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Invisible Boundaries

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The chapters of this book are all written by experienced psychoanalytically oriented psychotherapists and address different aspects of the psychotherapeutic treatment with psychotic children or adolescents. This volume collects the main contributions to the fourth conference of the child and adolescent section of the EFPP, held in Caen (France) in September 2001, on the general topic of "Psychotic Children and Adolescents and their Families".Contributors:Anne Alvarez; Britta Blomberg; Raymond Cahn; Genevieve Haag; Didier Houzel; Suzanne Maiello; Julia Pestalozzi; and Maria Rhode.

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CHAPTER ONE: Autism and psychosis

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Anne Alvarez

Philip Roth wrote recently that politics and literature are not only in an inverse relation to each other, they are in an antagonistic relationship:

To politics, literature is decadent, soft, irrelevant, boring, wrong-headed, dull, something that makes no sense and really oughtn’t to be. Why? because the particularizing impulse is literature. How can you be an artist and renounce the nuance? But how can you be a politican and allow the nuance? As an artist the nuance is your task. Your task is not to simplify. The task remains to impart the nuance, to elucidate the complication, to imply the contradiction. [Roth, 1998, p. 223]

For politician and artist, one could read researcher and clinician, or diagnostician and therapist. Yet the relationship need not be antagonistic. I will be saying a lot about nuances and complexities in children with autism and psychosis, but I shall also make a tiny attempt to bring some order to bear on the clinical issues and on the nature of these mysterious conditions of childhood.

 

CHAPTER TWO: Time, space, and the mind: psychotherapy with children with autism

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Britta Blomberg

Mind

When meeting children with autism in psychoanalytically based psychotherapy, it is necessary to have a multidimensional approach, in which the growth of the child’s cognition presupposes emotional learning and experience in a social context. In order to illustrate what psychotherapy with children with autism may entail, I intend to embark from the, nowadays generally accepted, concept of “Theory of Mind”. In Cassell’s Concise Dictionary (1995) “mind” is described as:

the intellectual powers in man; the understanding, the intellect; the soul; intellectual capacity; recollection, memory; one’s candid opinion; sanity; disposition, liking, way of feeling or thinking; intention, purpose; desire, inclination.

“Theory” is described in the same dictionary as:

supposition explaining something, esp. a generalization explaining phenomena as the results of assumed natural causes; a speculative idea of something, mere hypotheses, speculation, abstract knowledge ….

I want to start from the concept of mind and argue that no theory about this concept can exist before a mind has yet been established. A great deal of literature has been published in recent years on psychoanalytically based psychotherapy with children with autism. Many authors regard the central issue to be a communication disturbance (Alvarez & Reid, 1999, De Astis, 1997, Rhode, 2000). By this perspective one avoids becoming enmeshed in the inflamed debate about the right of interpretation regarding the understanding of the cause of autism. The children, regardless of the cause of their handicap, exhibit severe communication disturbances both towards their closest family and in other relations.

 

CHAPTER THREE: The symbolic and the concrete: psychotic adolescents in psychoanalytic psychotherapy

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Julia Pestalozzi

Unique disturbances in symbolization are characteristic of the pathology of schizophrenia. Drawing on the case vignette of a psychotic adolescent, I discuss theoretical problems in the symbolization process in general and then in psychosis, in particular the relation between “concretism” as a thought disorder and other psychotic defences. The ability to symbolize, on the one hand, and to maintain sufficiently stable ego boundaries on the other, are examined in their relation. My clinical experience supports my hypothesis that there is a close relationship between the impairment of the symbolization process in the adolescent or adult psychotic patient and his/her inability to engage in symbolic play as a child. Special attention is paid to the role of early trauma and consequent pathology of object relations for disturbances of symbolic play in childhood. Regression to concrete thinking is understood as the chance of the psychotic patient to give some meaning to reality in an unreal, delusional world and as his/her last chance to communicate at all. Conclusions are drawn for psychoanalytic techniques in the treatment of patients who are deeply regressed in this respect. Special attention is given to the particular circumstances and challenges of adolescence and to providing psychoanalytic psychotherapy to adolescent psychotic patients.

 

CHAPTER FOUR: Splitting of psychic bisexuality in autistic children

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Didier Houzel

The meticulous application of psychoanalytic technique, together with an outstanding “capacity for reverie”, enabled Frances Tustin to discover the nature of the unconscious fantasy that lies at the heart of autistic functioning and organization: that of an unbridgeable discontinuity between self and object, represented by the “broken button” of her young patient John and by the persecutory feelings of being ripped apart that practically all autistic children express in the course of their psychotherapy. Tustin summarized her findings in her description of the mouth-tongue-nipple-breast discontinuity and the concept of “premature psychological birth”—in other words, the necessity for the child to process an awareness of physical separation from the object, the maternal breast, even though, at that point in development, he or she does not yet possess the mental capacity to symbolize it.

I would like to dedicate this chapter to Frances Tustin. I know that she personally had to face up to terrible anxieties that had to be overcome in order for her to throw light on that fundamental level of human experience at which the Self, emerging from its confusion with the Object, begins to establish its basic identity. In a very moving interview I did with her, she talked of certain crucial moments in her own life, her analysis with Bion, and her discovery of the fantasy that lies at the heart of autistic spectrum disorder. The convergence of these three components was in itself striking, and from it a new light seemed to shine forth. As with any discovery in psychoanalysis, hers was made thanks to an alternating movement between her own personal analysis and her work as psychotherapist. To my mind, it is mainly thanks to that approach, which she carried out courageously and in relative isolation, that we now have a deeper understanding of autism and of the way psychotherapy can help children who suffer from it.

 

CHAPTER FIVE: Comment on Splitting of psychic bisexuality in autistic children

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Suzanne Maiello

Didier Houzel’s paper takes the reader not only to the traumatic origins of autistic states, but his thoughts represent a precious contribution to the exploration of primitive mental states.

Before presenting a few comments on the paper itself, I would like to join into paying tribute to the fertility of Frances Tustin’s thinking. Her legacy contains not only her ideas, but also the courage and constancy that are necessary when we embark on working with children who have withdrawn not to an “elsewhere”, but into “nowhere”, after their experience of a catastrophic laceration of the original container. They have disappeared into a “noplace” and a “no-time”, which Houzel describes as the unconscious fantasy of an “unbridgeable discontinuity between self and object”. This formulation leads to his notion of “pathology of otherness”, in which self and other seem to have fallen into the same nothingness under the threat of differentiation.

The clinical material presented in the paper offers the reader the opportunity to appreciate, over the ten years of therapeutic dedication, the author’s fine balance between sensitive clinical intuition and precise and creative thinking and represents a living example of what Houzel describes as psychic bisexuality of the container.

 

CHAPTER SIX: Conversation with Geneviève Haag (EFPP Conference, Caen, September 2001)

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Introduced by Hélène and Alexandre Dubinsky

Hélène and Alexandre Dubinsky began by referring to the profound influence which the work of Geneviève Haag has exerted on the psychoanalytic treatment of autistic children, on infant observation, and, more generally, on the understanding of primitive anxieties in children and adults who are not on the autistic spectrum. To begin the discussion, they asked her to speak on three questions: on the containing function, with special reference to excitability in children with autism; on the meaning of children passing a ball from one hand to the other (as illustrated in Anne Alvarez’ presentation); and on the issue of the gradual development of the mind, and those factors which make for its gradual nature.

Geneviève Haag

I will start with the question of why I believe that development is gradual—and this is an opinion, I think, that many of us share. Every living being unfolds like a plant, like a tree. I do not believe that everything is present or given at the beginning of life, except perhaps as potential. On the other hand, our efforts to analyse the course of development, starting from naturalistic or clinically-based observation, can suggest many hypotheses.

 

CHAPTER SEVEN: Conversation with Raymond Cahn (EFPP Conference, Caen, September 2001)

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Introduced by François Marty (EFPP Conference, Caen, September 2001)

François Marty

Introducing Raymond Cahn is very difficult for a number of reasons. The first is that reading and re-reading his work engenders a feeling of familiarity that discourages a critical stance. It is as though we had always known what he is telling us. My understanding of this is that we all need to re-interpret his approach to adolescence, to rediscover it, to create it for ourselves (or to imagine that we are doing so). In many cases, we realize that our own supposed discoveries are only a rediscovery of suggestions he made many years previously, when he opened up approaches that could help us to think about such difficult questions as the relationship between adolescence and psychosis. This makes for the first difficulty in introducing someone whose work makes us feel that we are very close to him.

Second, those of you who know his writings will be familiar with the breadth of his culture and of his range of reference, which includes literature, mythology, and history as well as psychoanalysis.

 

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