Thoughts on relatedness, transformation of self, and a new understanding of mourning

Abstract I have elaborated Stern’s theory of the formation, growth, and development of the self to explain how the threat of dissolution of self can result instead in adaptive transformation. His theory also led to my insight that mourning is intrinsic to the process of formation, growth, and development of the self, and my observation that the major work of mourning and transformation of self can be accomplished by resilient individuals in six months.

In 1968 I was appointed to a half-time position of research psychiatrist to an early renal hemodialysis and transplant program that was ending its first year of operation. The mortality rate on the hemodialysis service during my first three months on service was 95% for those patients on the service when I started. Facing such precarious circumstances, the patients had withdrawn into themselves and closed off emotionally. Though I saw them daily, they were closed off emotionally from meaningful relatedness. As this continued day after day, I felt useless as a psychiatrist and more like a chaplain. I felt I was not fulfilling the expectations of my research appointment. I was however reactive. Upon approaching the renal unit I would sense my ego closing down like the iris of one's eye or the diaphragm of a camera. Occasionally when talking with patients, I would have the sensation of falling through space; at other times of hanging over a chasm by a thin wire that would break should my feelings become too strong. I became irritable, slept fitfully, became preoccupied with feelings of loss and failure, and began to doubt a future for myself. Over the following weeks, I cycled through an intensifying emotional

PUBLIC INTEREST STATEMENT
While working as a psychiatrist with renal hemodialysis and transplant unit with a very high mortality rate, I was able to observe the ongoing confrontation with imminent death that my patients and I lived with continuously. They were unable to express their emotional responses; but projected them into me, causing me increasing distress. I eventually experienced a crisis, which resolved as a positive transformation of self. I have searched for an explanation of this occurrence for many years, which I found in the work of Daniel Stern. I elaborate his theory and describe how it has led to a new understanding of the process of mourning. storm, as I resonated with the traumatic situation of my renal patients. Memories of unresolved losses from my early childhood and adolescence became prominent.
These responses surprised me because I had been working closely with patients on a physical medicine and rehabilitation unit for several years, even conducting groups that included severely injured as well as paralyzed patients. I thought those clinical experiences had helped season me in working with severely injured and paralyzed patients. The work with the renal patients was more troubling, presumably because of the constant threat of death.
In my fourteenth week with the unit, my feelings rose to crisis level,and I was suddenly confronted with a frightening vision of "nothingness." I thought this endless void represented the confrontation with death deep in the minds of my patients, which threatened collapse of self in mine. Frightened by this threat of dissolution of self, I forced myself to pull back from all preoccupation with loss and failure and concentrate on the activities of my daily life. With this effort I was able to differentiate myself from my renal patients and preserve my intactness of self. Over the next days I had the sensation of a floor slowly forming beneath me. My mood improved, and my preoccupation with loss and failure faded away, I felt more self-confident and self-assured. By the sixth month I felt stronger than ever before in my life. My work with my renal patients became less burdensome, and my relatedness with them improved. I became preoccupied with the thought that a new self had formed, but I had no references to refer to for enlightenment. Then I found Bettelheim's article of his experience in a Nazi concentration camp, where his old self faced obliteration and became no longer of use. A new self was needed (Bettelheim, 1969). This encouraged me to conceive that a transformation of self had occurred.
The mortality rate in the second three months of my service fell to 5%. We attributed this to the increasing experience of the clinical staff.
The following three clinical vignettes further illustrate the process of transformation of self. A patient on hemodialysis in her sixth month with the renal program was admitted for treatment of medical complications. On the morning after admission, she recounted a vivid dream from the previous night, in which she fell through space, crashed into the earth, and died. Remarkably, she felt no fear, sadness or regret in the dream or upon awakening. She then told me that she now thought her illness might shorten her life, but she was no longer afraid to die. This was a significant improvement from her previous high level of fearfulness. In light of my experience months before, I thought her dream represented a recent transformation of self in which her new self could now observe the death of her old self with equanimity.
A private psychiatric patient from the late 1960's presented another experience of denial of mourning and determination to avoid emotional relatedness, but still experienced a transformation of self. He was a 19-year-old art student whose parents had died in an automobile accident two years previously. He began to develop severe problems concentrating and dropped out of college. At the urging of his extended family, he came grudgingly to a psychiatrist. He was antagonistic at our first meeting. Throughout subsequent sessions, he withheld emotional involvement and permitted only superficial discussion of events of his everyday life. When I asked about feelings, he accused me of "playing shrink." When I later asked how he wanted me to help him, he told me that I could not. When I asked about missing his parents, he became very angry and walked out of the session. In the subsequent session, he refused to talk about the incident.
After several weeks, he came to his session with a painting he had made of a clown. It was done in stark black on a white background. The face was distorted by grief, with tears running down his cheeks. My patient rejected my attempt to discuss the painting. I thought it portrayed the onset of his mourning. At the end of the session, he told me he was leaving it with me.
A few weeks later, he brought another painting, again done in black on a white background. An enormous penis dominated the entire picture. Smaller naked female figures, sketched in outline, were placed randomly, in various lascivious poses. The painting was provocative but it was not disorganized. He again permitted no comments, questions or discussion, and left the painting with me.
Several weeks later he brought a painting that was very different, and his manner was noticeably less oppositional. The purple outlines of two large eggs lay beneath a prominent horizontal purple line that I thought represented the earth. Above the line were three solid purple circles, supported by three purple stalks. Only one stalk attached to an egg, one hung free between the two eggs, and the third ended in the horizontal line of the earth. All were painted on a radiant golden field. The painting strongly suggested spring, rebirth, and renewal. I thought the two hollow eggs represented his deceased parents, and the three solid circles supported by the three slender stalks represented the patient and his two younger siblings. Again no discussion was permitted. He informed me this was his last session. He left the paintings with me, and I did not hear from him again.
I was surprised that he was able to complete his work of mourning through his painting, and to achieve a positive transformation of self, in light of his overtly negative "therapy" relationship. I wondered why he left his paintings with me. Was he showing me there are other ways than therapy to mourn a terrible loss? Did he want me to remember that he had done his mourning without my assistance? Was he leaving his experience of loss with me? In subsequent years I worked with several bereaved patients who did not want to mourn for fear of losing their attachment to their deceased loved ones. I thought that might have been why this patient did not want to openly mourn in his sessions.
A similar experience and chronology of mourning occurred following the death of my wife. For some days after her death, my feelings were muted. Then rapidly, grief, loss, and yearning became extremely painful, complicated by guilt for times that I had hurt her feelings, failed her, or frustrated her life goals. Cycles of grief, yearning, regrets, and hopelessness became increasingly intense and disruptive, reaching an intolerable level at week 14. At that time thoughts of selfdestruction occurred with feelings of pervasive hopelessness, and again I had a frightening confrontation with "nothingness," and a fear of dissolution of self. As before, I shut out all feelings of loss and hopelessness and focused on practical involvement in my daily life. Over the following weeks, I experienced the same welcome relief of an emerging hopeful and more stable self-state. By the sixth month, my moods were again positive, my interests had returned, and my daily activities were back to normal. Painful yearnings and regrets occurred, but were less frequent, less intense, and shorter lasting, and did not disrupt my overall feeling of well-being. My life continued to improve and in the tenth month, I was pleasantly surprised to experience a distinct sense of an intact sense of self-developing.
My own mourning experiences with the renal unit and and for my deceased wife reached a crisis at 3 1/2 months and resolved by six months. The dream of the dialysis patient revealed at her sixth month a transformation of self and a capacity to surmount her fear of dying. These three experiences support the findings in a review by Bonanno et al. (2011) of a study by Wortmen et al. (2001).
A review by Bonanno, Boemer, and Wortman (2008) of a study by Wortman and Silver (1989) supports this suggestion. In Wortman's large-scale study from the mid-1980's, her research group interviewed 1532 married couples on average three years before the death of their spouses. They later were able to interview 205 surviving spouses at 6, 18, and 48 months post loss. Bonanno later reviewed those records to assess the trajectories of mourning of those survivors. A grief reaction was defined as an increase in depression from pre-to post-loss that exceeded the standard normal range of variation (i.e., the standard deviation) for each group. They found that 46% of the 205 surviving spouses were no longer depressed at six months post loss. Of that 46%, 75% had experienced an initial period of intense grief, yearning for the deceased, and rumination about the lost spouse. The authors named this cohort the "Resilient Group." They were characterized as welladjusted, happily married, with sustaining friendships. The mourning trajectories of the remaining cohorts were distributed over the course of the study. Some survivors were still struggling with depression at the end of the study at 48 months.

Stern's theory of formation of self
Daniel Stern was a child psychoanalyst and researcher on the formation, growth, and development of the self of the infant. He developed his theories from close observations of the lived experience of mothers and children that were also captured on video. Central to his theory was the finding by Tulving (Tulving, 1972) that infants are born with a highly functioning episodic memory system that records their lived experience. This innate ability enabled Stern and fellow developmentalists to construct the theory that the newborn is able to sort out experiences of a similar nature, aggregate them into small, homogeneous clusters, and abstract out averaged prototypes or "episodes" (Stern, 1985, pp. 85-94). Stern named these episodes Representations of Interactions that have been Generalized, or RIGs. RIGs formed in close association with a care-taking other, were named RIGs with Evoked Companion, or RIGs-EC. RIGs (RIGs and RIGs-EC) are the basic building blocks of the self. "They are stored in the episodic memory system where integration of experience, indexing, and reorganization of episodic memory occurs, resulting in a growing, integrated network of organized self-experience … providing the infant with a unified sense of a core self (Stern, 1985, pp. 98-99, 110)." When Lichtenberg, a prominent Self-Psychology theorist, confirmed Stern's concept of integration of experience from birth as the driving force in the formation of the self, rather than differentiation from the mother figure (Lichtenberg, 1991), the self-object of Self-Psychology became analogous in function to an assembly of RIGs. A selfobject can be loosely described as a generative relationship originating between mother and child but commonly available throughout life.
As life experiences accumulate, further levels of the organization are created in "quantum leaps," leading to increasingly complex structures and functions (Stern, 1985, p. 34). The superordinate structures created by successive quantum leaps are called Domains of Self, of which there are four: the domain of emergent self (formed from birth to two months); the core self (three to seven months); the inter-subjective self (from 13 months onward); and the verbal self (from 15 months on) (Stern, 1985, p. 34). These domains are concerned with all aspects of self-function: biological, physiological, psychological and affective (Stern, 1985, p. 111). Each domain operates separately at its level of development of self, as well as in concert with the other domains, throughout life (Stern, 1985, p. 33) Stern explains, "(The domains) are constantly and simultaneously building up new structures, eroding old structures, rebuilding, dissolving to keep the domains up to date…. It is a network of many forming and dissolving dynamic processes in a state of dynamic equilibrium (Stern, 1985, p. 116). Because of this constant flux, the domains are vulnerable to trauma. Loss can be a major trauma, causing a grave disequilibrium of the domains of self, and making the image of the deceased very manifest. (Stern, 1985, p. 116)."

Hypothesis
Stern did not signify the relevance of his theory of the formation of self to the process of mourning. In assimilating his theory, though, I perceived that his description of the dynamic processes that keep the domains of self up to date, also described the process of mourning, which likewise keeps the domains up to date. The process of mourning appeared to replicate the process of growth and development that maintains the self throughout life.
To illustrate this replication, I propose that upon the death of a loved one, the domains of self instantly recognize that the image of the deceased is no longer viable. The redundant image becomes a foreign body in the domains. A severe discontinuity of self, and major disequilibrium of the domains of self results. The redundant image of the deceased becomes a foreign body in the domains. This activates an intense psychic reaction, akin to the response of the body to systemic infection. Powerful affects of grief, loss, hopelessness, anxiety, and anger are generated, increasing the prominence of the deceased image to facilitate its eradication.
This sequence of events triggers the initiation of mourning, which is a dual process consisting of the selective erosion of the image of the deceased and simultaneous creation of new RIGs that grow the new structures to replace those of the eroding image.
These are the identical processes utilized by the domains of self, as described on page 11-12, in maintaining the dynamic equilibrium of the domains, and "keeping them up to date." When the loss is of a loved one, the magnitude of the loss can overwhelm the capacity of the domains to cope on their own, so they eagerly seek a relationship with an attuned, responsive person or milieu. Activation of the memory of an earlier, robust care-taking relationship can also serve (Stern, 1985, p. 118). These relationships are selfobject, or RIG, or bridging relationships that ease the pain of loss, contribute energy and stability to the beleaguered self, and enable past life experiences to serve as a template for the construction of new RIGs that will reestablish the dynamic equilibrium of the domains of self.
As selective erosion of the image of the deceased moves toward completion, and the dynamic equilibrium of the domains is reestablished, meaningful relationships and activities are initiated, and the image of the deceased loved one fades into dormancy. This dormant image can be vividly activated by the attribute of a past experience, but the activation would most often be transitory, especially in the "resilient individuals" as described in Bonanno's study (Bonanno et al., 2008). The need to maintain a more prominent and constant image of the deceased would depend upon the magnitude of the role that the deceased served in the survivor's emotional equilibrium, the instrumental nature of the bridging relationship, and the availability of attuned others or attuned milieu.

Conclusion
I, therefore, suggest that the process of mourning is intrinsic to the over-arching process of formation, growth, and development of the self as described by Stern. I conjecture that the awareness of this inter-relationship has been obscured by the intensity of the powerful affects of mourning, the great disruption of the dynamic equilibrium of the domains of self, and the extensive erosion and reconstruction that occur in the dual process of mourning.

A clarification
The two experiences of "nothingness," or threatened dissolutions of self, that I experienced in the fourteenth weeks of my mourning, were likely related to the traumatic losses in my early childhood and early adolescence. By week 14 of mourning, my emergent self had formed, my core self would have been newly formed, and my intersubjective sense of self newly functioning. My experience of falling through space, losing my sense of a future, hanging over an abyss, or facing "nothingness" are characteristic examples of what Winnicott calls "primitive agonies" and that Stern locates as traumas to the core self. In normal circumstances at the fourteenth week of mourning, the complex transfer of functions, memories, and experiences from the eroded image of the deceased to the newly formed structures of RIGs in the domains of self would have occurred smoothly and out of consciousness. The traumas to my core self and intersubjective self could have made the transfers more difficult to achieve. By focusing intensely on my daily life, I conjecture that I was able to mobilize the basic integrity of my domains of self to effect the transfer.

Afterword
A comment by Stern on the far-reaching implications of his work: "Many basic psychoanalytic conceptions about drive, the number of drives, their allegiance to id or ego (or even such a notion as allegiance) and their developmental sequencing all need to be reconceptualized when confronted with the infant as observed (Stern, 1985, p. 240)."

Correction
This article has been republished with minor changes. These changes do not impact the academic content of the article.

Citation information
Cite this article as: Thoughts on relatedness, transformation of self, and a new understanding of mourning, Martin Laufe, Cogent Psychology (2019), 6: 1612620.