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Published:

August 15, 2019
 

Emotions, Thinking, and Internal Object Deficits: Anne Alvarez at Derner


by Laura DeRubeis-Byrne, 5th-Year Doctoral Cohort

We are honored to have had Anne Alvarez, Ph.D. present in the Lindemann Lectures in Human Development series, travelling from England to share her wealth of knowledge with us. Anne Alvarez is well known for her books The Thinking Heart: Three Levels of Psychoanalytic Therapy with Disturbed Children and Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline, Depressed and Abused Children. She also spent decades as a consultant child and adolescent psychotherapist at the Tavistock Clinic in London, including serving as Co-Chair of the Autism Service, where she continues to teach. 

Anne Alvarez has a wealth of experience working with severely impaired and disturbed children at the Tavistock Clinic who have impairment in their internalized object(s) that are perverse and/or masochistic. In work with these child patients, Alvarez urges clinicians to use reclamation. Reclamation is a call to action which pieces together fragmented bits of one’s experience and of one’s internal object relations. For these patients who naturally cannot get themselves to reflect, to consider self-other relatedness, an utterance that calls them to react, and to ponder, is the first step in transformation. 

In her talk, Anne Alvarez helped break down what’s transformative for different patients. Analysis of wishes and defenses works for many, but when working with patients experiencing borderline, psychotic, and autistic states, something else is needed. With these people, describing and enlarging meaning through emphasis on the “whatness” and “-ishness” of experience is a way of focusing on needs, containing projections, and facilitating introjections. Lastly, the level which insists on meaning seeks to reclaim, to discourage action and perseveration by a call, like “Hey!,” for example, which can be used when treating the autistic, psychotic, those in despair, and those with developmental delays and addiction and perversion. Feeling with the patient can help in terms of utilizing amplifications that can help to take the pressure off. 

For child patients who are on the autism spectrum or who experience psychosis, the other piece of the puzzle is insisting on meaning, particularly for the affectless states of autism, apathy and chronic despair. The internal object of the child in this state is one that is dead, worthless, and not there. With these patients, there is a theme of the “dead mother.” 

Dr. Alvarez presented her work with a 13-year-old child in a wheelchair named “Robbie.” She described him as physically floppy and shared her sense that “he did not know he was in there, with an underuse of hands for grasping.” She related Robbie to a baby experiencing the breast leaving its mouth and going along with it. That there is a sense of Robbie symbolically not having a mouth separate from his mother’s breast. When working with Robbie, she described to him exactly what she felt, as opposed to saying, “you want me to feel what you feel.” Robbie needed to be called back from his earlier state. From Alvarez it’s not done by using “What” or “Why” but “Hey!” After his “nervous breakdown” he was sobbing while his parents were at his bedside. Anne Alvarez said to Robbie, “Hey! Robbie,” to shake him up internally, to which he replied, “Hello, there!” In this moment something shifted in Robbie. Like a dog perking his ears, she got him to awaken enough to utter a mirrored response, while simultaneously allowing Robbie’s ears to perk up to his own self coming alive. The case of Robbie is an example of reclamation. 

Case Presentation: 

Shira Spiel, M.A., a clinical psychology doctoral student at Derner School of Psychology, presented a clinical case of a three-year-old child named “Darren” who turned four during the treatment. At around 15 months of age, Darren had a severe condition which affected his brain, requiring brain surgery, which left him with speech and developmental delays post-surgery. This child wore a helmet infrequently, was clumsy, was described as leading with his head, and at the start of play therapy he would smack and whack his head. 

When Darren dropped a toy, Shira exclaimed, “Drop!” to signify what had occurred as a reclamation. As a semi-concrete way of enacting and working through Darren’s brain surgery, they made a puppet, cutting the back of the puppet’s head with a pizza cutter, super gluing it together again. 

Throughout this play therapy, Ms. Spiel questioned whether play was too close and too intense. However, Dr. Alvarez believed it was extraordinary, in terms of the utilization of reclamation. At one point, Ms. Spiel draped a knitted cloth over her face while Darren used pretend drills and operating tools to enact surgery on his willing patient. At this juncture in the play Ms. Spiel felt anxious and confused throughout, which she and Dr. Alvarez discussed could be his feelings in the hospital. Play that was acted out tended to utilize non-verbal expression, combining physical act with the symbolic, which helped to integrate Darren’s experience. Themes of perversion were discussed and the blank face of Darren as he was operating, and how it gave Shira chills. Anne Alvarez stated: “what you were doing was essential, because you were giving words to the victim.” And the question emerged, “Could that phenomenon be pre-language? It must.”

Play progressed to Darren hitting and hammering plastic baby dolls with a blanket over their face. Ms. Spiel would label the body part, while Darren picked it up, tossed and stroked the baby, which was one of the first times Darren consistently smiled throughout the play. Ms. Spiel became bored with the repetition of the play while Darren also became bored during these moments. They both got stuck and Ms. Spiel felt hopeless, which Ms. Spiel broke through by expanding the play. Darren would play that he was feeding Ms. Spiel, so he could work through being swallowed and eaten. When Darren’s younger brother was born, play moved to anger, and was more active and verbal in the expression of fear. 

Anne Alvarez and Shira Spiel touch on the clinical significance of utilizing reclamation in clinical work with impaired children where a child can move from pre-verbal and pre-symbolic to symbolic if allowed the opportunity to be activated. How to allow space for the symbolic in our fast-paced world which seeks out empirical evidence and randomized controlled trials and quick fixes? The discussion following this case presentation touched on many points, one of which was neoliberal subjectivity, and this push towards cognitive behavioral therapy, alongside narrative reduction approaches to treatment, increasing depersonalization, increased need for devices, and a reduction in the capacity for dialogue. Dr. Alvarez also shared, in alignment with Churchill, that “we must wage war.” Emphasizing the importance or moral value is not enough, “we need to be activists. If you are going to work with damaged children, you must be psychopathologically and developmentally informed. If you are working with developmentally disabled patients, then you must expand your work beyond classical psychoanalysis and must bridge development with psycho-analysis.” 

 

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