Encopresis

(2013).
Psychoanalytic Psychology, 30(3):438-455

Encopresis Happens: Theoretical and Treatment Considerations
from an Attachment Perspective
Geoff Goodman, Ph.D.
The psychoanalytic literature has discussed many dynamic
aspects of encopresis, but no one has explored the meaning of the
underlying insecure attachment patterns that predispose the child
to encopresis. This article offers an attachment perspective to
understand the etiology of primary encopresis and suggests
relationship-focused intervention strategies to break through the
child's fortress of denial, omnipotent control, and sadomasochism
designed to create emotional distance from the therapist. Two
clinical cases of primary encopresis are presented to illustrate the
severe relationship difficulties that inevitably develop between
therapist and patient and the countertransference reactions likely
to emerge. In both cases, traditional interpretive strategies were
ineffective in establishing an emotional connection. Instead,
engagement through imaginative play and humor were used to
draw these children out of their defensive hiding place and bring
them into a genuine, reciprocal relationship with a person who
could help them to regulate underlying painful affects such as
separation, rejection, and loss. Traditional interpretive strategies
can be attempted only after the patient's capacity to mentalize
these affects has been revived.
The psychoanalytic literature has paid only sporadic attention to the
symptom of encopresis. Authors have expressed various points of view
regarding its etiology and treatment. One view suggests that encopresis is a
side effect of anal masturbation with the child's
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I gratefully acknowledge the assistance of Marcia Miller, Chief Librarian at
Weill Medical College of Cornell University—Westchester Division, in
locating and obtaining reference materials, and Tina Lo in checking
references. I also gratefully acknowledge the poignant comments of John
Rosegrant, PhD, on a previous draft and the clinical supervision of Thomas
Lopez, PhD, on the two clinical cases presented here. This work was
supported by two generous grants from the Association for Child
Psychoanalysis and the Jennie Dugan Fund of the Contemporary Freudian
Society.
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feces as the stimulating object (Aruffo, Ibarra, & Strupp, 2000). The
motivational force is the libidinal gratification that the child receives from
engaging in this behavior. The recommended treatment consists of developing
a therapeutic atmosphere in which the child feels comfortable talking about
his or her bowel movements so that the therapist's interpretation can move the
child along to the oedipal stage of psychosexual development. A second view
suggests that encopresis is an expression of the child's anger toward his or her
parents, who do not tolerate verbal expressions of anger (Edgcumbe, 1978).
Again, the therapist's interpretation is the vehicle through which conflicts
among the anal aggressive pleasures, superego pressures, and the demands of
the parents in reality can be resolved in favor of renouncing anal gratification
for genital gratification. A third view suggests that encopresis reflects either a
developmental arrest or a regression from the Oedipus complex, specifically,
castration anxiety (Barrows, 1996; Shane, 1967). The therapist's
interpretation of this anxiety brings about the working-through process in
which “both soiling and wetting gradually … disappear” (p. 307). A fourth
view suggests that encopresis is related to “separation from the maternal
figure” (Bemporad, Pfeifer, Gibbs, Cortner, & Bloom, 1971, p. 282). The
child retreats into a fantasy world to compensate for loneliness while using
encopresis to protest the mother's separation.
All these views hold merit in developing our understanding of the etiology
and treatment of encopresis. My aim is to examine this symptom from the
perspective of attachment theory, developed by the British psychoanalyst,
John Bowlby. Attachment theory conceptually overlaps with contemporary
relational theory in the sense that both theories recognize the supreme
importance of early relationships in developing mental representations, which
in turn play important roles in the individual's ability to regulate negatively
valenced emotions such as fear and stress using available relationships
(Goodman, 2002, 2005). This transactional model of the interplay between
relationships and mental representations subsumes both theories and can be
used to illuminate the etiology and treatment of various psychological
disorders such as borderline personality disorder (e.g., Bateman & Fonagy,
2004b). The application of attachment theory to an understanding of
encopresis would make a novel contribution because in contrast to the
prevailing drivebased explanations, attachment theory would provide a
relationship-based explanation.
A relationship-based explanation for understanding the etiology and
treatment of encopresis is largely absent from the literature. The keywords
“encopresis” or “fecal incontinence” and “attachment” identified no articles
in the PsycINFO database and only one article in the PEP database (Y.
Cohen, 1997). That article used an idiosyncratic definition of attachment as
“social fittedness” (p. 255) and focused on the merits of residential treatment,
not on encopresis.
This article focuses on only one type of encopresis—primary encopresis.
According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR; American Psychiatric Association [APA], 2000), primary
encopresis describes those children who never achieved bowel control.
Children diagnosed with primary encopresis are considered to be more
poorly functioning than children diagnosed with secondary encopresis (the
loss of previously attained bowel control). Previous authors (Anthony, 1957;
Lustman, 1966; Shane, 1967; Sugarman, 1999) described primary
encopretic children as having poorly functioning egos and disorganized and
uncontrolled behavior. The consensus is that children with primary
encopresis have a more primitive personality organization than children with
secondary encopresis.
I will argue that primary encopresis originates in the child's early
attachment relationships with his or her parents. A disturbance in these early
relationships creates vulnerability to the development of various symptoms at
later points in development. The
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shift in etiological focus from castration anxiety (Barrows, 1996; Shane,
1967) to anxiety about the attachment relationship necessitates an associated
shift in treatment focus from the interpretation of intrapsychic conflict to the
affective containment and regulation of conflicts expressed in the therapeutic
relationship. How would a treatment model that emphasized the therapeutic
relationship over transference interpretation work for a child diagnosed with
primary encopresis?
The features of encopresis seem tailor-made for attachment theory. Key
attachment concepts such as contact-maintenance, separation, and loss (the
obverse of attachment) are all present in the symptom. Retention reflects a
child's maintaining contact with a valuable object—feces. Separation
naturally occurs whenever the child has a bowel movement. Loss occurs
whenever the parents or child dispose of the child's feces. Every experience
of defecation represents the practicing of separation and loss for the child.
According to attachment theory, the parent provides what Bowlby called a
“secure base” for the child when his or her attachment system is activated,
typically during moments of perceived danger (e.g., loss, separation, fear,
stress, injury, fatigue, illness, or punishment; Bowlby, 1973; Main, Kaplan,
& Cassidy, 1985). The child achieves a feeling of security by seeking
proximity and maintaining contact with the primary caregiver. Fonagy and
Target (2003) underscored a subtle but important difference between Bowl-
by' s theory of the secure base and Fairbairn's (1952) theory of object-
seeking. In attachment theory, the goal of the child is not the parent, as in
Fairbairn's object relations theory, but rather a feeling of security or
closeness to the parent facilitated by the parent's proximity (see also Sroufe
& Waters, 1977). This subtle shift in understanding about the child's primary
motivation positions attachment theory as a theory of affect regulation rather
than a theory of object-seeking. By seeking proximity to a secure base, the
child is engaging in affect regulation. When the attachment system is activated
—experienced as a feeling of extreme anxiety—the child uses his or her
secure base to deactivate this system and return to homeostasis—experienced
as a feeling of security.
The parent can demonstrate three different patterns of behavior that relate
to her secure base function. According to Fonagy and his colleagues (Fonagy,
Gergely, Jurist, & Target, 2002; Gergely, 2000), the parent can contain
their child's anxiety by making facial expressions and vocalizations that
reflect the painful affect, yet indicate through these behaviors that the parent is
not actually feeling the painful affect herself (reflective mode). In the second
pattern, the parent can have difficulty containing this anxiety so that it leaks
into her facial expressions and vocalizations without any indication that the
parent is not actually feeling the painful affect (psychic equivalence mode). In
the third pattern, the parent can also have difficulty containing this anxiety, but
rather than reflecting it back without any marking, she instead reflects a
completely different feeling—usually positive affect—which produces a
disconnect between what the child is feeling and what the external world is
reflecting back (pretend mode).
Goodman (2010) argued that these three different patterns of parenting
behavior are directly related to three different patterns of children's affect
regulation discussed in the attachment literature. Marking is associated with a
secure (B) attachment pattern, a balanced pattern of affect regulation. On the
other hand, the anxious-resistant (C) attachment pattern corresponds to a
hyperactivating pattern of affect regulation, whereas the anxious-avoidant (A)
attachment pattern corresponds to a deactivating pattern of affect regulation
(Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993; Kobak &
Sceery, 1988; Main, 1990).
I am suggesting that children with primary encopresis use a deactivating
pattern of affect regulation and ignore painful signal affects (distress cues)
such as anxiety by focusing on the pleasure associated with the retention and
release of feces. Focusing on
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the pleasure derived from one's own bodily products simultaneously distracts
the child from painful affects and obviates the need to rely on the parents to
deactivate the attachment system. The child can also develop a sense of
mastery over separation and loss with his or her feces while ignoring the
experience of vulnerability and shame associated with parental rejection and
loss.
Overdependence on these affect regulatory processes is common.
Addictions, whether based on external substances or bodily functions, all
serve the purpose of denying painful affects such as anxiety caused by early
parental rejection (Flores, 2004). In the psychoanalytic encopresis literature,
anal masturbation associated with encopresis has also been referred to as an
addiction (Meltzer, 1966). Aruffo and his colleagues (Aruffo et al., 2000)
concluded, “An encopretic child is like an alcoholic who demands the right to
drink and will do so no matter who tries to stop him” (p. 1347). Encopretic
children demonstrate “remarkable constriction of affect” (Sugarman, 1999, p.
500), turn to feces as a substitute for people (Edgcumbe, 1978), as a comfort
in the face of disappointing caregivers (Rosenfeld, 1968), and as an attempt
to regain “a state of well-being” (Rosenfeld, 1968, p. 48). In summary,
encopresis coopts affect-regulatory functions normally served by the parents,
offers a pleasure pathway that dulls distress cues and keeps the attachment
system deactivated, and thus becomes increasingly resistant to change.
Of course, not every child with a deactivating pattern of affect regulation
develops primary encopresis. Other factors must also make a contribution to
the development of this symptom. The deactivating pattern of affect regulation
creates a general vulnerability (Rutter, 1985, 1987) that combines with other
risk factors in the development of primary encopresis. For example,
encopresis is four to six times more prevalent in boys than in girls (Anthony,
1957; Schaefer, 1993). Theories that characterize mothers as encouraging
sons' separation from them earlier than daughters (Chodorow, 1978) and
fathers as socializing sons but not daughters to repudiate the mother
(Benjamin, 1987) might account for a greater tendency among male toddlers
to demonstrate a deactivating pattern of affect regulation (see Aber & Baker,
1990). Greater neurological vulnerability in boys (Bemporad et al., 1971),
as well as genetic differences in reactivity to anal stimulation (Lustman,
1956), might also play moderating roles.
The parents' response to encopretic behavior might also contribute to its
selection as the child's primary method of self-regulation of painful affect.
Parents who perceive this behavior as a provocation and respond in kind
provide the child with negative attention that can also serve affect-regulatory
functions. Knowing from experience that the parents cannot provide the
emotionally responsive caregiving necessary to deactivate the attachment
system, the child comes to rely on the parents' enraged responses as an ersatz
substitute for emotionally responsive caregiving to facilitate affect regulation.
Bowlby's (1982) “goal-corrected partnership” between toddler and parent,
which consists of a negotiation between security and exploration needs,
becomes mutually antagonistic. Many psychoanalytic authors have noted
sadomasochistic interactions during this developmental phase as a core
feature of encopretic children (Aruffo et al., 2000; Forth, 1992; Meltzer,
1966; Schoenewolf, 1997; Shane, 1967; Sugarman, 1999). Retention and
release therefore acquire additional meanings, including punishment of
parents, omnipotent control of parents, and self-punishment. These additional
meanings, however, obscure the original function of encopresis: affect
regulation without outside assistance.
To treat encopresis, an attachment-based treatment model would address
the underlying vulnerability created by the deactivating pattern of affect
regulation. The therapist accomplishes this treatment goal by (1) using his or
her relationship with the child to modify the deactivating pattern and (2)
mentalizing the child's affects through the process
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of marking to establish mental closeness. The child would begin to use the
therapist to facilitate affect regulation and consequently diminish the use of
encopresis for this purpose. Because of deficits in symbolic function
associated with nonoptimal patterns of affect regulation, an attachment-based
treatment model would diminish the role of interpretation (P. M. Cohen &
Solnit, 1993; Lewis, Amini, & Lannon, 2000; Rosegrant, 2001) and
accentuate the role of the therapeutic relationship in healing these
affectregulatory processes.
In the following two clinical illustrations, I began making headway with
these encopretic children only after I prioritized my relationship with them
and made myself available as an affective container and regulator rather than
an interpreter of intrapsychic conflict. I constantly sought ways of making an
emotional connection with them—to give them a taste of a genuine, reciprocal
relationship. Like a baseball player waiting for the perfect moment to steal
second base when the pitcher is not paying attention, I tolerated seemingly
endless sadomasochistic interactions, waiting out my opportunity to make
authentic contact while going unnoticed. This process consisted of pursuing
emotional contact in the face of devaluation, rejection, and withdrawal, often
using humor to “mark” these affective expressions. Humor permitted me to
show my patients that (1) I understand what you are feeling (connection), and
(2) I can symbolize your feeling in a playful manner even though I am not
personally experiencing the same feeling (separation). Affects then become
mentalized—represented verbally in the minds of both therapist and patient.
I hope to demonstrate that keeping the child firmly in mind through
“retaining mental closeness” (Bateman & Fonagy, 2004a, p. 44) facilitated
these patients' shift away from relying on encopresis for affect regulation
toward relying on me, and later, their parents and peers, for this purpose.
These patients no longer felt compelled to control the anxiety associated with
separation and loss so rigidly, manifested somatically in their encopretic
symptoms of retention and release. The play process took place in a potential
space where our play overlapped (Winnicott, 1968), offering a pathway to
explore relationships one step removed from reality (Mayes & Cohen, 1993)
by testing out new ways of relating to me and regulating affect through me and
by forming new expectations of affective responses from me. According to
Bateman and Fonagy (2004b), the play process enables “feelings and
thoughts, wishes and beliefs [to] be experienced by the child as significant
and respected on the one hand, but on the other as not being of the same order
as physical reality” (p. 84). This process naturally facilitates symbolic
functioning, where words can encode unnamed affects and thus provide
affective containment.
First Clinical Illustration
Maverick (a pseudonym) was a 4[1/2]-year-old boy who was
experiencing toilet-training difficulties. He had bowel movements during the
day and night in his underwear. These accidents occurred at school, on the
school bus to and from school, and at home. Maverick could sit in his own
products for hours and not seem uncomfortable. When a classmate asked him
what that smell was, Maverick told him, “Just ignore it.” He also experienced
interpersonal difficulties. Maverick needed to control all his interactions with
his peers as well as with adults. Other children did not want to socialize with
Maverick because the play had to take place on his terms, with his choice of
activity and his rules. The parents and teacher reported that Maverick often
refused to follow directions, particularly when someone asked him to
transition from one activity to another (e.g., watching TV to going
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to bed, eating breakfast to leaving for school, playing with peers to sitting at
circle time). After two years of once-per-week individual psychotherapy with
me in which Maverick made only modest gains, I began four-times-per-week
psychoanalysis, recognizing Maverick's strong intellectual skills and stable
family system. Maverick was now 6[1/2] years old.
Most disturbing to his parents was Maverick's aggression directed toward
his brother, who is 2[1/2] years younger. When his brother wanted to inspect
one of Maverick's toys, Maverick would hit him hard enough to make him cry.
When Maverick's mother changed his brother's diaper, Maverick would
sometimes hit his mother. Maverick's use of aggression was not limited to his
brother or mother; he also sometimes hit his school peers when they refused
to play his games by his rules.
This aggression was not always reactive. In school, Maverick once threw
a live bunny against a wall for no apparent reason. When I asked about the
incident in the following session, Maverick expressed anger that the teacher
later refused to allow him to hold a baby chick. Maverick then demonstrated
this sadistic impulse in vivo by gleefully knocking onto the floor a Russian
matryoshka of cats, which he referred to as a mommy cat with her baby cats.
He described that a bad guy savagely attacked the mommy cat, who died
along with her babies. At the end of the session, Maverick instructed me to
pick up all the cats because “I like to order you around.”
To myself, I interpreted this play to mean that Maverick was feeling
completely unprotected by his secure base—his mother—and had mobilized
anger to counteract this feeling. Maverick's play suggests that he had no
secure base—his mother could not protect him from danger. The frightening
quality of this play also suggests that Maverick had formed a disorganized (D)
attachment relationship that over the years had become controlling-punitive
(Main & Cassidy, 1988). In a controlling-punitive attachment relationship,
the child has no confidence in his or her parent, feels utter helplessness in the
face of threat (Lyons-Ruth & Jacobvitz, 1999), and often reverses roles
with the parent to feel in control (Main & Cassidy, 1988). This strategy
reflects a deactivating pattern of affect regulation in which the child ignores
signals of danger by taking charge of the environment and refusing to rely on
others for help.
During other sessions, Maverick demonstrated possible indications of
trauma. While playing Uno or board games, Maverick would often upset the
game board and fling all the pieces and the board itself all over the office
without warning. He called this event “Hurricane Floyd”—a metaphor for his
chaotic mental state as well as his accidents. I later learned from his parents
that at age 2[1/2], Maverick's family had fled their home during Hurricane
Floyd, which terrified him. When asked about this incident, Maverick
reported that he remembered Hurricane Floyd and how loud the thunder and
wind were. He disclosed that he remembered his parents looking scared. He
then made a statement that he immediately retracted: “God was trying to get
me and my mommy.” Maverick's baby brother was born only 4 months
earlier, which I surmise placed stress on Maverick's mother. Maverick was
probably experiencing this new brother as the loss of emotional closeness
with his mother: the new baby required enormous amounts of attention that
Maverick was no longer receiving. From an attachment theory perspective,
Maverick might have perceived this new baby as a threat to his secure base.
With the secure base less emotionally and physically available, Maverick
was already probably feeling worry about his safety as well as anger toward
this new intruder. The hurricane only exacerbated these feelings, making them
more palpable. I believe that eventually, these feelings necessitated
Maverick's retreat from a normal developmental line (toilet-training) to his
encopretic symptoms, which allowed Maverick to self-regulate his affects of
unmentalized
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anger toward his unprotective parents and his unmentalized need for attention.
Over time, Maverick became skillful at deactivating unpleasant feeling states
through these symptoms.
In my early work with Maverick, I tried to contain his chaotic, hurricane-
like feelings of anxiety and rage by empathizing with him. Maverick
responded to this containment by becoming more organized in his play; the
hurricane-themed aggressive play eventually disappeared. Maverick's
encopresis, however, continued unabated. Both parents expressed impatience
and frustration with the lack of immediate results; they wanted these
behaviors to stop as soon as possible. During a collateral parent session,
Maverick's mother clearly articulated the emotional impact of this symptom
on her—“I want to kill him!”—which also reflected her inability to contain
and regulate his affects and thus reinforced the symptom in a vicious cycle.
I was feeling intense pressure from this exasperated mother to solve the
problem of the encopresis quickly; otherwise, she would surely end the
treatment as Maverick suspected. In the session that followed, Maverick was
preoccupied with saying “bye-bye” over and over again. I responded by
stepping up my interpretation of the aggression I felt certain was
unconsciously responsible for this boy's refusal to be toilet-trained.
Simultaneously, I moved away from the relationship-building work that
proved so effective earlier in the treatment. Maverick responded by
withdrawing from me—a kind of iatrogenic negative therapeutic reaction. I
believe that I fell victim to his mother's projective identification of her own
feelings of incompetence, inadequacy, and disillusionment partly because I
was experiencing those very feelings in myself: in spite of progress, the
encopretic symptoms were not remitting. His mother's projection into me of
unwanted aspects of her own parental representation exploited my own
vulnerability.
The unconscious purpose of my confrontational interpretations was to
coerce Maverick to start behaving properly rather than to help him to try out a
new mode of relating and to mentalize his affects. Fortunately, Maverick's
desire to come to sessions never wavered; instead, he protected himself
during sessions through withdrawal. He would play by himself in a corner.
How could I empathize with his mother's frustration, impatience, and
devaluation of the treatment, and not act on the pressure she was exerting on
me to change my method of working with Maverick? This sort of tightrope
walking became my primary challenge. Maverick began to interact with me
once again and reveal his internal world to me, and his mother experienced
less frustration and impatience. For example, he could once again allow me to
assume the voice of the Lego robot he was building and interact with me
through the Lego robot. This play had completely stopped during my
confrontational phase.
Analysis of First Clinical Illustration
Maverick's severe psychopathology, coupled with high intellectual
functioning, warranted an intensive, relationship-focused therapy that could
activate the chaotic and later controlling mode of relating in the therapist-
patient relationship. In the early phase of treatment, this approach served a
containing function for Maverick. He played the role of God, wreaking havoc
on a scared, helpless child played by me. Rather than trying to reestablish
control (deactivating pattern), I empathized with Maverick's scared, helpless
feelings (more hyperactivating pattern). This experience of containment
facilitated Maverick's use of me as a secure base—someone who, like an
attachment figure, could make him feel safe to explore his own mental
contents as well as mine. I also acted as a hyperactivating foil to his
deactivating pattern of affect regulation, defying his expectations
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stored in implicit memory. With children diagnosed with primary encopresis,
the therapist needs to offer a pattern of affect regulation on the more
hyperactivating end of the continuum to challenge the deactivating pattern that
will come to dominate the treatment (Goodman, 2010).
In the next phase of treatment, Maverick's mother introduced her
interpersonal dynamics into my relationship with Maverick. The frustration
and impatience that she was expressing to me resonated with my own
intrapersonal dynamics, producing a shift in my intervention strategy to
essentially a behavioral intervention implemented through a coercive focus on
Maverick's aggression. Through my own use of reflective functioning
(Fonagy et al., 2002), I recognized this enactment and implemented the
original intervention strategy. I attempted to contain his mother's feelings of
helplessness and embarrassment produced by fragmented mental
representations established in the context of her own childhood familial
relationships.
In the final phase of treatment reported here, I resumed my relationship-
building work with Maverick. Maverick responded by orienting toward me
again and using me as a secure base who permitted affective expression and
provided affective labeling. Maverick needed and benefited from intensive,
relationship-focused therapy. I quickly learned that my first shift in approach
had adversely affected the treatment. Because of my awareness of options, I
was able to consider moving away from a focus on behavior back onto a
focus on the child's mind. Like the baseball batter who experiments with a
different stance at the plate and figures out it is not working for him and so
returns to the old stance, I returned to the stance that had been working for me.
Although he left treatment before I felt he was ready, Maverick was no
longer defecating in his pants, had begun making friends at school, and was no
longer hitting his brother. Maverick's parents were feeling increasingly
uneasy about the potential stigma associated with their son's participation in
psychotherapy as he approached preadolescence—no doubt reflecting their
own discomfort with psychotherapy and, in their minds, its incrimination of
their parenting behavior. Five or so years after termination, I heard from
Maverick's mother. He was excelling at school and had a small group of close
friends. Apparently, he had learned to rely on others to help him regulate his
emotional states—perhaps begun in his therapy with me.
Second Clinical Illustration
Dennis (a pseudonym) was a 5-year-old boy referred to me for outpatient
psychotherapy by his parents. In the initial consultation, Dennis's parents
expressed exasperation at their only child's stubbornness, expressed in his use
of pull-ups for defecation instead of a toilet. They feared that Dennis's
toilet-training refusal was going to interfere with his self-esteem as he was
beginning kindergarten in the fall. At the time of referral, Dennis was
attending preschool for a full day, five days per week. Before this placement,
Dennis had attended a different preschool for a full day, five days per week
since age 2. His mother shared this information with me nondefensively,
never having considered the possibility that a very young child might need
more physical and emotional proximity to his secure base. I said nothing
about this arrangement because both parents had already shared with me their
need to work full-time. In the course of treatment, I also learned that the
parents did not have relatives nearby such as grandparents (i.e., secondary
attachment figures) with whom they could leave Dennis while at work.
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Dennis's parents reported that he had never been toilet-trained. At the time
of the initial consultation, Dennis had used a toilet “a handful of times,”
according to his mother. His parents reported that they had attempted toilet
training since Dennis was 3 by rewarding Dennis for using a toilet with
M&Ms or toys, which had only a temporary impact on his behavior. Out of
exasperation, Dennis's father sometimes used threats to get him to conform to
their expectations of using a toilet, for example, “I'm going to put you down
the drain.” He also admitted to kicking Dennis in the buttocks after some
accidents.
On the other hand, Dennis's mother sometimes behaved in ways that
allowed him to receive gratification from the encopresis. At the time of the
initial consultation, Dennis's mother was still cleaning up his accidents,
wiping him and putting new pull-ups on him. His parents' description of this
routine strongly suggested that Dennis enjoyed playing the role of the baby
with his mother, who readily shared her exasperation with me even with
Dennis in the office. His parents also reported other symptoms suggestive of
oppositional behavior and a need for control, such as refusal of food
presented to him at the dinner table, resistance to getting dressed in the
morning, and resistance to getting ready for bed. Dennis also had an obsession
with toy monster trucks, monster truck rallies (which he attended with his
father), and monster truck video games. What was originally a father-son
activity evolved into a devotion that far exceeded the father's interest. Dennis
stated that he wanted to be a monster truck driver when he grew up.
I treated Dennis for five years in once-per-week individual psychotherapy.
This therapy included working collaterally with his parents to agree on a
uniform behavioral approach to Dennis's difficulties and working with Dennis
individually to allow him to express any feelings that might be motivating his
reluctance to use a toilet. Since the initial referral, both parents had made
amazing progress in adjusting their behavioral approach to Dennis's toileting
difficulties. His father stopped making threats, while his mother stopped
cleaning Dennis after accidents, instead getting him to clean up after himself.
Dennis began to express angry feelings in therapy sessions, which coincided
with his increased use of the toilet. During our psychotherapy, Dennis
experienced some successes while sitting on the toilet and showed pride in
these successes. Nevertheless, Dennis still experienced accidents, which
prompted his parents to welcome the prospect of a more intensive,
relationship-focused treatment. Thus, I began four-times-per-week
psychoanalysis with Dennis at age 10. The parents were enthusiastic about
Dennis's beginning psychoanalysis. I initiated psychoanalysis because of
Dennis's high intellectual functioning: I believed that he could eventually
tolerate my attempts at symbolizing his mental contents such as monster
trucks, which I could use to represent internal feeling states. I hoped that this
work would eventually cultivate Dennis's own capacity to symbolize (i.e.,
verbalize) his feelings and reduce his need to act out his feelings by having
accidents.
At the onset of psychoanalysis, Dennis used the defensive processes of
isolation of affect and omnipotent control to exert the maximum degree of
control over his internal and external world. Consistent with a deactivating
pattern of affect regulation, Dennis was able to put his feelings into a
compartment and leave them there for long periods of time, which gave him
an illusory feeling of control. He also behaved as though he were more
powerful than I and could therefore order me around. For example, I had to
hold Dennis's toy monster trucks in a particular way; disobedience resulted in
withdrawal and complete emotional unavailability. He seemed to use
encopresis as a mode of distancing himself from others and forcing others to
distance themselves from him when he or they were getting too emotionally
close and therefore making him feel too emotionally vulnerable.
Paradoxically, these distancing strategies also maintained emotional
involvement, even though the involvement was antagonistic. Dennis learned
that fecal smells are an
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effective means of removing others from one's proximity, while keeping him
emotionally present in their minds as an antagonistic figure. I noticed Dennis's
needs for emotional distance and invincibility coexisting with his needs for
emotional closeness and camaraderie with me. Getting too close to me
emotionally put Dennis at risk of getting rejected or abandoned by me. These
are some of the most painful feelings experienced by human beings. I surmise
that Dennis experienced these feelings every morning before his parents
dropped him off for a full day of childcare at age 2, at around the time of his
parents' initial attempts at toilet-training.
My countertransference reactions were consistent with a therapist who
was perpetually assigned a masochistic role to play: I felt helpless,
disillusioned, ineffectual, frustrated, humiliated, dismissed, marginalized, and
invisible. Typically, I did not feel all these feelings in the same session, but
invariably, I felt at least one of these feelings in every session. My
countertransference reactions were notable because unlike many of my other
therapeutic relationships, I knew exactly what I was feeling in a session with
Dennis. There was no ambiguity. In spite of my knowledge of the origins of
Dennis's psychopathology, I still found my responses to these
countertransference reactions at times challenging. For example, Dennis once
intentionally threw a ball at my face and hit me in the eye. When I pointed out
that he had hurt my eye, he started making clucking noises that indicated that
he thought I had stopped playing because I was chicken, afraid of getting hurt.
I felt not only angry but also too stunned to say anything other than to stop the
play. Perhaps I was afraid of expressing my own anger—no matter how
justified it might have been as a self-protective response.
Feelings of helplessness induced in me by Dennis led me at various points
in the treatment to consider reducing treatment frequency to prepsychoanalysis
levels. Self-reflection, however, always helped me to analyze these moments
of countertransference and to recognize them for what they were: self-
protective attempts by Dennis to push me away and thus diminish his feelings
of vulnerability. Disdain was perfectly suited to accomplish this self-
protective goal. In those moments when Dennis was feeling disdainful of me,
sometimes it was good enough to act as simply a container rather than a
retaliator. Retaliation would only gratify his need for engagement through
control without the dreaded experience of any accompanying feelings of
vulnerability elicited by the risk of loss of control and by extension, risk of
loss of me. Making me angry and getting me to punish him (e.g., by yelling at
him or withdrawing from play with him) would represent to him my loss of
control, not his. He could control me and not risk having to face what it feels
like to lose someone he loves and depends on for security and comfort.
Dennis's controlling stance protected himself from genuine contact with me
based on feelings of mutual love and caring. These feelings require both
persons in a relationship to risk feeling hurt by the other person and even risk
losing the other person. Dennis felt too frightened underneath his façade to
risk more genuine engagement with me. It was easier to provoke me into
fighting with him—a controlling form of contact minus the emotional risk.
Early in the psychoanalysis, I attempted an exclusively interpretive
approach focused on Dennis's feelings. This strategy repeatedly failed as
Dennis emphatically stated that he did not want to talk about his feelings. He
even complained to his mother (who reported it to me) that I asked the same
five boring questions in every session—all having to do with feelings. I
eventually realized that an exclusively interpretive approach was not going to
facilitate a therapeutic alliance. I gradually shifted from an attitude of looking
for opportunities to make meaningful analytic interpretations to an attitude of
looking for
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opportunities to make meaningful emotional contact with Dennis as a feeling,
desiring person.
This new stance also proved difficult. During the first half of the first year
of analysis, Dennis erected roadblocks to the path of my discovery of his
personhood. He incessantly played competitive board and card games in
which he compulsively cheated to guarantee a favorable outcome. One time,
in the only game I played with him in which he never cheated, I beat him in
checkers. Afterward, I told him that I knew how he could change his strategy
to beat me the next time (he had moved his back line too early) and that I
could share this information with him. Dennis declined this offer and instead
resorted to cheating in all future checkers contests. In Dennis's mind, lack of
knowledge was equated with vulnerability; thus, Dennis knew everything. He
therefore categorically denied any acknowledgment that I might know
something that he did not know.
I came to understand why an exclusively interpretive approach would not
work with Dennis, at least in this early phase of treatment: interpretation
requires a patient who realizes that he or she is not omniscient and is
therefore willing to consider the information given by the therapist. A
standard psychodynamic interpretation such as, “You poop your pants to push
people away so that you can be in control of rejecting feelings,” implies that
the listener (in this case, Dennis) does not already know this information
about himself. Because Dennis knew everything, he did not need to hear this
information from me. Another therapeutic strategy would be necessary.
The equation, “knowledge equals power,” and its corollary, “lack of
knowledge equals vulnerability,” made the therapeutic work especially
challenging for me. Not only did Dennis deny that I possessed knowledge that
could be beneficial to him, but also Dennis refused to share knowledge about
himself with me, thus making me feel helpless. At times, it was almost
impossible to learn anything about his life outside sessions—his home life,
teacher and peer interactions at school, or friendships. Sometimes Dennis
actively refused questions about his life; at other times, he just ignored me
altogether.
One exception to this knowledge blackout was Dennis's only discernible
passion: monster trucks. Dennis often spent entire sessions talking about
monster trucks—their designs, the drivers, the tricks they perform, the
winners in various categories of monster truck contests, and their sponsors.
He also demonstrated an encyclopedic knowledge of monster truck trivia. At
some point, I quietly entertained the idea that Dennis might have subthreshold
Asperger's disorder because of his markedly restricted repertoire of interests,
but his frequent eye contact and physical affection initiated with both parents
directly refuted this idea. In these sessions, I played the role of the interested,
admiring pupil of the master teacher's vast knowledge and expertise. He was
delighted and content to maintain a monotonous pattern of sharing facts about
monster trucks. I felt marginalized in our relationship, unable to reach him.
The extensive mirroring he received from me, conducted in the context of a
more hyperactivating pattern of affect regulation, allowed him to begin to
form an image of himself in my mind as someone worthy of attention and
admiration. It also implicitly challenged his deactivating pattern by eliciting
affective engagement. The goal then was for Dennis gradually to identify with
this new self-image and its accompanying expectations of comfort and support
from his family, friends, and me and risk affective engagement with us.
Toward this end, I sought to break up this in-session monotony. Dennis
was making a Lego house for a monster truck driver to live in. I started
building a Lego monster truck, but Dennis instructed me to stop because the
truck would be unable to fit into his Lego garage. I countered that I was going
to build a truck called the (Dennis's last name)
- 448 -
Express that I would make out of aluminum, an ultralight metal that would “get
some really sick air” (a colloquial expression I learned from Dennis that
indicates that during a jump, the truck stays in the air for a long time). Dennis
immediately refuted this claim because aluminum monster trucks were
outlawed in 2000, and monster trucks also have to be a certain weight. I then
told him that I was going to hide cinder blocks in my truck's secret
compartment that the inspectors would never find, which I would take out
after the precontest weigh-in. Dennis countered that there could be no secret
compartments. In spite of its mildly antagonistic nature, we were engaged in a
relationship. I was making emotional contact with him by using my own
imagination and getting him to engage with my mind.
In the following session, Dennis brought in his toy monster trucks in a
customized suitcase, laid them out on the floor, set up ramps and obstacles,
and directed each truck through the obstacle course with no variation—each
truck performing identically to the previous one. I took a truck and began
doing unconventional tricks with it—counteracting his deactivating mode of
relating. Dennis immediately dismissed my tricks as “impossible.” I reminded
him that my own truck, which was sponsored by the American Psychological
Association, had already performed all these tricks in real life. Dennis
responded to this tall story with vigorous denials. Yet as I watched him run
each truck through his obstacle course in monotonous succession, something
novel happened—he began performing more unconventional tricks with his
own trucks. I settled into the role of an arena announcer, mirroring him by
enthusiastically praising his unconventional tricks as “unbelievable,”
“incredible,” and “unprecedented.” Dennis allowed himself to smile when I
pretended to be an arena announcer. He even joined me occasionally in the
announcing duties by highlighting a special feature of a particular trick. We
were collaborating for perhaps the first time in treatment. He was
surreptitiously getting a taste of a relationship without having to defend
against it with his characteristic deactivating pattern of affect regulation. My
efforts at engaging him—getting him to experience mental closeness to me—
went unnoticed by him.
By making up tall stories, I was introducing myself as a person with my
own intentions and feelings. Essentially, I was introducing Dennis to a
separate person eager to engage with him on a series of adventures in fantasy,
which he ultimately preferred to the deactivating monotony of his own
ritualized play that characteristically shut me out. I chose story lines that
mirrored his own stories, yet illustrated to him that I had a different
understanding of them—an instance of marking. For example, in my story, I
too had a monster truck that competed with the others, yet my monster truck
was built differently (perhaps a model of his disavowed, devalued
self-representation) and performed unconventional tricks (perhaps a model of
his idealized, exhibitionistic self-representation).
Just as a mentalizing caregiver communicates his or her understanding of
the infant's mental states through the process of marking—using exaggerated
facial and vocal expressions to indicate that the caregiver is aware of the
infant's mental state but is not experiencing what the infant is experiencing
(Fonagy et al., 2002), so too did I use exaggerated storytelling to indicate to
Dennis that I was aware of his mental state but was not experiencing what he
was consciously experiencing. Thus, I was both attached to him as a secure
base and separate from him. This stance simultaneously confirmed the
existence of our relationship and challenged his need to dominate and control
me, which deprived me of my subjectivity and thrust him back into his
isolated, lonely position.
My work with the parents was limited but effective. I believe that my
ability to act as a container for their own frustration with Dennis's
provocative behavior helped them to contain this frustration in their
interactions with Dennis and perhaps also allowed him in
- 449 -
turn to risk relating to his parents in a more prosocial manner. An opportunity
to practice my containment and thus facilitate their capacity for self-reflection
came in the form of an e-mail message from Dennis's mother four months after
I began psychoanalysis: “I CAN'T TAKE IT ANYMORE!!!!!!!! Do you know
of any good boarding schools or military schools or ‘scared straight’
programs? I am serious. If this is him at 10, I can't deal with this as he gets
older.” I responded that Dennis's expressing his anger more directly could
lessen his need to communicate his anger through his behavior such as
defecating in his pants. Two months later, his mother expressed her frustration
on learning that Dennis's school was recommending that she get him a tutor: “I
am SO ANGRY!!! [Dennis's father] and I finally have a few dollars put away
and are saving so I can buy a new car next year. Now I have canceled my first
therapy appointment as I can't afford that—his music lessons are also
canceled. Here we go again—more money into ‘fixing’ [Dennis]!! Horrible
for a mother to say about her son. This doesn't even count the braces he will
need. I just look at my sister who has a child the same age as [Dennis]. No
eyesight issue, no allergy issues, no toenail issues, no pooping issues, no
academic issues, no weight issue, etc., etc., etc., it just goes on and on with
him. I am crying as I write this—anger and guilt fill me. Have to stop and
compose myself as I'm at work.”
Almost six months after this message, Dennis's mother wrote: “From my
point of view, [Dennis's] personality and attitude have changed. We see he
has more empathy, is more appreciative and is more verbal. Overall, he
seems much happier. This is great progress. Thank you.” Although Dennis
still occasionally had accidents, he was on his way to becoming a separate
yet connected preadolescent who was about to face a series of new
challenges presented by adolescence. Dennis and I continue to work together.
I am excited to discover where this process will take us next.
Analysis of Second Clinical Illustration
In this case, I realized that an exclusively interpretive approach focused on
Dennis's feelings was failing to reach Dennis behind his primitive fortress
protected by barbed wire and armed guards. Such interventions were aimed at
a symbolic level of thinking not yet sufficiently consolidated for therapeutic
use. He also had the problem of knowing everything that would have defeated
such a strategy. I gradually shifted to looking for opportunities to make
meaningful emotional contact with Dennis as a feeling, desiring person—the
first therapeutic principle I used. In so doing, I held in my own mind the image
of a boy-in-the-making who is worthy of caring, attention, and admiration
rather than yelling, rejection, and abandonment. Dennis could observe my
attitudes and behaviors toward him and begin to identify with and perhaps
internalize this nascent self-image, which was both similar to and different
from his own image of himself. This principle emphasized my mentalizing his
feelings, desires, and intentions on his behalf, using imaginative play and
humor, rather than articulating mental representations located in the
transference. Through the use of imaginative play and humor, I elicited
affective engagement that rendered his deactivating mode of relating
unnecessary.
Bateman and Fonagy (2004b) have suggested that treatment approaches
that emphasize transference interpretations expect too much agentive thinking
from the patient, which the patient could perceive as blaming. In contrast, a
mentalizing approach “would not expect the patient to understand much of the
discourse that the therapist might verbalize in relational terms” (Bateman &
Fonagy, 2004b, p. 117). Primitively organized patients such as Dennis
experience widespread “symbolic failure, particularly associated with
incongruent mirroring” (Bateman & Fonagy, 2004b, p. 118). Thus,
transference
- 450 -
interpretations, particularly with severely disturbed patients, whose symbolic
capacity has clearly failed, would be ineffective. Only after a primitive
symbolic capacity has become activated should a therapist attempt
transference interpretations with such patients. Thus, “retaining mental
closeness” (Bateman & Fonagy, 2004a, p. 44) is the therapeutic principle
used to accomplish the enhancement of mentalizing capacities.
Providing a “gentle challenge” (Dozier, 2003, p. 254) to a deactivating
pattern of affect regulation is the second therapeutic principle I used to
accomplish a secure mode of relating to others. A more hyperactivating
therapeutic response defies the child's expectations of rejection stored in
implicit memory, which is not verbally mediated, yet governs his or her mode
of relating to others. Verbal interventions cannot access this form of memory
(Lyons-Ruth, 1999; Stern et al., 1998).
These two therapeutic principles represent the essential ingredients of an
effective treatment for patients diagnosed with primary encopresis. A
relationship-focused intervention approach requires the temporary use of
mentalizing interventions early in the treatment process that serve the
treatment goals of relationship-building and stabilization before more
ambitious interventions such as transference interpretations are attempted.
Child patients need to feel secure enough in the therapeutic relationship and
skilled enough in their symbolic capacity to explore the contents of their own
minds, particularly the split-off mental representations contained therein. In
Dennis's case, I noticed that underneath the controlling, know-it-all attitude
lurked a scared, wounded child that I needed to reach somehow through
imaginative play and humor. I made my differently built truck show off by
doing its own thing: my truck was driving to the hum of a different engine. In
the future, when Dennis becomes more vulnerable in sessions for longer
periods of time, I might be able to sprinkle into my work some interpretations
that verbalize the symbolic meaning of his patterns of relating to others.
Transference interpretations would come still later, when Dennis's capacity to
symbolize his affective experience has developed further.
Conclusions
Both Maverick and Dennis shared a tendency to act self-sufficient and
precociously autonomous, which necessitated a dismissal of unpleasant affect
states and a consequent desire to control all relationship outcomes to avoid
the emergence of such states. Not coincidentally, both patients also shared a
symptom, encopresis, that reflected a disconnection from unpleasant body-
based sensations and a desire to isolate themselves from others, while
enraging their parents in the process. These behaviors thus insured the
patients some level of proximity to their parents, albeit with a hostile,
sadomasochistic tinge.
Both sets of parents, perhaps inadvertently, signaled their lack of comfort
with their child's need for closeness, protection, and comfort; thus, a goal-
corrected partnership was never established. Maverick's parents had a new
baby during Maverick's toilet-training phase while simultaneously struggling
with the aftermath of Hurricane Floyd. I suspect that they were emotionally
unavailable to Maverick during this time, which Maverick undoubtedly
experienced as a rejection or abandonment. He responded by turning away—
deactivating the experience and communication of his attachment needs that
his overwhelmed parents might have ignored or even been irritated by.
Dennis's parents placed him into full-time childcare at the age of 2—also
during Dennis's toilet-training phase. During the first two years of his life,
Dennis's mother also faced enormous challenges at
- 451 -
her workplace, which might have distracted her from being emotionally
present. Like Maverick, Dennis also responded by deactivating the
experience and communication of his attachment needs. In contrast to my
experience with Maverick's mother, I felt better able to contain Dennis's
mother's frustrations with her son. Additional clinical experience working
with my countertransference as well as additional therapeutic work on myself
probably account for this difference in response to these two mothers, who
shared a sense of profound hopelessness and helplessness.
The success of both treatments depended on my recognizing the latent
needs for attachment and closeness and not allowing these patients to deceive
me (as they had deceived their parents) into listening to the manifest content
of their presentations, which could easily be summed up by the command,
“Get away!” Dozier (2003) suggested that therapeutic interventions are most
effective when the therapist provides a “gentle challenge” (p. 254) to the
patient. By relentlessly pursuing emotional contact and intimacy with
Maverick and Dennis (hyperactivating pattern) even though they signaled
distance (deactivating pattern), I was defying their expectation that I would be
uncomfortable with their need for closeness, protection, and comfort. I was
letting them know instead that these needs were acceptable to me, and
therefore, that they were acceptable to me. My patients' defensive needs to
interact sadomasochistically were no longer necessary.
Because of both patients' compromised symbolic capacity (i.e., using
nonverbal channels of communication to act out their feelings rather than
expressing them verbally), I chose to help them to mentalize their affects
rather than act them out in a bodily function (encopresis) from which they
were disconnected. In the case of Maverick, I got sidetracked by his mother's
anger and disapproval of my work, which temporarily shifted me into an
essentially behavioral approach. After figuring out the nature of this
enactment, I reset the treatment course back to its original relationship-
building process. In the case of Dennis, I initially felt a need to engage in
interpretive work but realized that this need was mine and was in fact getting
me nowhere. Mentalizing affects with storytelling can facilitate the child's
perspective-taking and theory of mind (Mar, Tackett, & Moore, 2010) and
eventually pave the way for later exploration of mental representations. A
mentalizing approach (Fonagy & Target, 2000; Midgley & Vrouva, 2012;
Verheugt-Pleiter, Zevalkink, & Schmeets, 2008) can prepare encopretic
patients for later interpretive approaches that include transference
interpretations and exploration of fantasy material related to parental and self-
representations.
Another way of putting this idea is that the child needs to make contact
with the therapist in a genuine, reciprocal relationship in which the child
becomes aware of having a mind with mental contents, while the therapist
also has a mind with separate but related mental contents. Only then can the
therapist proceed to explore fantasy material and try out more symbolically
advanced intervention strategies. In a later treatment phase, the therapist can
help the child understand the complexity of his or her internal conflicts, for
example, that a symptom like encopresis exists because it protects the child
from emotional vulnerability, specifically, from the risk of rejection and
abandonment, by preemptively alienating others. In all treatment phases, the
therapist is striving to make emotional contact with all parts of the patient's
self, which eventually permits the patient's exploration of the contents of his
or her mind as well as the therapist's mind. Through this empathic connection,
the therapist provides a mental secure base from which the patient can
explore unknown territory and to which the patient can return when the terrain
becomes too frightening. Child therapists need to acquire a whole arsenal of
artist's tools. In some situations, a therapist might need a chisel, whereas in
others, a paintbrush will do. Our field needs fewer technicians and more
artists.
- 452 -
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Article Citation [Who Cited This?]
Goodman, G. (2013). Encopresis Happens. Psychoanal. Psychol.,
30(3):438-455

Encopresis

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Psychoanalytic Psychology, 30(3):438-455

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