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CHAPTER THIRTEEN: Shahar: art therapy of a boy with Attention Deficit Hyperactivity Conduct Disorder

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

Hyperactive children are prone to be also impulsive and aggressive, especially if the home environment does not provide both adequate limit-setting and emotional support. The problems of behavioural maladjustment of such children are frequent and occasionally serious enough to justify a distinct diagnostic category, namely Attention Deficit Hyperactivity Conduct Disorder (ADHCD). We have already mentioned in Chapter Six that such a diagnosis should not automatically imply that the child presents the features of an antisocial personality, and it should be applied sparingly. Children with ADHD are frustrated by their developmental impairments (it should be remembered that many children with attention deficit present also other impairments) and angry, like most other devel-opmentally handicapped children. In most cases, however, children with ADHD have an internalized sense of social values (in other words, an integrated super-ego) and a capacity to form affectionate relations, both in the family and outside of it. Their main difficulty is not inadequate socialization but impairment of drive inhibition, affect dyscontrol, and impulsivity. Such children can deriveconsiderable therapeutic benefit from “developmentally informed” psychotherapy, supplemented by parental guidance, in addition to any other therapeutic modality, as described in Chapter Nine.

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CHAPTER TWO: Early development and the developmental matrix

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

The twentieth century, heralded as “the century of the child” (Key, 1911), lived up to that name. The past decades have witnessed a growing interest in the study of children in general and infants in particular, reflected in an expansion of developmental studies. Volumes have been written on child development, and prestigious journals devoted to the subject are being published. The exponential growth of scientific data necessitates a re-assessment of psychoanalytic theory of emotional development. The early developmental theories formulated by Freud (1905, 1915) and his students, as well as those of most later psychoanalytical writers, were, by and large, inferred from reconstruction arrived at during the process of psychoanalysis of adults or older children. Mahler, Pine, and Bergman (1975) were the first psychoanalysts to conduct systematic observations of infants and toddlers. Studies conducted more recently by psychoanalysts such as Stern (1977, 1985) and Shuttleworth (1989) attempt to integrate data from systematic observations of infants and toddlers with data derived from adult or child analysis and are, therefore, more valid empirically than earlier studies. Even so, the subjective experience of the preverbal infant eludes our investigative tools, and theories of early emotionaldevelopment are based, at best, on extrapolation and conjecture, and at worst on fantasies and projections of the adult patient or of the investigator. In spite of these limitations, systematic observations of the infant's behaviour, of his emotional expressions, and of his response to his caregivers provide us with valuable data that have greatly modified our early views on emotional development.

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CHAPTER NINE: Developmentally informed therapy

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

There are several therapeutic modalities for patients whose maladjustment is, in part, a result of developmental impairment. Pharmacotherapy, remedial tutoring, physiotherapy, occupational therapy, and even exotic methods such as therapeutic horseback riding have been employed with varying degrees of success. As a matter of fact, in many cases the optimal treatment plan seems to be a combination of several modalities that complement one other. Our concern here is with remedying the adverse consequences of an atypical endowment for the emotional development of the subject, and therefore our main focus is on psychotherapy, including psychoanalysis. Nevertheless, we will briefly refer to other means of helping the patient, since they need to be included in an overall treatment plan. Such a multimodal treatment plan is illustrated by the case of Dror (Chapter Six).

Our approach to the treatment of patients (and children in particular) who are affected by developmental impairments encompasses the following core elements (the order of presentation does not necessarily imply chronology or degree of importance):

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CHAPTER FOUR: Emotional effects of developmental deviations: the injured self

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

Developmental deviations do not appear as isolated entities. To the contrary, they affect the emotional and social development of the infant and of the child, and they become incorporated into the structure of personality. We have already mentioned some of the effects of idiosyncratic development on how the infant perceives his environment and reacts to it; the response of the caregivers will be discussed in more detail in Chapter Seven. Here we will discuss the effects of developmental deviations on how the infant (and later the child) perceives himself.

Emotional development revolves around the polarities of gratification and frustration. The loving, empathic care of the mother (or an alternate caregiver) assures the prompt satisfaction of physical needs, such as hunger, and of emotional needs, such as the wish for attention or physical closeness. Satisfaction of needs instils in the infant a sense of security, or “basic trust” (Erikson, 1963). Satisfaction of needs, however, is not always possible or prompt, and as a result the infant experiences frustration. If the frustration is neither too distressful nor too prolonged it stimulates growth. The child learns to anticipate satisfaction and delay the satisfaction of his need. For example, a hungry infant who was crying dejectedly a momentago may laugh at the sight of his familiar cup even before gulping the cereal it contains. Anticipation occurs when the infant recognizes the signs of approaching satisfaction; hence, anticipation involves a degree of cognitive organization and an ability to relate the present perception to a remembered one and to the gratification experienced in the past. At the same time, the cycle of frustration and satisfaction stimulates cognitive growth and the ability to contain drives. In other words, emotional development and perceptual-cognitive organization depend on each other. Frustrations also motivate the child to find the means to overcome obstacles and satisfy his wishes; in this way frustration, too, stimulates cognitive and motor development. This stimulation occurs, however, only if the child's efforts lead frequently enough to a successful outcome. If the child's efforts remain futile too often, the result is a temper tantrum or loss of interest, withdrawal and listlessness. Only the sequence of wish-frustration-effort-satisfaction-pleasure has a growth-promoting effect.

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CHAPTER SIXTEEN: Cognition in psychoanalysis and psychotherapy

Aleksandrowicz, Dov R.; Aleksandrowicz, Malca Karnac Books ePub

Psychoanalysis, from its very inception, was conceived of as a cognitive process, influencing the emotional life of the subject, i.e., the person undergoing psychoanalytic treatment. We have in mind, naturally, Freud's first model of the mind, the “topographical” model (Freud, 1923). Freud recognized three domains of psychic processes motivating behaviour: conscious, pre-conscious (i.e., not conscious but available to consciousness), and unconscious. This division was not, in itself, an innovation. The existence of unconscious mental processes had already been recognized by philosophers and psychologists from Leibnitz onward (Massey, 1990). Freud's groundbreaking idea was the concept of the dynamic, i.e., repressed unconscious, an idea so revolutionary that it is being disputed by some cognitive theorists (e.g., Daniel Schacter) and neu-roscientists (e.g., Karl Pribram) even today (both quoted in Loden (2001)). Freud came to the conclusion that some unconscious contents are maintained in that state by the force of repression, and that some of those repressed contents, mainly unacceptable impulses and painful traumatic memories, are at the roots of psychoneu-rotic symptoms. Therefore, the process of psychoanalysis involves removing the repression and bringing the unconscious contentinto consciousness. Other models of the mind followed, and the understanding of psychoanalytic therapy became more complex, during Freud's life and after Freud, but the fundamental idea of making unconscious, repressed content conscious remained one of the mainstays of psychoanalysis. The declared goal of psychoanalysis— i.e., gaining insight—implies, therefore, acquiring new knowledge about one's own unconscious psyche, and this process is unquestionably a form of learning, i.e., a cognitive process. In view of this, it is quite notable that exceedingly few psychoanalytical theorists studied cognition and learning, neither in general nor in the specific context of the psychoanalytic process (Bieber, 1980a; Bucci, 1997; Greenbaum, 1985). The reason for such apparent neglect, most probably, was that Freud, like Breuer, considered affect to be the primary mover in the causation and in the cure of psychoneurotic disorders, and he assigned cognition an auxiliary role in both (Bieber, 1980a, p. 25). Other analysts followed the same approach and implicitly treated cognition as merely an instrument in the process of psychoanalysis. In general, psychoanalysts who did study cognitive processes directed their interest predominantly to the issue of memory and repression (Shevrin, 2002).

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