The Thinking Heart: Three levels of psychoanalytic therapy with disturbed children / Edition 1

by Anne Alvarez

Overview

How do we talk about feelings to children who are cut off from feeling? How do we raise hope and a sense of safety in despairing and terrified children without offering false hope? How do we reach the unreachable child and interest the hardened child?

The Thinking Heart is a natural sequel to Live Company, Anne Alvarez' highly influential and now classic book about working with severely disturbed and damaged children. Building on 50 years experience as a child and adolescent psychotherapist, Alvarez uses detailed and vivid clinical examples of different interactions between therapist and client, and explores the reasons why one type of therapeutic understanding can work rather than another. She also addresses what happens when the therapist gets it wrong.

In The Thinking Heart, Alvarez identifies three different levels of analytic work and communication:

• the explanatory level – the "why - because"

• the descriptive level - the "whatness" of what the child feels

• the intensified vitalizing level - gaining access to feeling itself for children with chronic dissociation, despairing apathy or 'undrawn' autism.

The book offers a structured schema drawing on and updating some of her classic work. It is designed to help the therapist to find the right level of interpretation in work with clients and, provides particular help with the unreachable child. It will be of use to Psychotherapists, Psychoanalysts, Clinical and Educational Psychologists, Child Psychiatrists, Social Workers, Special needs teachers and carers of disturbed children.

Anne Alvarez is a Consultant Child and Adolescent Psychotherapist and is retired Co-Chair for The Autism Service at the Tavistock Clinic, London. She is currently a visiting teacher and lecturer for the Tavistock Clinic, and a Lecturer on the San Francisco Psychoanalytic Society Child Programme.

Product Details

ISBN-13:	9780415554879
Publisher:	Taylor & Francis
Publication date:	04/04/2012
Pages:	232
Product dimensions:	6.10(w) x 9.10(h) x 0.50(d)

About the Author

Anne Alvarez is a consultant child and adolescent psychotherapist and is retired co-chair for the Autism Service at the Tavistock Clinic, London. She is currently a visiting teacher and lecturer for the Tavistock Clinic, and a lecturer on the San Francisco Psychoanalytic Society Child Program.

Table of Contents

List of illustrations xiii

Acknowledgements xv

Introduction 1

The plan of the book 4

A particular element in descriptive work: attention to moments of gladness and curiosity 5

Brief note on the table and figures 6

1 Levels of therapeutic work and levels of pathology: the work of calibration 7

Introduction 7

The continuum of technique from the top level down 11

Elaboration of the state of mind of the patient relevant for work at the three levels 14

Conclusion 24

Part I Explanatory level conditions 27

2 Some emotional conditions for the development of two-tracked thinking: the sense of agency and the sense of abundance Anne Alvarez Piera Fiurgiuele 29

Introduction 29

The development of two-tracked thinking and observation of Alice 32

Observation of Paul 35

Observation of Angela 40

Summary and clinical implications 41

3 Obstructions to and developments toward sequential thinking: some connections between phantasy, thinking and walking 43

Introduction 43

A word about definition: phantasies and thoughts or phantasying/ thinking? 45

A correspondence between motility and thinking, and the need to include the temporal along with the spatial dimension in work with three children 47

Technical implications 51

Discussion and conclusion: the development of walking and of language 52

4 Making links and making time: steps toward the de-compression of thoughts and the establishment of links between thoughts 55

Introduction 55

The temporal shaping of reality: a modulating presence 56

Bion on the relationships between thoughts 57

Daniel and the conjunctive link 59

The 'and' link in play: an ordinal link 60

Discussion: play and syntax 61

Conclusion 63

Part II Descriptive level conditions 65

5 The equal role of delight and frustration in the development of a sense of reality 67

Introduction 67

Psychoanalytic theories of frustration 68

When frustration is too great: the problem of 'tenible surprises' 71

Can some apparent 'defences' against frustration be seen rather as attempts to overcome or regulate frustration and disturbance? 72

Pleasure, safety and delight as necessary to emotional health 74

Pleasurable states as active, accompanied by thought and provoking of thought 75

Conclusion 77

6 Moral imperatives and rectifications in work with tormented and despairing children: wishes or needs? 78

Introduction 78

Developments in psychoanalytic theory 79

Technical implications of developments in psychoanalytic theory 79

The grammar of projective identification: technique with wishes versus needs 80

The patient and my unmasking interpretations 82

Discussion: four considerations 86

Conclusion 89

7 Motiveless malignity: problems in the psychotherapy of patients with psychopathic features 90

Introduction 90

A child with psychopathic features 91

Some clinical differentiations between neurotic, borderline and psychopathic states of mind 93

Technical problems with patients with psychopathic features 95

A second example of a child with psychopathic features: Billy 97

Discussion and conclusion: four technical issues 100

8 Issues of narcissism, self-worth and the relation to the stupid object: devalued or unvalued? 102

Introduction 102

Definition of narcissism 103

Some background history of the move to an internal two-person psychology regarding narcissism 104

The question of narcissistic psychopathology in children 105

Three sub-types of narcissism 106

The developmental trajectory in narcissism and some further technical issues 110

Three sub-types of apparent narcissism and the question of technique 111

Conclusion: consequences of recovery and further technical issues 115

9 Types of sexual transference and countertransference in work with children and adolescents 116

Introduction 116

A brief history of psychoanalytic ideas on childhood sexuality 116

The question of the normal erotic transference and counter-transference 120

An example of perverse sexuality in a child 122

Disordered sexuality 124

The normal sexual self and questions of technique: that is, use of our countertransference responses to these 125

Childhood sexuality: the question of the parental object's role 127

A clinical example of delayed Oedipal development 128

Conclusion 129

10 Under-integrations and integrations at the paranoid-schizoid level 130

Introduction: Bick's controversial views on unintegration 130

Can all apparent unintegrations be seen as the result of disintegrating processes acting upon prior integrations? 131

Do unintegrated states exist at all? The question of the degree of cohesiveness of the early ego 132

Is unintegration the primary and earliest phase of development? Do Bick's ideas challenge the views of Klein and the developmentalists? 134

Is integration a necessary precondition for object-relatedness? 134

What else remains of value in the Bick argument? Do some needs take priority over others? 135

The question of integration at the paranoid-schizoid level 136

Modes of early pre-depressive and pre-Oedipal integrations and integrators: technical implications 137

Conclusion 143

Part III Intensified vitalizing level 145

11 Play and the imagination: where pathological play may demand a more intensified response from the therapist 147

Introduction 147

The issue of the importance of play and the imagination 148

Psychoanalytic theories of phantasy and play 150

The significance of play and the imagination for introjection and thinking 151

Infant studies: the importance of playing 'with' 152

The continuum of levels of symbol formation 153

A clinical example of a patient at a fourth position below or beyond a symbolic equation: technical implications for working with meaningless play 155

A clinical example of apparently transitional play which was in fact at times closer to a symbolic equation, at other times more addictive and frenzied 156

The problem of perverse play: a fifth position on the symbolism

continuum 158

Discussion: can we still be psychoanalytically minded and play with the child, or even innovate and rouse the desire to play? 160

Conclusion 162

12 Finding the wavelength: tools in communication with children with autism 163

Introduction 163

Normal infant development and proto-language 165

Language and triadic skills involving visual regard 165

Therapeutic implications of impairments in communication: getting on the right developmental wavelength 167

Joseph 168

Discussion and conclusion 172

13 Further reflections: countertransference, the paranoid and schizoid positions, and some speculations on parallels with neuroscience 174

Introduction: the level of mental disturbance and mental illness in children and adolescents 174

Re-examining the paranoid-schizoid position 174

The danger of 'manualizing' psychotherapy 177

Countertransference 178

Further examples of intensified work 178

Some possible parallels with neuroscience 181

A technical parallel 183

The transference 184

The setting 185

Appendix 187

Bibliography 190

Index 207

Editorial Reviews

"The Thinking Heart would be a useful text for any psychoanalytic scholar, independent psychotherapy practitioner or group of practitioners hoping to deepen their psychoanalytic understanding, particularly in relation to child psychoanalytic sychotherapy... [this book] reminds me why I continue to work with children and why I love it so much, despite the many challenges that go hand in hand with child psychotherapy." - Jenny Perkel, New Therapist, November/December 2012

"The Thinking Heart is a very full and moving book. It repays the careful responsive mindfulness that Alvarez advocates in clinical practice... In this book's lyrical synthesizing of science and art in examining the process and efficacy of psychotherapy with disturbed children, we can indeed hear her heart beat as we hear her think, as though they were one and the same process." - Sarah Sutton, ACP Bulletin, 2012

"Alvarez is a great teacher; her knowledge is immeasurable, her writing is brave and her reflections are humble. She claims that her thoughts are ‘only considerations, because the complexity of the human mind... ensures that there can be no manual’ (p86). I believe that the work of Anne Alvarez is the closest we can get to such a manual." - Jeanine Connor, Therapy Today, November 2012

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