Casey Loughran Zandona

Responding to Infant Sleep-Related

Crying: A Theoretical Exploration of

Caregiver Response from

Attachment and Object Relations

Perspectives

infants’ psychological development. Particular attention is paid to the popular sleep-training

technique—letting a baby “Cry It Out”—as there is an alarming lack of consideration within

empirical and theoretical literature of the psychological impact of this parenting strategy on an

infant. This thesis begins with an overview of current empirical research on infant sleep and

crying behavior, and proceeds to include an in-depth look at attachment and object relations

(mostly Winnicottian) theories, specifically in respect to how caregiver and infant negotiate

sleep, infant crying, the process of separation, and the intrapsychic development of self and

other. Intersubjective theory is integrated into much of the discussion, as it brings the

subjectivity of the caregiver into view, which is really at the core of parenting decisions. At the

end of the thesis, there is a broader consideration of the complex impact of the sociocultural

RESPONDING TO INFANT SLEEP-RELATED CRYING:

ACKNOWLEDGEMENTS

I would first like to thank my husband—André—for his endless love and support, and for

muddling through this process with me. I would also like to thank my parents for their

inspirational love of this field and for always believing in me. I am particularly grateful for my

previous therapists, especially Steven Elig, who provided me with good object experiences to

carry with me while writing this thesis. I would like to give a very special thanks to my dog

Samba for laying beside me while writing this thesis, making himself available for snuggles, and

continuously reminding me that I have at least one good attachment in my life. And finally, I am

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...................................................................................................... ii

TABLE OF CONTENTS .......................................................................................................... iii

CHAPTER

I INTRODUCTION ............................................................................................................ 1

IV OBJECT RELATIONS THEORY ................................................................................... 49

V DISCUSSION ................................................................................................................... 65

REFERENCES ......................................................................................................................... 91

they both hold the early infant/caregiver relationship as central to one’s psychological

development. The application of these theories to the phenomenon will hopefully lend valuable

insights into sleep training techniques and clinical approaches to psychodynamic psychotherapy.

The sleep training technique of focus will be letting a baby “cry it out” (CIO), which is

defined in current literature as “extinction of sleep-related crying through systematic parental

nonresponsiveness in order to teach the children how to sleep independently” (Ramos et al., 2006).

This technique was chosen because the CIO strategy is most commonly recommended by family

and friends (Sears & Sears, 2003), parenting literature (Ramos & Youngclarke, 2006), and

pediatricians (American Academy of Pediatrics, 2012) in the United States.

The theoretical exploration of this phenomenon is warranted because there is a startling

a sample of 700 pediatricians nationwide “believed it was their job to counsel patients/guardians

regarding sleep hygiene, yet few pediatricians (18%) had ever received formal training on sleep

disorders” (Faruqui, Khubchandani, Price, Bolyard, & Reddy, 2011, p. 539). In fact, “residents

has not been explored within psychoanalytic literature. Much of psychoanalytic thinking

explores the physical and intrapsychic separation from the other, and sleep is a prime location of

separation between infant and caregiver. Psychoanalytic theorists have proposed

conceptualizations about how certain caregiver responses impact an infant’s development, but

further exploration into the specific effect of caregiver non-response, or caregiver absence, is

warranted.

Application to Social Work

Having a greater understanding of how a caregiver response to infant sleep-related crying

impacts the development of attachment and object relations can lend valuable insights into the

field of social work. It can lead to a more intricate understanding of the clinician’s provision of

Methodology

This thesis will first provide an overview of the phenomenon—the scope of sleep-training

recommendations, the nature of infant sleep patterns and crying behavior, a detailed description

Attachment Theory

The attachment theory chapter will begin with the theories put forth by John Bowlby and

Mary Ainsworth. These theorists lay the foundation of attachment theory by illuminating the

importance of the attachment bond in the infant’s behavioral functioning and psychological

development, as well as by developing the timeless categories of attachment patterns. The

exploration into the intrapsychic process of separation/individuation will then be discussed

within the theories proposed by Margaret Mahler, as well as from the intersubjective perspective

as introduced by contemporary attachment theorists such as Daniel Stern and Beatrice Beebe.

Specific topics of interest will include the intrapsychic development of self and other, the

attainment of self-regulatory capacities, and the process of internal and external separation from

introducing seminal concepts such as the “good-enough mother,” the holding environment, and

transitional phenomenon (Winnicott, 1951). The negotiation of hate within mother/infant

relationship and the use of the object will also be explored, as that is central to how a caregiver

hopefully lend insights into how a caregiver’s response (or lack thereof) to an infant’s sleep-

related cries impacts the infant’s psychological development. The intent of this thesis is to spark

interest and hopefully inspire a greater discussion into this topic.

It is of note that the language used within this thesis varies. Psychoanalytic literature

traditionally talks about the infant/caregiver dyad in terms of infants and mothers. In recent

years, there has been contemporary focus on primary caregivers of all gender identities. Since

this thesis is relevant to all types of dyadic caregiver/infant relationships, this writer will utilize

the term “caregiver” and a more fluid use of pronouns in general discussion, but will utilize the

term “mother” to remain consistent with the language used in earlier literature.

And without further ado, onto the phenomenon chapter.

caregiver and enhance the attachment relationship. Bowlby (1969) explains, “the function of

attachment behaviour is protection from predators… it affords the opportunity for the infant to

learn from mother various activities necessary for survival” (p. 224), making it evolutionarily

state of distress and his energy is diverted away from essential growth-promoting

activities. When an infant is quiet and alert, he is “more receptive to interaction with and

learning from his environment,” which “promotes an inner organization that allows the

physiological systems of the body to work better” (Sears et al., 2003, p. 14). As Nagera (1966)

states, “the mother acts as an organizer and stimulator of maturational processes (of a

physiological and psychological nature) which steer development into appropriate channels.”

Thus, an essential role of the caregiver is to decrease the infant’s level of distress in order to

support the infant’s natural development. This includes the caregiver intervening to reduce

distress around sleep time, because sleep is an essential process for the infant’s neurological

development (discussed above).!

combination with the information discussed above, these findings indicate that it is essential to

an infant’s development and survival for a caregiver to promptly respond to an infant’s crying by

feeding or touching the infant. This conclusion directly conflicts with the CIO strategy in which

influence infant sleep-related crying, and those inform decisions about how one would respond.

An example of the interaction between infant sleep and infant crying is seen when an

infant experiences separation anxiety. During this phase of development, an infant reacts to

separation from her caregiver with “frightened expressions, withdrawal, or distress” (Davies,

2011, p. 152). Since sleep is a primary location of separation, an infant experiences greater

distress around sleep times, increased sleep disruptions (Davies, 2011), and increased sleep-

related crying (Sears et al., 2003). Understanding the psychology behind the increased incidence

of sleep-related crying equips caregivers to optimally respond to her infant’s needs. !

Some hypothesize that infant sleep-related crying is a result of an infant’s inability to

self-soothe or self-regulate. If an infant’s emotions are deregulated (as is the case when

this mutual regulation that self-regulation is possible. “The parent’s response to the baby’s

distress provides the scaffolding that enables the baby to work on calming herself” (Davies, 2011,

p. 137). Without appropriate caregiver response to an infant’s distress signals (crying), an

location where crying occurs because there are many psychological and biological reasons for

sleep pattern disturbance and thus increased emotional deregulation. Since sleep is required for

optimal development and infants do not have the capacity to self-regulate, the caregiver is

enlisted by the infant to support the infant’s sleep by serving as a regulatory other. The optimal

way in which a caregiver can provide this regulatory function is to promptly increase proximity

to and touch the infant (Ainsworth et al., 1977).!

Dr. Richard Ferber is commonly regarded as the pioneer of the CIO technique. In

addition to being a pediatrician, he is an associate professor at the Harvard Medical School and

directs the Center for Pediatric Sleep Disorders at Children’s Hospital Boston. He is famous for

baby’s] room all night” (p. 83). This disclaimer is a response to the criticism the CIO technique

has received (Sears et al., 2003). Instead, Ferber offers the Progressive-Waiting Approach

(PWA) that involves progressively waiting to respond to the baby’s crying in order to “rapidly”

techniques is the “extinction of sleep-related crying” in order to “teach the children how to sleep

independently.” Thus, this thesis will continue to regard Ferber as endorsing the CIO approach.!

Ferber (2006) recommends that parents should begin to “institute major changes” in their

infant’s sleep habits when the infant is around 3 to 4 months of age (p. 97). He reasons that an

infant’s sleep cycle has matured at that point, and he should be capable of independently falling

asleep and sleeping through the night. This contradicts with research findings on infant

biological development; an infant’s circadian rhythm has not matured by 4 months of age,

making it impossible for the infant to sleep through the night (Nagera, 1966). The “major

changes” Ferber’s recommendations include the mother not responding to her baby’s nighttime

crying with physical touch, or sustained physical presence. He outlines how to do this in the

temporal increment). Time is added to these wait times every night until the baby stops

crying. By the seventh night, the mother could be waiting 30 minutes to respond to her baby’s

cries. This approach promises that the baby will most likely be sleeping independently through

independently. Ferber states that the "task is to teach your child new sleep associations so that

she can fall asleep without being held, without eating, and without sucking on the breast, bottle,

or pacifier" (p. 140). The mother should “let [her baby] fall asleep under the same circumstances

that will be present when [she] wakes normally during the night (in his crib or bed, not being

held or rocked),” and should respond this way “after nighttime wakings” as well (p. 74).!

Many caregivers find not responding to his or her baby’s cries intolerable and worry that

the CIO approach has significantly negative repercussions. In a survey of 300 mothers, 95

percent said that this approach “doesn’t feel right” (Sears et al., 2003, p. 343). Ferber assures his

audience that the PWA does not have a negative psychological impact on the baby: !

When [parents] realize they will have to let a child do some crying, they often fear that

Ferber’s claim that the PWA “will never cause psychological damage” is based in experience

reality (“long experience has shown”) and is not grounded in empirical evidence. While Ferber

does have a lot of experience in the field of infant sleep, he cites no objective evidence to

included two experimental conditions in which parents ignored their child’s sleep-related crying

by not responding to them (either absolutely no response or a systematic decrease in

response). The findings indicated that a decrease in the child’s sleep problems correlated with a

decrease in maternal stress, and that both experimental conditions led to improvement in the

child’s sleeping problems within 28 days. The proven benefits of this study are undeniable and

have far-reaching implications that benefit the infant. But it is concerning that the psychological

impact on the infant was not measured, especially since early infant/caregiver interactions have a

lasting impacts on the infant’s development and personal characteristics (Blatt et al., 2003;

Bowlby, 1969; Bowlby, 1977; Sroufe, 2005; Sroufe, Egeland, Carlson, & Collins, 2005;

Weinfield, N. S., Whaley, G. J. L., & Egeland, B., 2004). !

that is not what is “best” for the infant. What is best is for the infant to sleep independently.

Ferber states that, when a baby cries at night, “repeatedly going in to comfort him… is often not

the best thing to do” (p. 99) because it creates a “poor sleep pattern” of relying on the mother to

Rickert, 1989; Hiscock & Wake, 2002; Leeson, Barbour, Romaniuk, & Warr, 1994). Caregiver

ratings after recorded improvement in infant sleep indicate “rapid and dramatic improvements in

[the caregivers’] overall mental health status… increased sense of parental efficacy, enhanced

marital satisfaction… reduced parental stress… and [reduced] fatigue” (Mindell et al., 2006, p.

1270).

These positive outcomes have value to both caregiver and child. It is reasonable to

assume that a rested, less-stressed caregiver might be more available, more responsive, and better

equipped to parent than a stressed, exhausted, and resentful caregiver. This begs the question: is

it more advantageous for an infant to have a caregiver that responds to nighttime crying, or is it

more advantageous for a caregiver to ignore nighttime crying in favor of a full night of sleep so

yet Dr. Sears is a fervent opponent of the CIO technique. Dr. Sears refers to CIO as “a method

that trains babies with less sensitivity than we train pets” and as an “insensitive dogma” (Sears et

al., 2003, p. 312). He reasons that not responding to an infant’s cries “keeps parents from

baby's signals;” the “baby loses trust in his mother’s availability and ability to comfort him;” and

the baby “loses trust in his own ability to influence her comforting behavior to meet his needs”

(p. 345). This break in trust then threatens the essential attachment between infant and caregiver

that the infant depends on to sleep. Instead of the CIO technique, Dr. Sears recommends a

number of different options, including co-sleeping arrangements. Dr. Sears states that co-

sleeping provides an environment in which feeding is naturally available, caregivers typically

report better sleep, and the caregiver and infant spend more time together, which contributes to

the infant/caregiver attachment (Sears et al., 2003).

Recent research findings suggest that the CIO technique could lead to an increased risk

for sudden infant death syndrome (SIDS). Multiple studies have concluded that an infant

“Co-sleeping is defined as any situation in which” a caregiver “sleeps within sensory

range of an infant (on the same or different surface) permitting mutual monitoring, sensory

access, and physiological regulation, including (but not limited to) the delivery and ingestion of

evidence in support of this strategy. Even in the most popular book that outlines CIO (Ferber,

2006), there are no citations of studies that prove the efficacy of this technique. Most

recommendations in support of CIO are based on experience reality—the use of one’s experience

as evidence (Ramos et al., 2006; Faruqui et al., 2011). And again, it is concerning that no

research studies have measured the impact of CIO on the infant’s mental health. Studies have

measured how the CIO technique impacts maternal stress (Reid et al., 1999), which inadvertently

impacts the infant’s mental health; but research on how CIO affects the mental health of the

infant is warranted.

Sociocultural Considerations!

A caregiver’s sociocultural surround has a profound impact on how she responds to her

males (Daly & Wilson, 1997; Lancaster & Kaplan, 2000). Also, caregivers are less likely to

respond to infants who have a low birth weight (Bereczkei, 2001) or are severely ill (Soltis,

2004). These findings show that a caregiver’s environment necessarily impacts his or her

the sample in a study by Leerkes, Parade, & Gudmundson (2011) was “Euro-American;” and 40

of the 43 participants in a study by Reid et al. (1999) were “Caucasian.” This lack of cultural

representation within research indicates significant bias and limited generalizability of research

findings. Recommendations on parenting strategies based on this literature should not be

regarded as optimally applicable to all cultures, as every culture embraces their respective norms

that could conflict with those of westerners.!

In fact, many non-western caregivers agree “that separate sleeping arrangements are

unthinkable,” and instead engage in the practice of co-sleeping (Rothbaum & Rusk, 2011, p.

107). Co-sleeping offers many benefits (i.e., greater ease of breastfeeding and closer contact)

that do not necessarily correlate with the infant achieving independence. Ferber, whose

accessible and increased his display of attachment behaviors (crying). It was only when the

mother returned to the room and provided close bodily contact was the infant able to stop crying.

Insecure, ambivalent/resistant attachment. In the Strange Situation, the

consistently positive” (p. 315). This typically results in the infant’s ambivalency about seeking

contact with the mother when in distress; the baby wants to be soothed, but he is not sure

whether the mother will be able to soothe him. The infant “does not seem to have confident

expectations of the mother’s accessibility and responsiveness,” and is consequently “unable to

use the mother as a secure base from which to explore an unfamiliar situation—at least not as

well as infants in” the secure attachment group (Ainsworth et al., 1978, p. 315).

Insecure/ambivalent infants tended to cry more intensely and for longer durations than

secure infants when separated from their mothers. In their natural setting, these infants were

more “easily frustrated, overreliant on their mothers, and generally incompetent in problem-

solving situations (Ainsworth et al., 1978, p. 315). Ainsworth et al. (1978) stipulated that these

Insecure, avoidant attachment. In the Strange Situation, the insecure/avoidant infant

responded to reunion with the mother with “striking avoidance… steadfast ignoring of the

mother, despite her efforts to coax the baby to come to her” (Ainsworth et al., 1978, p. 317).

contact” (Ainsworth et al., 1978, p. 317).

Ainsworth and colleagues (1978) maintained that the observed avoidant behaviors served

a “defensive function” whereby the infant protected himself from the mother’s continued

rejection and inability to meet his needs (p. 316). This is similar to Bowlby’s (1973) theory that

children respond to separation with protest, despair, and then detachment. Bowlby hypothesized

that continued inaccessibility and unresponsiveness from the mother results in the infant’s

detachment; he relinquishes his need to have a regulatory other. This is protective in that it

allows him to develop compensatory defensive strategies through which he is able to continue

functioning. As a result, the infant ceases to display attachment behaviors, ceases to cry, because

he no longer seeks his mother’s support.

colleagues (1978) point out that insecure/avoidant infants observed outside of the Strange

Situation demonstrate “deficiencies in exploratory behavior and cooperativeness and difficulties

with inappropriate aggression in establishing harmonious interaction with adult figures” (p. 320).

the heart of insecure, disorganized children, no behavioral/attachment strategy can be found

because the attachment figure is the source of fear. “Distress without resolution” is the primary

observation.

Main and Solomon (1990) reviewed videotapes of Ainsworth’s Strange Situation and

concluded that some infants did not have an organized strategy to deal with stressful separations

and displayed unique, previously unclassified, behaviors. Main et al. (1990) observed

disorganized/disoriented infants exhibiting the following behaviors in the Strange Situation:

sequential and/or simultaneous contradictory behaviors, undirected or interrupted expressions

and movements, stereotyped or mistimed movements, freezing, slowed or “underwater”

expressions, displays of apprehension towards the mother, and general disoriented or

Laurent, & Parent, 1999). Lyons-Ruth and Jacobvitz (2008) discuss typical behaviors of

disorganized infants in a naturalistic setting. These include internalizing and/or externalizing

behaviors, dissociation, fearful and/and disorganized behaviors, greater avoidance of and less

which is typical of disorganized/disoriented attachment behavior.

Continuity of Attachment Styles

Empirical research has demonstrated the consistency of attachment styles throughout

time, and has linked infant attachment insecurity to later psychopathology (Carlson, 1998; Dutra

& Lyons-Ruth, 2005; Erickson, Sroufe, & Egeland, 1985; Grossmann, Grossmann, & Walters,

2005; Sroufe, Egeland, Carlson, & Collins, 2005; Weinfeld, Whaley, & Egeland, 2004).

The Minnesota Longitudinal Study (Sroufe et al., 2005) found babies’ attachment

patterns as measured at twelve and eighteen months were the same throughout development

(measured in toddlerhood, preschool, elementary school, adolescence, and adulthood—age

thirty). The validity and generalizability of these findings are unmatched due to the large sample

Researchers have also found that insecure attachment predicts psychopathology as early

as preschool age. Erickson, Sroufe, and Egeland (1985) established that preschool-age children

with insecure attachments (anxious/avoidant and anxious/resistant) exhibited maladaptive

they outlined the associations between patterns of attachment and later psychopathology. Dozier

and colleagues progress through Axis I and Axis II disorders and discuss how attachment theory

contributes to understanding each disorder. For example, they ground the empirical evidence

that insecure attachments (both resistant and avoidant) predict depression in adolescence in

attachment theory. When a child experiences repeated losses or noxious events early in his or

her life, the child develops a model of himself as fundamentally unlovable or incompetent,

resulting in pervasive hopelessness as characteristic of depression. Similarly, persons with

borderline personality disorder are often found to have disorganized attachments as a result of

early sexual abuse, emotional neglect, prolonged separations from primary caregivers, and/or

other types of early maltreatment.

Foundational Understanding of Attachment

Bowlby and Ainsworth laid the foundation of attachment theory, drawing light on the

prime importance of the bond between mother and infant. Their observations led to

significance in a child’s attachment and development:

Conditions especially referred to are… a mother's sensitivity to signals, and her timing of

interventions, and, on the other, whether a child experiences that his social initiatives lead

to predictable results, and the degree to which his initiatives are in fact successful in

establishing a reciprocal interchange with his mother. When all these conditions are met,

it seems likely, active and happy interchange between the couple ensues and a secure

attachment develops. When the conditions are met only in part, there is some measure of

friction and discontent in the exchanges, and the attachment that develops is less secure.

Finally, when the conditions are met hardly at all, grave deficiencies of interchange and

attachment may result. (p. 343-346)

or attachment to that figure” (Ainsworth et al., 1978, p. 17). This internal organization of

relating becomes a template for a person’s relational pattern throughout his or her life.

process of separation is represented intrapsychically.

Theory of Separation-Individuation

The theory of separation-individuation includes series of “successive reorganizations of

the mother-infant relationship over the first three years of life” (Lyons-Ruth, 1991, p. 1). Mahler

proposed that the infant first experiences herself as intrapsychically joined with the other, and

only gradually proceeds through a series of phases—autistic (later renamed “awakening”),

symbiotic, and separation-individuation (Mahler, 1971; Mahler & La Perriere, 1965; Mahler,

Pine, & Bergman, 1975). The end goal of this process is to achieve intrapsychic individuation

from the other (the infant perceives self and other as separate, stable entities) and to achieve a

certain degree of object constancy (the infant internalizes a positively cathected image of the

whereby the infant perceives an omnipotent fusion between the intrapsychic self and other with

only a dim awareness of the mother as external. The separation-individuation phase (from

approximately 5 months to 3 years of age) consists of four sub phases (differentiation, practicing,

the one hand, and to have mother magically fulfill [his] wishes without having to recognize that

help was actually coming from the outside, on the other” (Lyons-Ruth, 1991, p. 95). One would

observe a child in the rapprochement sub phase recoiling from his mother’s attempt to play and

engage in physical touch (this behavior is described as “ambitendency”). Mahler would describe

this behavior as “a fear of re-engulfment by the narcissistically invested,” where the child

envisions the mother as a dangerous other that will deflate his omnipotence (Lyons-Ruth, 1991,

p. 118).

Successful weathering of the rapprochement crisis marks the completion of the

separation-individuation phase. The infant achieves self and object constancy, relinquishes the

need for primitive, defensive splitting, and realistically perceives self and other as separate,

the mother’s careful attunement to the child’s progressive steps away (Mahler, 1971; Mahler et

al., 1965; Mahler et al., 1975). As described above, Bowlby and Ainsworth maintain that an

infant needs to experience a mother who is reliably and appropriately responsive to his needs in

rapprochement crisis. The child’s ambivalent feelings towards the mother are part of normal

development, according to Mahler, and can occur in the context of a secure attachment. Bowlby

and Ainsworth conceptualize this ambivalence as evidence of insecure attachment; the infant

does not feel secure in his attachment and will pull away from his mother because he is unsure

she will meet his needs.

Bowlby, Ainsworth, and Mahler would all perceive a child continuing to display

ambitendency as pathological. Mahler views rapprochement as a temporary crisis that, if not

resolved, can result in developmental arrest. Ambivalent relating maintained beyond the

rapprochement sub phase would be indicative of a borderline dynamic where separation becomes

associated with being emotionally abandoned by the object (Mahler, 1971). Bowlby and

development. Their theories diverge in the interpretation of ambivalent behaviors, but all

maintain that the infant’s achievement of separation requires an attuned, responsive other.

Mahler’s contribution remains pivotal in the development of attachment theory. She initiated a

organizes the infant’s internal experience and creates generalizable mental representations to

guide his independent functioning. In many ways, Stern’s theories fundamentally conflict with

those proposed by Mahler. Instead of a distinct intrapsychic separation between self and other,

Stern maintains that healthy separation ideally includes an intrapsychic connecting of a core self

with an other; it is increasing relatedness, in new forms.

Intersubjectivity

Stern proposes that intersubjectivity, or “sharing of subjective experience,” is possible

when the infant gradually comes to “sense that others distinct from themselves can hold or

entertain a mental state that is similar to one they sense themselves to be holding” (Stern, 1985,

p. 124). An infant recognizes that his internal experience can be shared with someone else when

Mutual regulation. An infant develops the ability to regulate her own affect by

developing an IWM of regulatory interactions with her mother. Beebe (2005) describes this as

“mutual regulation” to capture the bi-directional nature of regulation in that “each partner affects

experiences.

Self- and Interactive Contingencies

Another way an infant develops a coherent understanding of self and other is by

developing self- and interactive contingencies—forming expectancies of the world.

Contingencies involve an infant anticipating the consequences of his behaviors, particularly the

caregiver’s response, which “organizes the infant’s expectation the he can affect and be affected

by the partner” (Beebe et al., 2014, p. 30). It has been found that the development of expectancy

is a “powerful organizing principle of neural functioning” (Beebe et al., 2014, p. 31). These

contingencies align with Bowlby and Ainsworth’s initial postulations about how attachment

security is dependent on the infant’s ability to predict his caregiver’s responses to his attachment

moment-to-moment adjustments that each individual makes to changes in the partner's behavior.

This process is usually out of awareness" and is “bi-directional” (Beebe et al., 2014, p. 46). Both

self- and interactive contingencies ultimately allow an infant experience herself and world as

experiences her caregiver as available and appropriately responsive to her cues (i.e., crying); she

can predict both her caregiver’s and her own affective and behavioral responses (self- and

interactive contingencies). This pattern of intimate relating establishes coherent and adaptive

IWMs that can be generalized to all relational interactions. When the infant perceives discrepant

information (i.e., the mother is sometimes responsive, and sometimes not), the infant forms a

discrepant/disorganized IWM that could potentially result in the infant ambivalently relating to

or detaching from herself and others.

Disorganized attachment. Much of Beebe’s work focuses on the disorganized category

of attachment. When observing mother/infant dyads, Beebe and colleagues found that mothers

of infants with disorganized attachments “lowered their contingent touch coordination with

touch" (italics original, p. 57). Again, infants need to be able to predict that their mothers will

when distressed” and may result in dissociative processes (p. 56). This is consistent with

observations made in Ainsworth et al.’s (1978) Strange Situation Procedure; infants with

disorganized attachments respond to reunions with their mothers with unpredictable, incoherent

behaviors.

Beebe et al. (2014) invite the mother’s subjectivity into their discussion of the origins of

attachment security by exploring why mothers experience difficulty joining with the infant.

They suggest a mother’s own distress overwhelms her ability to evoke the infant’s painful affect

into her own body. The mother’s “own visceral response of distress disturbs her ability to enter

into, and to empathize with, the infant’s distress” (p. 152). This prevents the mother from

responding to and matching the infant’s affect and prevents the infant from forming a coherent

From the perspective of mutual regulation, psychopathology is likely to arise in situations

where there is persistent and chronic interactive failure. In these situations the infant is

forced to disengage from people and things because the infant has to devote too much

because they are used to preclude the anticipated experience of negative affect, even in

situations where negative affect might not occur. The infant gives up attempting to

appreciate the nature of the immediate situation and instead approaches new situations

already withdrawn and biased to act inappropriately. This severely constricts the infant's

engagement with the world, future options, and even autonomy and may lead to failure-

to-thrive, depression, and other forms of infant psychopathology. (p. 117)

This quotation complements Beebe’s formulation of attachment security by describing how

intimate patterns of relating can become defensive due to persistent interactive failures, or a lack

of joining between infant and caregiver. When these defenses are rigidly and pervasively

employed, the infant is no longer responsive to his or her environment. Rather, the infant

Tronick (1989) observed this in his Still Face Experiment. When infants failed to elicit

their mother’s regulatory behavior through “other-directed behaviors” (i.e., crying), the infant

began to self-comfort using “self-directed regulatory behaviors” (i.e., thumb sucking) (p. 114).

psychopathology” (p. 114).

The theoretical perspectives above present different frameworks from which to look at

caregiver response to infant sleep-related crying. Attachment theory provides a different

orientation to this phenomenon than that of behavioral modification programs, such as the CIO

technique. Behaviorists (i.e., Ferber) focus on changing crying behavior; whereas attachment

theorists focus on how crying is a representation of the attachment relationship and how sleep is

a separation that requires regulatory capacities and the negotiation of self and other

subjectivities. This attachment theory chapter shifts the paradigm from which to think about

crying, sleep, and caregiver response. Drawing behavioral and attachment theories together

theorists (Ainsworth et al., 1978; Beebe & Lachmann, 2014; Bowlby, 1969; Stern, 1985;

Tronick, 1980) present contrasting arguments. Cumulatively, they assert that an infant needs to

experience repeated affectual exchanges with a regulatory other such that he or she understands

explore.

Other questions surfaced by applying attachment theories to the phenomenon include the

following: what is the impact of the CIO technique on the infant’s intimate relating and

attachment pattern; when (whether it be age or developmental stage) can a caregiver expect their

infant to be able to fall asleep alone; what do sleep-related cries communicate; how does a

caregiver negotiate his or her own subjectivity (need to sleep) with that of the infant (need for

comfort/regulation). All of these questions will be explored in the Discussion Chapter of this

thesis.

CHAPTER IV

psychoanalyst was deeply informed by his initial career as a pediatrician. Winnicott joined the

psychoanalytic community in the early stages of the development of object relations theory. He

declared allegiance to Freudian and Kleinian theory, was supervised by Klein, and analyzed by

Kleinian analysts; but he continuously revised the essence of their theories.

One fundamental difference between Winnicott and Klein rests in the nature of

aggression. Klein posited that aggression manifests as a reaction to reality—a world that does

not coincide with one’s own subjective needs. Winnicott, on the other hand, maintained that

aggression actually creates reality and allows for both the infant and mother to recognize and

assert their own subjectivities (discussed below). Ultimately, Winnicott focused on the external

world of the infant, whereas Freud and Klein focused on the internal. The tension between Klein

Nature of the Mother/Infant Relationship

Winnicott emphasized that the formation and emergence of the self is based on the nature

of the mother/infant relationship. He coined the terms “primary maternal preoccupation” and

mother in a state of “primary maternal preoccupation.” During this period, the mother is

engaged in somewhat of a temporary psychosis in which she completely devotes herself to the

infant and suspends her own needs in favor of the infant’s. The mother is, in essence, creating an

“island” that allows for the infant to be absorbed in his or her own experience. The infant is in a

state of quiescence; her experience is simply held, observed, and responded to by the mother.

This allows the infant to develop a sense of omnipotence whereby the world completely adapts

to what he or she needs. When a need state emerges (e.g., hunger, discomfort), the infant

expresses the need in spontaneous gestures and the mother quickly responds to those cues. This

allows for the infant to develop his or her True Self (discussed below). Winnicott explains that

this instinctual phenomenon begins in utero and continues into the first months of life.

under “good-enough” circumstances, the mother naturally and gradually decreases her maternal

preoccupation, which exposes the infant to “external reality” and ultimately facilitates the

infant’s separation from the mother.

infant is able to simply live in a state of “going on being.” Greenberg and Mitchell (1983)

eloquently describe good-enough mothering as “an initial perfectly responsive facilitation of [the

infant’s] needs and gestures; a nonintrusive 'holding' and mirroring environment throughout

quiescent states (p. 198).”

After some time, the good-enough mother slowly recovers from a state of primary

maternal preoccupation and becomes more aware of her own subjectivity. She begins to lessen

her adaptation to the infant’s needs in a process Winnicott (1949) described as a “graduated

failure of adaptation” (p. 246). The mother does not promptly or consistently respond to the

infant’s every gesture. This results in the infant becoming aware of a reality that is outside of his

omnipotent control—the mother. This is the beginning of the infant’s separation from the

scenarios of not good-enough mothering essentially impinge upon the infant’s ability to

experience quiescence and omnipotence. As a result, the infant forfeits her own needs and

wishes in order to mold to the needs and demands of the mother.

experience and support his development. Instead, the infant becomes distracted by and invested

in the mother’s subjectivity, and disengages from his own needs.

Transitional Phenomenon

Good-enough mothering facilitates the transitional phenomenon—a state of being

between subjective omnipotence and external reality. In health, there is a continuous vacillation

between these two states throughout one’s life.

Subjective Omnipotence

Winnicott (1951) proposed that the infant begins life in a state of subjective omnipotence.

He describes this as an illusory experience in which the infant perceives external reality as under

his or her omnipotent control. The good-enough mother facilitates this experience by remaining

Object Relating and Object Usage

The infant begins by relating to the object. Initially, he internalizes part of the object,

integrating it into his internal structure that is under his control. Throughout this time, the infant

respectively.

Object Relating

The subject’s world, at first, remains unintegrated and populated by part objects. The

subject internalizes those part objects and experiences them as part of oneself, without a separate

subjectivity. This creates the subject’s intrapsychic structure. In order to begin relating to the

object, the subject projects the cathected part objects onto the object. The subject essentially

empties the self into the mind of the object, depleting the subject’s internal structures. The

object then becomes the meaningful host of the subject’s projected parts, allowing the subject to

find herself in and begin relating to the object. Winnicott (1969) describes the role of projection

in object relating as follows:

By internalizing and then projecting part objects into the world, the subject encounters

stimuli as parts of the self, not as separate. The object is related to as a “bundle of projections”

(Winnicott, 1969, p. 88). Benjamin (1995) describes how, during this stage in development,

Object Usage

The subject proceeds from object relating to use by placing the object outside of one’s

omnipotent control and into external reality. This happens after the intrapsychic destruction of

the object. By destroying the cathected object, the subject proceeds from a state of denial of the

reality of the object to an affirmation of an external other. With the recognition of the object as

separate, the subject is then able to use it. Here, Winnicott (1969) highlights the difference

between object relating and object use:

This thing that there is in between relating and use is the subject’s placing of the object

outside the area of the subject’s omnipotent control; that is, the subject’s perception of

the object as an external phenomenon, not as a projective entity, in fact recognition of it

spontaneous gestures (aggression), and she sets aside her own subjectivity (need to not have her

nipple bit) in favor of the infant’s (need to destroy her). Greenberg and Mitchell (1983) describe

how the “mother's nonretaliatory durability allows the infant the experience of unconcerned

As Winnicott states, there is no “waste-disposal” in this situation. The infant looses a balance

between the intrapsychic and intersubjective worlds, and instead lives in a world of fantasy.

If the object repeatedly survives the destruction, it subsumes the quality of a “surviving

object” (Winnicott, 1969, p. 93). This “contributes to the object-constancy” and signals to the

subject that the object can be used (Winnicott, 1969, p. 93). The surviving object becomes a

whole, enduring, and separate other, and no longer remains in parts within the subject’s psyche.

This usable other is communicated to and loved.

Intersubjective Understanding of Object Relations

Intersubjective theory, especially the work of Jessica Benjamin, extends Winnicottian

concepts by focusing on the subjective experience of the caregiver, and how the intersubjective

As the infant enters into this new awareness and begins to enact aggression towards the

caregiver, the caregiver experiences the child as changed—the infant is actively expressing his

independent will, not simply his needs. The caregiver initiates her own process of

agency and selfhood while simultaneously recognizing and respecting the child’s will. This is

the delicate dance of the good-enough mother—the graduation failure of adaptation,

acknowledgement of one’s hate, and the provision of the holding environment. Both caregiver

and infant must recognize and assert their separate subjectivities (Benjamin, 1995).

The achievement of mutual recognition allows for the power within the caregiver/infant

dyad to be dismantled. Neither partner retains omnipotent control over the other. Rather, this

intersubjective understanding allows the caregiver and infant to use and love the other, and

separation is achieved. This mutuality prevails with the object’s continued survival of

intrapsychic destruction. The dialectic need to both assert oneself and recognize the other is

inherent in all relationships.

Crying is an expression of a need state (as discussed in the Phenomenon Chapter).

Winnicott outlines how best to respond to an infant’s needs—the mother is at first primarily

preoccupied with the infant and completely adapts to the infant’s needs. The good-enough

Sleep training literature that endorses the CIO technique suggests that the infant achieves

the ability to sleep independently when the caregiver stops responding to the infant’s cries

(Ferber, 2006). Winnicott maintains that the infant is able to separate from the mother after

destroying the intrapsychic symbol of her—the cathected part object—and placing the object into

external reality. These are two fundamentally different ways to conceptualize independent

functioning. The former implies that the infant’s achievement independence from the caregiver

is dictated by the mother’s behavior, whereas the later asserts that separation is predicated on the

infant’s natural developmental process. Winnicott views the mother’s role as facilitating this

independence, not controlling it. How does one reconcile this conflict?

Winnicott theorizes that the mother prematurely imposing her own needs on the infant

negative psychological repercussions. In fact, research studies illustrate that an infant’s

maladaptive behaviors (e.g., tantrums and difficult eating behaviors) improve after the

implementation of the CIO technique (Adams & Rickert, 1989; Reid, Walter, & O'Leary, 1999).

CHAPTER V

prompt, predictable, and appropriately responsive caregiver in the formation of a secure

attachment. Theorists such as Beatrice Beebe and Daniel Stern integrate an intersubjective

perspective into attachment literature, inspiring a greater appreciation for the complex

negotiation between the mother’s subjectivity and that of the infant. They emphasize how this

interaction serves as the impetus for a mutually constructed sense of self and other. From the

object relations tradition, Winnicott’s work focuses on the intrapsychic impact of the

mother/infant relationship. He details how the attuned, good-enough mother facilitates the

infant’s conceptual development of self and other, how mother/infant differentiation naturally

manifests with the inevitable clashing of subjectivities, and how an infant transitions from

internal to external reality.

relationship as a whole, acknowledging the range of self-other tensions and the multi-faceted

impact of the environment. Finally, considerations about parenting strategies and clinical

approaches will be addressed in response to this analysis.

room, maybe steal him away. Maybe he will die. We knew of no particular identifiable,

significant trauma in his history.

Sarah listens as Noah expresses his mortal fears. She tries to show him she

understands his fear of somehow losing his connection with her and his dad. She tries to

reassure him that his world is not such a dangerous place. He listens to her, and his fears

continue.

In analysis, we start to realize that maybe, in part, Noah is seeing an aspect of our

world and its dangers that is barely tolerable to us all: to Sarah, to her husband, to her

analyst. Yes, of course he wants and needs some reassurance about his relative safety.

But also, perhaps, more acknowledgment of what he too clearly sees.

Noah then seems a little bit calmer. Still scared, but much more interested in talking to

her and in what she has to say.

Soon, in fact, the following conversation emerges at another bedtime:

Noah: But, mom, you love yourself more than me.

Mom: Well, ah, not really… I, ah, parents… love their children just as much as

themselves.

Noah: But, mom, I think I love myself more than you.

Mom: Well, that’s probably how it should be for kids. You need to love yourself a whole

lot, probably should love yourself best.

Noah continues to be very frightened of going to sleep.

During our next several analytic hours, Sarah continues to talk about how she

handled Noah’s fears—feeling pushed beyond the limits of her understanding by his

assertiveness, unable to think, overwhelmingly emotionally challenged. The analyst felt

between our love for ourselves and our connections with loved others; the self-other

tensions that intertwine with our whole sense of meaning, faith, and love, in the face of

everyone’s multiple agendas, as well as shared, background existential terror. He

to things and people apart from him. She contemplated the possibility of acknowledging,

in words he might grasp, that such a tension—such multiplicity, actually—existed inside

her. It seemed unquestionably to be a tension that Noah intuitively sensed.

A few nights later, Sarah told Noah: “You were probably seeing something more

clearly about me and you than I had realized… you saw that I love you as much as I can

imagine loving anyone. And there are also other things I love, and love to do—things

that sometimes take me into my own mind, sometimes away from you.”

Noah looks at her for a while. He nods his head, seeming to signal that he hears

her. He seems much calmer, nestles in, body relaxing, and soon falls asleep. Things

settle down. (p. 164-165)

psychoanalytic thinking in that the caregiver’s role is to adapt to the infant’s needs (Winnicott,

1960). Where psychoanalytic theory and the CIO literature diverge is in the interpretation of the

infant’s needs (as symbolically expressed through crying).

implicit detail for signals of need states. This attentiveness also facilitates the process of the

caregiver coming to “know” her infant (Beebe et al., 2014). The caregiver then aligns with her

intuitive understanding of her baby and her own capacities as a caregiver, and responds to the

cries/needs accordingly. This attuned listening is evident in the case of Noah and Sarah when

Sarah carefully attended to Noah’s need for a durable, whole object to use while falling asleep.

Sarah’s understanding of, holding, and responding to this need enabled Noah to self-soothe and

fall asleep.

This perspective opens up the possibility that the CIO technique is an appropriate

caregiver response to infant sleep-related crying. An attuned caregiver could sensitively read the

infant’s cry as the infant struggling with something it can definitively master—falling asleep

It is important to note that, irrespective of which theoretical lens one assumes, removing

oneself from the ability to listen to an infant’s sleep-related crying (as practiced in the CIO

technique), forecloses the opportunity to know the infant on a more intimate level. The

infant’s ability to really “know” him or her self.

The psychological etiology of crying extinction. Attachment and CIO literature differ

in how they explain the extinction of crying behaviors after repeated caregiver non-

responsiveness. As discussed in Chapter III of this thesis, early attachment theorists have

observed how children react to their caregiver’s absence with displays of protest, despair, and

ultimately detachment (Bowlby, 1973; Heinicke, 1956; Heinicke & Westheimer, 1966). On the

surface, the crying behavior observed during the implementation of the CIO technique mirrors

that observed by these theorists: the infant’s crying increases in intensity the first time the

caregiver does not respond to the cries, and proceeds to decrease after subsequent episodes of

nonresponsiveness until extinction.

Once detached, the infant’s crying behavior markedly decreases. This defensive strategy is

typically observed in infants with insecure attachments (Ainsworth et al., 1978). Notably,

insecurely attached infants can appear to function independently (e.g., falling asleep without the

crying extinction after repeated caregiver non-responsiveness as adaptive: the infant develops the

capacity to self-soothe and begins to function independently.

The difference between these two perspectives is striking. One asserts that crying

extinction following caregiver absence is adaptive and signals an increase in functional capacity;

while the other deems it to be indicative of a defensive structure that is associated with insecure

attachment and future psychopathology. If Sarah had not been appropriately responsive to

Noah’s expressions of anxiety and he began falling asleep without worry, would this indicate

adaptive, healthy development? Or would it indicate a defensive surrendering of Noah’s need

for his mother’s containment of his emotions due to her unreliable availability? Perhaps a closer

look at psychoanalytic theory about infant development, especially the relational and

the response of a mother practicing the CIO technique. Sarah remained both physically and

mentally present throughout Noah’s sleeping difficulties. From a psychoanalytic perspective,

Sarah’s attunement and “good-enough” mothering facilitated Noah’s development of self-

may experience emotional abandonment if the caregiver does not respond to his or her

expressions. Current attachment literature explains how an infant only knows his or her own

emotional experience when the caregiver joins with and matches the infant’s affect (Beebe et al.,

2014; Stern, 1985). If the infant has not experienced “good enough” joining, the caregiver’s

absence at bedtime could activate the infant’s primitive anxieties because the infant is not able to

understand, tolerate, or manage his or her own affective experience. These anxieties an only be

remedied by the caregiver’s attunement.

An infant can develop an intrapsychic representation of a regulatory other (a RIG or an

IWM) to guide his or her behavior in situations where the caregiver is absent (Beebe et al., 2014;

Stern, 1985). This representation is only developed after repeated experiences with an attuned,

caregiver prematurely stops responding to the infant’s sleep-related cries, the infant will most

likely resort to defensive strategies (e.g., detachment or dissociation).

The infant may also respond to the caregiver’s absence with annihilation anxiety. In the

annihilation of the infant’s internal object world because what was a reflection of his

intrapsychic world (the external presence of the caregiver) no longer exists. As a result, the

infant develops a defensive structure for protection—a False Self.

False Self. Crying is the assertion of a spontaneous need alive within the True Self. A

good-enough mother facilitates the development of the True Self by repeatedly holding, making

sense of, and implementing the infant’s omnipotent expressions (Winnicott, 1960). When the

good-enough mother presents the breast in response to the infant’s hunger cry, the infant is able

to remain in a state of spontaneous being and self-assertion, and to develop a healthy sense of

omnipotence. When the caregiver does not provide a good-enough environment, it shocks the

infant’s self and threatens his continuity of being. The infant feels as though his diffuse,

one positive and very important function: to hide the True Self, which it does by compliance

with environmental demands” (p. 146-147).

The infant of a caregiver practicing the CIO technique could experience the caregiver’s

jeopardizes the infant’s development of the True Self and forecloses on the opportunity for True

Self expression.

Caregiver hate. Humans have an innate tendency to protect their own self-interests

(Winnicott, 1949). This results in an inevitable clashing between self and other subjectivities

within all relational exchanges. This self-other tension necessarily applies to the caregiver/infant

dyad and manifests when the infant’s need for the caregiver to respond to his or her sleep-related

cries conflicts with the caregiver’s need (e.g., to sleep or have intercourse). It is only natural for

the caregiver to respond to this intersubjective tension—the emergence of differing

subjectivities—with hate.

Winnicott (1949) evocatively writes about how the mother “hates the infant from the

advised in sleep training literature (Ramos & Youngclarke, 2006)—it promises the rapid

satisfaction of the caregiver’s needs.

The caregiver does not recognize his or her own hate at first. The good-enough caregiver

likely responds to the infant’s every sleep-related cry, completely adapting to the infant’s needs.

Over time, the caregiver gradually recovers from the state of primary maternal

preoccupation and his or her own subjectivity slowly comes into view (Winnicott, 1960). During

this process, the caregiver starts to notice how the infant’s sleep-related cries pull the caregiver

away from his or her own life (e.g., the marriage or the ability to be rested enough to work).

Such self-other tension results in the experience of hate; the caregiver hates the infant for crying

because it interferes with the caregiver’s self-interests. At this point, the caregiver might be

compelled to stop responding to the infant’s cries and to begin letting the baby CIO. This

scenario is natural in that the caregiver senses that letting the baby CIO is developmentally

appropriate.

by repeatedly attempting to destroy the object. If the object survives the infant’s attacks and

proves itself to be durable, the infant is able to integrate the good and bad part objects into a

whole enduring object (thereby attaining object constancy). In this scenario, the infant never

dyad is essential in this process (as evident in the case analysis above). The caregiver’s

negotiation of his or her own transitional experience and ability to recognize and tolerate his or

her intersubjective separateness directly affects the infant’s development. If the caregiver does

not successfully navigate the self-other tensions that inevitably occur, the caregiver might make

his or her hate/separateness known to the infant prematurely. That hate could manifest as the

caregiver not responding to the infant’s cries; and the infant might interpret this lack of response

as retaliation, thereby halting the infant’s development. Retaliation would overwhelm the

infant’s ability to hold onto the soothing, good part object representation of the caregiver and

would prevent the infant from progressing into a transitional experience.

It is also possible that a caregiver who cannot recognize or tolerate his/her separateness

One might argue that an infant’s sleep-related cry could sometimes be the external

manifestation of the intrapsychic destruction of the object. Since sleep is a primary location of

separation, the infant may attempt to destroy the object when trying to fall asleep in effort to

retaliatory bad object act against the infant’s True Self expression—crying. Either way, it seems

as though letting an infant CIO before the infant has entered into a transitional experience and

has obtained object constancy could hinder the infant’s intrapsychic development of self and

other and capacity for separation.

Graduated failure of adaptation. It has been established that the caregiver’s premature

imposition of her own needs or unveiling of her hate towards the infant negatively impacts the

infant’s psychological development (Winnicott, 1949; Winnicott, 1951). It is also true that the

good-enough caregiver eventually, and only gradually, makes his or her own subjectivity known

to the infant by entering the stage of “graduated failure of adaptation” (Winnicott, 1951). It

could be then that letting the infant CIO is part of the caregiver’s graduated failure of adaptation

inflexible and indiscriminately expressed False Self personality, an insecure attachment, and

later psychopathology (Beebe et al., 2014; Winnicott, 1960). If the caregiver does not engage in

a graduated failure of adaptation in a good-enough way, the infant’s development is arrested.

access to both himself and the external world. Without this, the infant may have a traumatic

encounter with reality; instead of it being graduated, it is sudden, unexpected, shattering, and

annihilating.

This understanding of graduated failure of adaptation begs the question—does the CIO

technique qualify as a graduated failure of adaptation, or does the CIO technique cause the infant

to prematurely and abruptly encounter objective reality? Perhaps Ferber’s (2006) “Progressive

Waiting Approach,” where the caregiver waits to respond to the baby’s nighttime wakings at

progressive intervals on subsequent nights, more closely resembles Winnicott’s (1969) graduated

failure of adaptation. But, the way Winnicott and other psychoanalytic theorists describe good-

enough caregiver responses is more based on an intuitive knowing of self and other than it is on a

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