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30 octobre 2005
Int J Child Psychotherapy
Yawning : analytic and therapeutic considerations
Ned Marcus
Jewish child Care associoation, New York
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Abtract : A thirteen-year-old patient is presented, to demonstrate how the active analysis of nonverbal expressive behavior, in this case yawning, was of value in understanding and treating a youngster who, because he was so withdrawn, would not otherwise have been amenable to the standard one-to-one psychotherapeutic approach. In discussing the clinical material, the literature concerning nonverbal expressive reactions, particularly in respect to yawning, is reviewed. In the process the psychogenetic, dynamic, structural, energic, and adaptive aspects of yawning are described. It is the author's opinion that only by focusing on specific non verbal reaction such as yawning can the unwieldy task of ,naking some meaningful statement about a manifestation as protean as the nonverbal in therapy occur.

Whereas nonverbal communication may become an issue in psychotherapy due to the patient's own interest in certain specific nonverbal reactions (Marcus, 1969), or because a nonverbal response is particularly striking or interesting to the therapist, there are instances when the meaning of a patient's nonverbal behavior should be explored even though neither the patient nor the therapist finds the behavior to be especially intriguing. This becomes imperative when the nonverbal reaction is the sole response the patient evidences, because its avoidance would otherwise result in a therapeutic stalemate. This is important when dealing with the difficult child-patient who favors primitive communications and who is often silent and withdrawn during sessions.
A noncommunicative thirteen-year-old will be presented, whose incessant yawning constituted his principal expressive response during a phase of treatment lasting many months. The suggested active approach to the nonverbal behavior, led not only to an understanding of this patient's nuclear pathology, but also provided an opportunity to delineate the metapsychology and therapeutic praxis of yawning. Only through the restricted in-depth analysis of unitary nonverbal reactions can the large and somewhat unwieldy task of comprehending the psychological significance of the nonverbal be reduced to manageable proportions.
The patient, whom I will call Ray, was originally referred for psychotherapy at age 11 because of longstanding difficulty in learning to read. He was also irritable and socially isolated. Although his IQ placed him within the high average range of intellectual functioning, his academic performance was extremely poor. Neurological examinations were negative. When Ray was asked what the trouble was, he often responded by saying that the reason he was "bad" was that he was "too bored o be bothered with anything."
Ray's family background was highly pathological. Ray's mother was a strongly narcissistic lady who identified Ray with his "crazy" father. The father was subject to hypomanic episodes, at which times he was very loud and flamboyant. The father repeatedly disappointed the family by not being able to sustain the grandiose life-style associated with his elevated moods. Because of this, any natural signs of emotional intensity or spontaneity on Ray's part were looked upon with great suspicion by the mother, and Ray therefore differentiated himself by becoming, in certain apparent respects, his father's opposite: that is, bland to the point of being schizoid.
Ray had already started therapy on the occasion of his father's last and most disastrous hypomanically inspired business venture. The mother, once more faced with her husband's failure, finally effected a separation. Contact between Ray and his father was now restricted to weekends, when the father would not uncommonly take his son with him to the race track, telling Ray that the boy's presence was responsible for his wins or losses. This may partly explain Ray's belief, which emerged in therapy, that he could exercise magical powers simply by passively existing.
After approximately two years of treatment, the boy's initial therapist decided that given Ray's rejecting mother and disturbed father, nothing more could be done unless Ray were removed from the parental home. As staff psychiatrist at the Jewish Child Care Association, which subsequently became responsible for Ray's care, I started to see the boy on a twice-a-week basis, six months after he was placed at a small group residence.
The new course of treatment following placement did not begin auspiciously. Ray was not happy about having to live apart from his mother. Session after session, he sat silently staring and yawning. Rather than agree with Ray that nothing was worth talking about, and rather than discuss reports of his continual failure in many areas outside the therapy (something that had been done by others, resulting in further lowering of his already lowered selfesteem), I simply described Ray's immediate nonverbal behavior to him. In response to this, Ray, somewhat annoyed, spoke of how he felt he was always being unjustly criticized for everything he did. I tried to point out that I was not criticizing him but merely making "observations." I only partially succeeded in convincing Ray of my sincerity because, in actuality, I had been mildly disconcerted by his extreme passivity.
At about this time I began to receive information that outside therapy, Ray had begun to improve in his ability to more actively enjoy himself. Within the treatment, with continuing feedback about his behavior, Ray now became increasingly somnolent and withdrawn-making it almost impossible for him to follow the simplest conversation. Yawning during sessions became more and more pronounced and, in keeping with a decision to comment upon whatever the patient brought to sessions, yawning at this point became the major focus of the therapy.
Ray at first insisted that yawning was in no way significant. Although continuing to yawn, he did perk up a bit when I evidenced real interest in what he was doing. Ray then admitted to feeling more relaxed when he yawned. He also explained that yawning was a way of influencing the person at whom the yawn was directed. The infectious nature of the reflex was seen to be an important aspect of its dynamic. This formulation was an outgrowth of Ray's own hesitant associations (increasingly verbal in nature) about what he was doing.
The patient said he was troubled since he noted that I also yawned. He did not know whether it was he who influenced me or vice versa. Passive dependency was seen to be linked with a concern about being controlled or controlling others. Pursuing this theme, Ray beamed when he announced that he would like to dominate me, that is, put me to sleep; but felt that he, of all people, could never influence anyone. Because his social withdrawal and boredom had always been experienced by others as a psychological null factor, this underlying
fantasy of dominating other people had never been made explicit. This clarification allowed therapist and patient to understand how passive-dependent states may screen very active fantasies of omnipotent effectiveness. Further analysis of yawning proved to be a rich source of information about the complexity of his passive-active strivings.
Ray mentioned that he was puzzled by the fact that he could not make any noise when he yawned. I speculated that early in life, perhaps when he was very young, he either did not want to hear a certain sound or was severely reprimanded for making noise. Following this comment, the patient was amused to find that not only could he vocalize when yawning, but that he had become more verbal in his communications outside the therapeutic setting as well. It could not be verified whether the psychogenetic reconstruction had been accurate; nonetheless, Ray remembered that his mother had always been impatient of any of the verbal demands he made. It was easy to see why Ray was so taciturn. The analysis of his yawning made his passivity more understandable.
The patient claimed at this time that his therapist must be a mind-reader. Ray also believed that he could read and control the therapist's mind. He was convinced that he yawned because I was thinking he would. He was also convinced that by thinking sleepy thoughts, he could force me to yawn. His preoccupation with mind-reading, with thought and behavior control, was clearly involved in his compulsive yawning. The patient was encouraged to describe all the nonverbal cues that initiated yawning, and he gradually became aware that he had generally made interpersonal exchanges more magical than they really were. The magic depended on the unconscious nature of Ray's subliminal awareness of people's nonverbal behavior. As long as this appreciation was unconscious, the influence one person had on another did not appear to be causably explicable, except in some magical fashion. Of course the unconscious of one person can directly understand and be influenced by the utterances of the unconscious of someone else (Szalai, 1934), and when Ray had understood that this was part of a rationally explicable process, his belief in telepathy was greatly diminished.
The continued delineation of the extent to which one can exercise conscious control over simple reflex activity gave the patient a greater sense of freedom and enabled him to recognize in what manner he could choose to influence or be influenced by others in respect to the satisfaction of passive-dependent drives.
He became concomitantly capable of admitting something of the aims and goals of his behavior-aims and goals that formerly had been repressed in the interest of mollifying a superego demanding precocious self-reliance.
Having acknowledged that the threatening controlling nature of his interpersonal, nonverbal relationship with me was not that "sinful," his yawning was now more and more frequently accompanied by smiling. He no longer had to punish himself as severely and began to enjoy himself within the therapeutic setting.
Ray's understanding of telepathy made him wonder about the fact that he was for many years convinced that he had gone through a complicated reincarnation. Ray described vague recollections, either fantasied or real, of pleasures experienced "in another life." It became clear that the smiling cum yawning now in evidence constituted a reenactment of an earlier experience of pleasure. Meerloo (1955) has reported that the act of yawning may itself consist of an unconscious reminiscence. The hypnoid state so often accompanying or induced by compulsive yawning lent itself to producing a disassociated state, which no doubt created Ray's subjective impression of having lived "another life." Just as the conscious awareness of the importance of subliminally perceived and emitted cues resulted in a decreasing belief in telepathy, so a continuing analysis of Ray's yawning resulted in a modification of his belief in reincarnation. He now knew that he was actually in mental possession of an earlier pleasant identity, probably as a yawning, contented infant. He understood that he had never been an individual who had lived at some entirely different historical period, but more simply one who had isolated one part of his life from the whole.
Further details about this case reveal little more about yawning per se.
Although yawning within the therapeutic setting persisted without abatement in the modified "happy" form described above, yawning and its associated lowered level of consciousness as well as the boredom with which Ray initially presented became a much more peripheral aspect of Ray's life. Agency staff dealing with Ray at the small group residence noted that he was no longer withdrawn and participated in group discussions and games with his peers. Although he was still the noncommunicative "pseudo-defective" at school, his increasing assertiveness at the residence led to a change in the attitudes of those around him, particularly regarding his placement. Now able more directly to articulate his wish to return to his mother and being able to make this demand on the basis of his increased maturity, he succeeded in persuading both workers and parents that he was ready to leave the agency.
By helping him to understand something about the degree to which he had idiosyncratically invested relatively miniscule "events" in his passive state with values that these events did not deserve, Ray was made to see that he really had been doing nothing prior to placement. This involved a certain therapeutic paradox. Ray accepted the reality concerning the "nothingness of his passivity" only when the passivity was taken to have some value-that is, some small adaptive feature that others had repeatedly denied out of their frustration and fear of this child's negativism. This value could only be recognized by a therapist who through his interpretations demonstrated his empathy, an empathy that also encouraged Ray to trust others more fully and to believe that others would treat him more appropriately regardless of what he did or did not do. With the renewed confidence in himself and others, he was able to allow himself to risk unleashing an active self that had always been a part of his nature, but that he had tied up in the passive defensive maneuvers he employed. I believe there were two reasons why he remained passive within the therapy even though he changed outside of it. First, in therapy his passivity was tolerated to an extent not permissible elsewhere. Secondly, the passivity that had not been worked through more fully emerged whenever Ray was no sufficiently engaged, as in school, or when he was engaged to a degree he felt dangerous, as in therapy.
I did not actively involve myself in implementing Ray's desire to return home, and Ray found his relationship with me on these grounds exceedingly boring. His energies were now exclusively taken up with conferences conducted by the agency social worker pursuant to his living with his mother. Upon returning home, Ray decided he did not wish to seek further psychiatric help. Even though he was bored and tired with me during the final phase of treatment (since I had not involved myself in pursuing his wish to go home) there is no doubt that psychotherapy did allow this boy to move in the direction of greater participation in life.
Presentation of the foregoing patient provides a springboard from which one might plunge into a more elaborate discussion of the psychological phenomenology of yawning. Some fifty years ago a number of authors, (Dupart, 1921; Hauptman, 1920; Lewy, 1921) published clinical studies dealing primarily with the physiology of the reflex. However, Lewy stressed the psychological nature of yawning and its not infrequent association with psychiatric illness. Goldie and Green (1961) reviews an even earlier work by Charles Darwin, "The Expression of Emotions in Man and Animals" published in London in 1872, that also touches upon the psychological or communicative aspect of the reflex.
Phylogenetically and neurologically, yawning is probably a very primitive reaction. Ontogenetically it may also be considered a very basic response. Both Moore and Goldie comment that yawning is present at birth. Joost Meerloo (1955) writes that slow muscle contractions around the mouth-something like yawning-have been recorded from the fourth intrauterine month. Could a postulated early psychogenetic fixation point associated with yawning explain why Ray was so preoccupied with a life before life while yawning? Its archaic nature may have played some part in this.
Yawning is intimately associated with a state of consciousness just preceding sleep. As a stretch reflex bringing about reduced muscle tension, yawning may be a prelude to sleep. However, by initiating a Bainbridge reflex (which increases cardiac output and thereby increases cerebral blood flow), yawning may decrease generalized neurological depression making the individual more alert. Hence, by yawning one may perhaps bring about a level of consciousness somewhere between sleeping and wakefulness. Familiarity with Ray's psychodyanmics revealed that it was precisely this intermediate state that he wished to achieve. By compulsively yawning, Ray defended himself both against falling asleep and against anxious hyper-vigilance. This in turn is most consonant with that view of mental phenomenon-including nonverbal behavior-as essentially overdetermined.
Ray's object relations were also consistent insofar as they were those of a person fixated at the early or primitive stage we hypothesized would be associated with compulsive yawning. Scrutiny of the nature of yawning explains the manner in which the unfolding of this reflex provides a framework upon which Ray ultimately elaborated more complex emotional and ideational intrapsychic realizations of drive satisfaction through the establishment of specific types of object relations. For example, Ray's desire to "be with his mother" went beyond a wish for mere physical proximity. His associations made it clear that he secretly desired to regress to a point that he claimed to have vaguely remembered-a time before his "reincarnation." He wished to return to that phase of his existence when he was unable to be consciously frustrated by a rejecting mother because at that time he was unable to clearly perceive any other person as separate from himself. In his ongoing behavior Ray attempted through yawning and the attendant hypnoid state to deny momentarily the fundamental differentiation of self and object. He thereby happily merged with the love object. His beatific expression during the soporific state of yawning in the latter part of his therapy, suggested that he had truly returned to the "booming" satisfying confusion of infancy. Yawning, and for that matter any primitive reflex, may be viewed as a defense against maturation favoring a return to an earlier type of object relationship (Otto, 1935).
Another adaptive aspect of Ray's yawning may be perceived when one considers the quality of the manner in which he related to others while yawning. Because of the infectious nature of primitive reflexes in general and of yawning in particular, yawning favors unconscious imitation as few other responses do. Through the strategy of who-makes-whom-yawn, Ray was not only able to more fully maintain the fiction of a desired symbiosis but was, thereby, also able to model himself after another person-becoming, as it were, the parenting or caretaking individual himself. He thereby resisted further regression and avoided a more autistic adjustment. Through this maneuver, Ray made himself less dependent on the love object. Ego strength was always sufficient to preclude a psychotic break. Therapy consisted in further strengthening this youngster's ego by providing it with insights into the nature of nonverbal behavior formerly ascribed to uncontrolled magic.
Meerloo stresses in his discussion of archaic reflexes that displaced aggression may be expressed through incessant yawning. This too seemed to have been operative in Ray's case. A consideration of the phylogenesis of yawning suggests an aggressive anlage for the reflex. According to Darwin, baboons "yawn" when threatening one another. As expressive behavior, yawning must, nonetheless, be viewed as a rather ritualized, covert form of aggression actually guaranteeing inhibition of the more destructive expression of the drive. It is, in this respect, exactly analagous to smiling. Considering the patient's remark about how pleased he was with the idea of dominating the therapist by making him sleepy, it is easy to see that Ray's yawning probably was equivalent to an aggressive act. On the other hand, by yawning the patient repressed the more overtly angry thoughts that could not be expressed lest he expose himself to horrendous retaliation by someone outside himself whom he intimated he had endowed with great powers.
At first, during the initial stage of treatment, Ray handled the ongoing dilemma of his relationship to me by working himself into a bored state. The patient, fearing an overwhelming loss of control due to the high level of instinctual tension associated with boredom (Fenichel, 1934), regressed to the less dangerous condition of drowsy yawning. In this instance one might speculate that Ray's yawning (and yawning more generally) was not only a defense against the more overt, less regressive expression of aggression, but also a defense against libidinal drives becoming manifest in relationship to an overvalued parental figure. In this context the yawning was consonant with a state of a more inhibited libido as well as aggression. Ray kept both friend and foe at a distance, dulling the pangs of both anger and separation.
When Ray first began to yawn I found the session spent with him very tiresome. I began yawning myself. My reaction was not unusual. Yawning, more than other nonverbal expressive reactions, often provokes compulsive imitative behavior. In contrast to smiling, however, yawning is provoked by more diffuse stimuli and is at the same time more concretely imitative. For example, auditory cues such as other people's auditorily perceived yawning may be sufficient to induce large numbers of people to yawn.
In both crying and smiling, endogenous factors as well as exogenous cues are important in determining the response. This is also true of yawning. Consideration of the relationship between endogenous and automatic exogenous smiling in early infancy has been well researched by Emde (1970). Automatic endogenous smiling is usually extinguished before the flowering of social smiling at four months. Emde postulated and proved that there would be a developmental stage before the extinction of primordial endogenous smiling and the full flowering of automatic exogenously determined behavior when a summation might be brought about by satisfying the two sets of conditions connected with both. Yawning is curiously like both automatic or reflex smiling and the earlier endogenous smiling of the drowsy infant. It too is a neuromuscular reaction involving the mouth, most often in evidence during drowsy states, and making its appearance very early in life. The association between yawning and drowsiness is even more pronounced than that between smiling and drowsiness, since it never disappears even later in life. Yawning is unique because of all the expressive reflexes it is the most clearly associated with sleepiness, rather than with any more complex emotional state. At the same time, being the most concretely imitative in nature-that is, the most automatically or reflexly exogenous-it may be viewed as an expressive reaction that never loses either its primitive exogenous or endogenous characteristics. It never becomes as fully associated with autonomous ego functioning as do both crying and smiling. This explains how problems centering on those primitive processes of identification-the diffusion of ego boundaries and problems of symbiosis-may be expressed through the inappropriate expression of yawning. The delineation of Ray's problem suggests the manner in which the control of yawning may be one of the earliest aspects of the definition of one's individuality. The counter-transferential aspect of working with Ray is also illustrative in this context.
Reciprocal yawning became a problematic aspect of the therapy. I was irritated when I started to treat Ray, because I was excessively frightened that I would be swept into an overwhelming regression in imitation of my patient. I felt the desire to manifest an active resourceful response vis-à-vis the patient's massive passivity. At the same time I wished to allow the patient maximum freedom to express whatever he deemed most appropriate. I was aware that a classical analyst might restrict himself to relative inactivity in dealing with an analysand's silence, but the patient's yawning was so seductively regressive that I feared I would passively "give up" and merge with the other person, just as Ray had seemingly done. When I tried to arouse the patient, calling his attention to his behavior, Ray regressed to the sleepy yawning state as a defense against the anxiety thereby generated. A cycle was in the making whereby the therapist, in attempting to rouse the patient and thereby deny his own passive wishes, was provoking a state of more irritable boredom in the patient-precipitating further regression and more and more compulsive yawning. A perpetuation of the cycle was avoided when I began to trust my ability to stay awake while relaxing with Ray. When I told the patient that he was not being criticized about his yawning, my statement was not an entirely unconvincing intellectual formulation because I had been willing to discuss my own behavior which, of course, included my own yawning.
My supposition about the part the so-called "noise-making" while yawning played in the patient's original conflicts freed the patient to talk more freely outside the therapy. This amelioration of the patient's tendency to be verbally undemonstrative and my knowledge about the importance auditory cues played in precipitating yawning suggests that yawning may be involved in the development of speech. I would not have thought of yawning as a precursor of verbal communication had I not been able to empathize with the patient about the adaptive aspects of his behavior. Rather than criticizing the patient for his "defense," it proved in this instance more constructive to have him improve upon what he was doing.
Perhaps too much was made of the patient's yawning. At some appropriate moment it might have been reasonable to point out how tiresome the whole matter had become. To some extent voyeurism and covert exhibitionism had run away with me. I had become gradually more and more interested in developing a certain expertise about yawning. Hence, I did not interest myself in the patient's concern over going home and did not involve myself more actively in planning for his separation from the agency. I thereby avoided recognizing the pain connected with the loss of a patient with whom I partially identified. In this way I may unconsciously have dissuaded Ray from continuing treatment after leaving placement. Improper involvement with yawning resulted in a diminution of respect for the patient's need to move in the direction of greater individuation and constitutes one of the dangers of the therapist's being less than optimally attuned to the patient's nonverbal behavior.
A thirteen-year-old patient is presented to demonstrate the therapeutic efficacy of analyzing nonverbal behavior in order to understand more fully the specific phenomenology of yawning. Yawning served a dynamic need to regress. Object relations in this case were obviated by a subjective sensation of merging noted during the hypnoid state associated, and perhaps brought about, by the patient's yawning. In this manner the patient denied separation
from significant others. The automatic, compulsive, imitative nature of his yawning also favored the diffusion of ego boundaries, allowing the patient both to control others magically and to be controlled in turn. Through the depression in his level of consciousness, again associated with yawning, he escaped the dictates of both instinct discharge and conscience.
Viewed from the standpoint of progression rather than of regression, the imitative aspect of yawning may have played a part in a primitive internalization of the object through identification. Yawning, through its controlled reduction in the level of consciousness, might have aided the patient in mastering an unavoidable separation, thereby facilitating differentiation from the object. Satisfying his own passive strivings through yawning perhaps made the patient independent of the real presence of the need-satisfying object. In this context, the capacity to yawn when appropriate may be viewed as constituting a regression in the service of the ego, facilitating a more relaxed, more resourceful autonomous utilization of passivity in the face of life's unalterable vicissitudes.
Nontherapeutic counter-transference may be engendered by a patient fixated at a stage in which a primitive expressive response such as yawning predominates. The therapist is human. He communicates nonverbally as well as verbally and, hence, his own nonexpressive behavior should also be understood, and it should sometimes be a verbally articulated part of the therapy as well.
Hopefully, a detailed discussion of one patient's yawning in conjunction with the review of the literature has helped clarify rather than obfuscate a subject that by its very nature may not favor alert scrutiny.
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