separation-individuation process. (p. 18)

A key concept that is discussed throughout the volume is the importance of the mother’s mirroring function for the developing infant. Kernberg integrates the work of cognitive and developmental psychologists, psychoanalysts, and neuroscientists, stressing in particular the recent discovery of mirror neurons. She reminds us of the following:

Normally, mothers will automatically help their children to discern which facial expressions mirror the child’s internal state and which expressions belong to the mother. Mothers accomplish this by maximization; they tend to exaggerate facial expressions when in the mirroring mode. This is also seen in language use; people tend to speak differently when interacting with infants, a communication form dubbed as “motherese.” Another mechanism whereby mothers help their infants to distinguish what belongs to them and what does not is by a certain amount of discrepant mirroring. (p. 7)

This is an important concept to bear in mind. Mothers do in fact mirror their child’s affective state, for example, anxiety or sadness. However, mothers normally do not reflect back to their infant a completely congruous affective state. The mother learns to empathize with her child without overly identifying with the child’s distress. The question, of course, is with regard to how mothers are able to do this. How do they reflect back an infant’s distress so the infant can master the distress and not be overwhelmed by emotions or affects? If a mother were to reflect an identical affect state to the infant, the infant would become overwhelmed and not master unpleasant affects such as anxiety or depression. We all know that anxious mothers communicate their anxieties to their children, and children with overstimulating mothers can be become excited to the point of having difficulty controlling themselves. For example, a toddler falls—as toddlers always have and always will—perhaps cutting him- or herself. If a mother reacts dramatically, fearing a tragedy, the likelihood of the toddler becoming upset will increase dramatically, and an anxious propensity will be internalized. Most mothers spontaneously respond with an exaggerated tone and say something like the following: “Oh, my Johnny got a boo-boo. Boo-hoo, bad sidewalk! Let’s give your knee a kiss.” Then the child will usually calm down quickly. Most mothers seem to be able to respond intuitively in this way to their infants and toddlers.

By mirroring an exaggerated version of the child’s unpleasant affects (negative emotion), the mother communicates to her child that she really is not upset. This “markedness” of the affect has an “as if” quality and communicates to the child that the mirrored affect is not real but pretend and that the mother does not experience the negative emotion. This process allows the child to develop a differentiation between him- or herself and the mother and soothes him or her as any negative emotions subside (4–7). In other words, mothers do not function as a blank mirror simply reflecting their child’s affects but rather help their children modulate and contain negative emotions.

Mirror neurons demonstrate that there is congruence between visual and motor responses, which is by now well known. When one observes another person performing an action (perception), one’s own motor cortex responsible for that action is activated. Kernberg contributes to our understanding of the profound pathological responses of children who witness violence. She notes that “mirror neuron response does not contribute to the ability to differentiate between being an observer of an action or an executioner or a recipient of an action—therefore in an affect-laden situation such as abuse, the child is affected equally as much as the victim of abuse” (p. 10).

When Kernberg discusses her own observations as well as the work of others, one gleans a developmental line in a young child’s responses to viewing his or her image in the mirror. At 3 months, the child may respond as if the image is his twin. Between 5 and 8 months of age, the child may respond to his image as though it is a sociable companion. At 6 months, the child touches the mirror, and if the examiner puts a toy behind the child, the child will turn around and look for the toy. In other words, by that point the child begins to appreciate that the image in the mirror is a reflection of “reality.”

Between 1 year and 18 months of age, the child compares his movements with the movements of the mirror image. At 18 months, when the child and mother are seen in the mirror, the child may be asked, “Who is there?” The child may respond, “Mommy,” while pointing to his or her own reflection. That is, in the child’s mind, the differentiation between self and mother is not yet clearly demarcated. Between 17 and 24 months, children show self-consciousness in front of the mirror—either embarrassment or self-admiration like an “uncanny experience.” Between 21 and 24 months, 75% will demonstrate self-recognition. After age 2, 95% of children will say, “That’s me,” and virtually all will do so at age 3.

In examining toddlers’ reactions to themselves in the mirror, Kernberg describes the following four factors: confident exploration of their own mirror image, pleasurable self-recognition, active attempts to integrate the experience, and uncertain or peculiar reactions to the experience.

Children with secure attachments will demonstrate positive emotions, whereas those with insecure attachments will show negative emotions. In an affect mirroring study of 66 children between the ages of 3 and 13 years, Kernberg found that normal children showed positive affects, had pleasure curiosity, smiled, liked their faces, and noticed that they possess physical features similar to various family members. In contrast, sexually abused children avoided eye contact with the mirror image or said that they were ugly. The abused children were full of negative affects and also demonstrated sexualized behaviors, such as exposing their bodies in the mirror.

Of the many clinical examples, one of the most dramatic was that of a 5-year-old sexually abused boy. He “literally attacked and stabbed the mirror image with a toy sword several times with expressions of anger, aversion, and disgust. ‘I am ugly when I am being painted and dressed and look at myself.’” (p. 101)

As a result of success with young and school-aged children, Kernberg systematically studied 65 adolescents. She noted the following:

Adolescents in the normal group take for granted the fact that their appearance is an integral part of who they are…they have identified with their mothers’ perceiving them in both body and personality. Lack of flexibility and openness to mutual exchange may have profound consequences for adolescents with severe personality disorders. (p. 151)

The image of the mirror as a reflector of one’s own image is a powerful metaphor. It very aptly describes the mother-child relationship and, in fact, the therapeutic relationship as well. When mothers reflect back to their children, they help their children differentiate what is coming from within their own selves and what they perceive as coming from the outside world. This initial reflection helps the child develop his or her own capacity for self-reflection and the mode of pretend that helps enable him or her to develop greater capacity to regulate and master unpleasant and difficult emotions (8). Whether a psychiatrist is administering a psychotropic medication, engaging in cognitive behavioral treatment, conducting supportive or psychodynamic psychotherapy, or conducting psychoanalysis, he or she is always reflecting back to the patient. The patient receives the input, digests the input, and utilizes the input as best he or she can. In ideal circumstances, the patient leaves the treatment with a greater tolerance of negative affects.

Although this volume is a difficult read, and could have benefited from more thorough editing, Kernberg’s work is one that we should all take in, digest, and utilize in our own clinical and theoretical explorations.

1. Amsterdam BK: Mirror Behavior in Children Under Two Years of Age (doctoral dissertation). [University of North Carolina. Order No. 6901569] Ann Arbor, MI, University Microfilms,1968
 
2.Amsterdam BK: Mirror self-image reactions before age two. Develop Psychobiol 1972; 5:297–305
 
3. Amsterdam BK, Levitt M: Consciousness of self and painful self-consciousness. Psychoanal Study Child 1980; 35:67–83
 
4. Gergely G: Reapproaching Mahler: new perspectives on normal autism, symbiosis, splitting and libidinal object constancy from cognitive developmental theory. J Am Psychoanal Assn 2000; 48:1197–1228
 
5.Gergely G: The social construction of the subjective self: the role of affect-mirroring, markedness, and ostensive communication in self development, in Developmental Science and Psychoanalysis. Edited by Mayes L, Fonagy P, Target M. London, Karnac Books, 2007, pp 45–82
 
6.Gergely G, Watson J: The social biofeedback model of parental affect mirroring. Int J Psychoanal 1996; 77:1181–1212
 
7. Gergely G, Watson J: Early social-emotional development: contingency perception and the social biofeedback model, in Early Social Cognition: Understanding Others in the First Months of Life. Edited by Rochat P. Hillsdale, NJ, Erlbaum, 1999, pp 101–137
 
8. Fonagy P, Gergely G, Jurist LJ, Target M: Affect Regulation: Mentalization and the Development of the Self. New York, Other Press, 2002
 
+

References

+Book review accepted for publication August 2008 (doi: 10.1176/appi.ajp.2008.08071092).

+Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.

+

References

1. Amsterdam BK: Mirror Behavior in Children Under Two Years of Age (doctoral dissertation). [University of North Carolina. Order No. 6901569] Ann Arbor, MI, University Microfilms,1968
 
2.Amsterdam BK: Mirror self-image reactions before age two. Develop Psychobiol 1972; 5:297–305
 
3. Amsterdam BK, Levitt M: Consciousness of self and painful self-consciousness. Psychoanal Study Child 1980; 35:67–83
 
4. Gergely G: Reapproaching Mahler: new perspectives on normal autism, symbiosis, splitting and libidinal object constancy from cognitive developmental theory. J Am Psychoanal Assn 2000; 48:1197–1228
 
5.Gergely G: The social construction of the subjective self: the role of affect-mirroring, markedness, and ostensive communication in self development, in Developmental Science and Psychoanalysis. Edited by Mayes L, Fonagy P, Target M. London, Karnac Books, 2007, pp 45–82
 
6.Gergely G, Watson J: The social biofeedback model of parental affect mirroring. Int J Psychoanal 1996; 77:1181–1212
 
7. Gergely G, Watson J: Early social-emotional development: contingency perception and the social biofeedback model, in Early Social Cognition: Understanding Others in the First Months of Life. Edited by Rochat P. Hillsdale, NJ, Erlbaum, 1999, pp 101–137
 
8. Fonagy P, Gergely G, Jurist LJ, Target M: Affect Regulation: Mentalization and the Development of the Self. New York, Other Press, 2002
 
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