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Psychoanalysis and Developmental Therapy

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Many books have recently appeared on a variety of psychoanalytic topics, but relatively few have dealt specifically with problems of technique and with the theory that informs those techniques. It is therefore particularly fortunate that this book does just that.The central and greater part of the book consists of a series of detailed descriptions of clinical work with children. The authors have something in common, all have trained wholly or in part at the Anna Freud Centre. They have been guided in their understanding of their patients' problems by a fundamentally psychoanalytic orientation in which the role of internal conflicts, anxiety, guilt, love and hate, primitive as well as more sophisticated object relations, and a complex variety of defenses take a central place. They have also been influenced by their knowledge of normal development and their awareness of the pathological consequences of uneven or faulty development. Their psychoanalytic technical approach has been influenced by recent advances in our understanding of development, in particular of the nature of infant attachment, of the vicissitudes of attunement between mother and baby and their consequences, and of the vital importance of mentalization and the reflective function.

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1. An interpersonal view of the infant

ePub

Peter Fonagy & Mary Target

This chapter aims to help extend ideas emanating from infant observational data into clinical work. Research on the social development of infants is probably the area of empirical science with most influence on psychoanalysis. The work of Stern (1985,1994) as well as of Robert Emde (1980a, 1980b, 1981, 1988, 1992) established infant research as central to the further evolution of psychoanalytic theory. There have, however, been some cogent objections to the impact of infancy research on psychoanalysis. For example,.Wolff (1996) warned of the epistemo-logical dangers in extrapolating from infant research to the behaviour of adult patients. Others point to what such perspectives omit from the traditional psychoanalytic approach (e.g. Fajardo, 1993; Green, 1995). We welcome this dialogue and to an extent agree with these cautions, particularly that new ideas should not be felt to devalue the truth of the old—that the baby should always be taken safely out before dealing with the bathwater. Nevertheless, our sense is that many clinicians would join us in seeing the findings of psychoanalytically oriented empirical studies of early development as of clear relevance to clinical understanding and technique (see Lichtenberg, 1987).

 

2. Psychoanalysis and developmental therapy

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Anne Hurry

“Where are finished or developing character structures open to influence? We know they are open to many influences, because there are many people who never have therapy and who still undergo quite extraordinary personality changes during their life-time, according to experience in relationships … sometimes experience through frustration, sometimes through satisfaction, sometimes through a new world opening up to them. And this is largely an unexplored field, but very worthwhile to explore from what we see happen in child analysis.”

Anna Freud,1 quoted in Penman, 1995

Psychic development is a lifelong process, subject to both inner and outer influences, the outcome of a continuous interaction between what is innate or has become inbuilt in us and the relationships and circumstances that we encounter.

Today, there is considerable interest in the “innate”, in the genetic roots of psychological development and its disturbances, and our growing knowledge here should prove valuable in helping us to offer appropriate treatments. (See Cohen, 1997, for a brief review of organizing or influencing biological factors in various childhood disturbances.) But emphasis on the innate can be used to oversimplify complex psychological phenomena. Biological reduc-tionism, increasingly evident in the current scientific climate, can lead to a kind of therapeutic nihilism: psychotherapy becomes an irrelevancy or restricts its aims, offering only improved management; gene therapy or drug therapies are seen as the answer to psychological difficulties.

 

3. “Tom”: undoing an early developmental hitch

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Anne Hurry

At 10 years of age, Tom was a miserably unhappy, anxious child. He would run away from home or threaten suicide, saying that his parents did not love him. He walked in his sleep and had nightmares. He was failing at school, hated the teachers, and felt that they hated him. He hated and fought with his older brothers.

Tom was from an intact and fundamentally loving family, but early illness, hospitalizations, and medical procedures had traumatized him and had caused his parents great concern. Painful physical illnesses, including middle-ear infections, continued up to an operation at the age of 3 years. Tom woke, screaming, during the operation. Throughout latency he remained vulnerable to infections, and he often had headaches or tummy aches. These reinforced parental concern for his health.

Tom’s early illnesses served to initiate a masochistic mode of relating. Physical pain, and later also psychic pain, became a way of reaching and controlling the object. Yet this was only part of the picture. The capacity for positive object-relating which emerged in treatment suggests that, in early pain-free times, mother was able to relate happily with him.

 

4. “Paul”: the struggle to restore a development gone awry

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Anne Hurry

For most of his analysis, “Paul” maintained he did not want to come, and he tried to manipulate the ending of treatment. Towards me he was sadistic, degrading, mocking, and insulting, often consciously hoping to render the situation unbearable for me, and to force me to finish with him. All earlier attempted interventions at a number of different institutions had broken down or come to nothing. By the time he was 11 years old, Paul’s difficulties were such that analysis seemed his only chance, even given his expressed unwillingness to come. At this point his Irish parents were prepared to insist on his having help. They were alarmed by his extreme hatred of his younger sister and by his crippling phobic symptoms and contamination fears. Family life had been taken over by their attempts to cope with Paul’s difficulties.

There were many other problems. Paul had nightmares of vampires and rats, and he would not eat meat or food that had to be chewed. He was extremely messy, spilling and smearing his food. He was clinging and demanding and often “abusive, offensive, and insulting”. Not surprisingly, he had no friends.

 

5. “Martha”: establishing analytic treatment with a 4-year-old girl

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Anne Harrison

In this chapter, I describe the early months of treatment of a little girl in five-times weekly analysis. I focus on the particular quality of the difficulties that she brought and consider what it was that we had to struggle with together for interpretative work to begin.

“Martha” was 4 years old when she was referred for assessment. Although intelligent and musically gifted, she was disabled by fears and phobias, a need for rigid control, and, above all, an inability to form relationships outside her immediate family. At home, she demanded to be bottle-fed, to be carried, to use nappies, and generally to be treated as a baby. The referral was initiated by her nursery school, who were alarmed that now, in her last year before school, she continued to avoid any real engagement with staff and seemed entirely to blank out the presence of the other children. Her parents were doubtful about the referral at first, feeling that, although she was odd and difficult, this was perhaps an unavoidable aspect of what made her special.

 

6. “Donald”: the treatment of a 5-year-old boy with experience of early loss

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Viviane Green

Donald’s” early development unfolded in a chaotic environment. His young parents had not planned for a baby. They battled acrimoniously, separating in his first year. Thereafter he had no permanent home. Mother was an alcoholic, and father would take over when he felt that Donald was at risk, or Donald would stay with his aunt and uncle.

It was father who approached the Anna Freud Centre’s Well Baby Clinic for help in managing the baby’s outbursts of kicking and screaming. He kept regular appointments. Mother came twice; she sought to convey her love and interest in her child, but she went to great lengths to conceal the extent of her alcoholism. Both parents tried to stabilize their son’s rather chaotic routine, but father felt overwhelmed by his parental responsibilities and had difficulty in setting limits.

When Donald was almost 4 years old, he began to attend the Centre’s nursery school. An appealing and intelligent child, he enjoyed a wide range of activities. He was proud of his physical abilities, and he had a playful imagination. But he found it difficult to contain his aggression and would bite other children without provocation. He became attached to the staff but was defiant and provocative towards them. His anxiety and unhappiness were evident in his agitation and severe nail-biting.

 

7. “Michael”: a journey from the physical to the mental realm

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Tessa Baradon

In this chapter I discuss a particular aspect of the role of the analyst’s mind in constructing the psychological world of the child patient.

The material is drawn from the case of “Michael” who, at 6 years of age, continued to express affect and ideas through his body and seemed blocked in his capacity for symbolic representation. The referral came from his headmistress, who regarded Michael as the “silliest boy in the school”. He was unable to cope in the classroom or the playground and had no friends. Although his parents recognized some of his difficulties, throughout his treatment they remained conflicted about whether he needed help or had simply been born with a certain “character”.

Michael was from an intact and closely knit family. His primary caretaker and attachment figure was the mother, whose investment in Michael was intense and highly ambivalent: an idealized closeness with him—gratifying but intrusive to both—alternated with rages in which loving ties were temporarily withdrawn, leaving him desolate and furious. At the age of 2 years, after his brother’s birth, Michael was taken from his mother to spend three weeks with his father in their country of origin. In the parents’ account, problems came to a head at this stage: thereafter, Michael remained a frightened, restless child, unable to separate or settle at nursery and school.

 

8. “Maya”: the interplay of nursery education and analysis in restoring a child to the path of normal development

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Marie Zaphiriou Woods & Anat Gedulter-Trieman

This chapter shows how education and analysis can work together to promote children’s development. In exploring the border between therapy and education, Edgcumbe (1975) defines education as “the contribution of the environment to the development and maturation of the individual’s personality, capacities, skills, and talents” (p. 133). While acknowledging that children’s parents are their first and most important educators, she highlights the essential contribution of teachers, particularly in the areas of learning and socialization. A good teacher may provide a unique opportunity to form new and different relationships, with wide-reaching implications for development in all areas of the personality, especially for children from isolated and troubled families. Similarly, one of us [MZW] has shown how “Nursery provision … can encourage body management, enhance self-esteem, improve relationships, stimulate speech development and intellectual functioning in general, and so facilitate adjustment to the community at large” (Zaphiriou Woods, 1988, p. 295). Under-5s are particularly amenable to a teacher’s influence because “their personalities are still in the early stages of structuring. At this age, benign external influences can contribute to the growth of positive self and object representations which can modify or counterbal- ance the pre-existing structures arising from less than satisfactory early experiences” (p. 295).

 

9. “Leo”: multiple interventions in the case of

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Maria Grazia Cassola & Adriana Grotta

Having shown signs of difficulty from birth, “Leo” has always been kept under observation and has been under the care of a number of different NHS professionals. At the age of 5 years, displaying marked autistic features, he was taken into psychotherapy by a private therapist [AG].

The psychotherapy was developmental in nature. Leo lacked psychological structure and had never developed a differentiated sense of self and other; interpretative work would have been incomprehensible and irrelevant to him in the period of treatment recounted here. He has recently, aged 9, made important and unexpected developmental steps. We therefore describe the various different types of intervention used and discuss the factors that have promoted his development.

Leo is a good-looking boy with large blue eyes. In the past, he was unwilling to make eye contact; now, he increasingly uses his eyes to get in touch with others, although when eye contact becomes too intense he looks frightened and averts his eyes. A year ago, it was discovered that he was short-sighted and had a congenital cataract; he was happy to be given glasses.

 

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