The impact of words on children with ADHD and DAMP Consequences for psychoanalytic technique

Children with attention-defi cit/hyperactivity disorder (ADHD) and disorder of attention, motility control, and perception (DAMP) are often sensitive to the analyst's interventions. This is not always due to the literal import of the intervention. The children sometimes react as if the words were dangerous concrete objects, which they must physically fend off. The author traces this phenomenon to the child's unstable internal situation. A bad, un-containing internal object is easily awakened and threatens to expel the analyst's words independently of their content. This results in violent clinical situations. Infant research and psychoanalytic work with infants and mothers evince how a complex semiotic process develops between mother and baby. The prerequisite for this process to get started and maintained is a secure external object, which gradually is internalized. Findings from developmental research and clinical infant work are used to illuminate analytic work with children with ADHD and DAMP. Vignettes demonstrate how important it is for the analyst to phrase interpretations after having gauged the state of the analysand's internal object as well as his/her own countertransference. If this is overlooked, the psychoanalytic dialogue easily capsizes. The author provides some technical recommendations on the psychoanalysis of these children. As part of the theoretical discussion he raises the general question of how the representations, which the baby forms in interaction with the mother, and the analysand forms in interaction with the analyst, should be classifi ed. Rather than dividing them into bipartite thing- or word-presentations (Freud), the author suggests C. S. Peirce's tripartite semiotic classifi cation in that the baby forms representations of icons, indices, and symbols.     

The Black Man and the Mermaid: Desire and Disruption in the Analytic Relationship

This paper considers the impact of desexualization of the maternal on the development of female sexuality. A “chance encounter” revealing a desire in the female analyst, previously unsuspected, disrupts a female patient's prior sense of homoerotic immersion with the analyst. I argue that a girl's would-be oedipal competition is encased within a patriarchal structuring of sexuality where the mother is rendered solely reproductive and preoedipal, not erotically sexual. I examine the meanings for a patient of internalizing a female figure, her analyst, who is viewed as both maternal and sexual. I suggest that a female sense of genital inadequacy and inferiority may have a component of not being able to link the mother's (and in the transference, the analyst's) use of her genitals with her use of her mind/maternal function. I unfold a thesis regarding maternal desexualization that I believe, given mother–infant symbiosis, has rather extensive applicability, and that can lead to viewing any third party as a “dark” interloper.     

The role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

‘Telepathic’ phenomena and separation anxiety

By discussing a treatment characterized by its difficult ending, the author strives to show the dynamic impact of separation on phenomena that can be seen as ‘telepathic’. Led to develop some inalienable attachment to her analyst in the primary transference, the analysand found herself caught up in the contradiction of her visceral dread of dependency, which compelled her to interrupt the work in progress. She then began to work out her analyst's comings and goings and to run into him in public places, as if to be assured of his immovability. This phenomenon arose with high frequency as the effect of some idealization of the maternal object aiming to deny the spatiotemporal gap. The chance that the experience of rejection via indifference may be repeated also entailed the transferential unfurling of a fantasy involving a double, undifferentiation counterbalancing the lived experience of separation. Furthermore, a ‘telepathic’ dream occurred as confirmation of this twin relationship which illustrates the analysand's refusal to renounce her narcissistic object. Projective identifications, agglutinated ego nuclei along with primitive cross‐identifications could, among other concepts, account for such phenomena which are projective in nature yet real all the same. Such mechanisms could have the power to relay thoughts the moment undifferentiated parts of the ego – if not unborn parts of the self – were activated in a potentially symbiotic zone. Marked by a feeling of dispossession, the analyst's countertransference not only seemed to underscore this hypothesis, it also gave a partial explanation for it. Until the analyst could recognize his own nostalgia for a symbiotic relationship, he had to encourage the occurrence of those unexpected meetings which stemmed from a convergence between the transference and the countertransference.     

Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.     

Contacting a 19 month‐old mute autistic girl: A clinical narrative

Conveying that psychoanalysis offers rich opportunities for the very early treatment of autistic spectrum disorders, this clinical communication unfolds the clinical process of a 19 month‐old ‘shell‐type’ encapsulated mute autistic girl. It details how, in a four‐weekly‐sessions schedule, infant Lila evolved within two years from being emotionally out‐of‐contact to the affective aliveness of oedipal involvement. Following Frances Tustin's emphasis on the analyst's ‘quality of attention’ and Justin Call's advice that in baby–mother interaction the infant is the initiator and the mother is the follower, it is described how the analyst must, amid excruciating non‐response, even‐mindedly sustain her attention in order to meet the child half‐way at those infrequent points where flickers of initiative on her side are adumbrated. This helps attain evanescent ‘moments of contact’ which coalesce later into ‘moments of sharing’, eventually leading to acknowledgment of the analyst's humanness and a receptiveness for to‐and‐fro communication. Thus the ‘primal dialogue’ (Spitz) is reawakened and, by experiencing herself in the mirror of the analyst, the child's sense of I‐ness is reinstated. As evinced by the literature, the mainstream stance rests on systematic early interpretation of the transference, which has in our view strongly deterred progress in the psychoanalytic treatment of autistic spectrum disorders.     

The unwelcome child and a lack of acceptance of new ideas

Ferenczi’s idea of the unwelcome child and his death instinct is used as a background for discussing the treatment of adult patients who do not expect to be received and understood and who turn their aggression back upon themselves, destroying their will to live. When these patients enter analysis, they are very difficult to reach because they have internalized an obstructive object (Bion, 1958). Further, I have linked the unwelcoming of a child to the hatred of the new idea. The paper highlights the deadening defenses that arise in response to awareness of premature separateness between mother and baby, inevitably experienced by an unwelcome child. Coming alive involves suffering the pain of the original loss. To avoid this pain, patients reject anything new, and become stuck in monotonous, seemingly lifeless, patterns where new ideas and new ways of being threaten the static order. This includes the threat that relationship with the analyst brings.

     

Being, thinking, creating: when war attacks the setting and the transference counter-attacks

When trauma enters into the reality of the analyst and of the analysand, when it attacks the setting, what becomes of the analyst’s role? How can transformations be brought about? With reference to three clinical situations, the author attempts to explore how the articulation between transference and countertransference – the inter‐relation – structures the situation; the analyst must remain in his or her role as analyst through managing to create and to reflect upon the clinical aspects of that situation when faced with the unpredictability of what war brings in its wake. It then becomes possible to see how the work of the negative can be confined to the outer limits of the setting.     

From mimesis to agency: Clinical steps in the work of psychic two‐ness1

In this paper, through the study of the clinical process of a girl starting treatment at the age of 3 years 10 months, who was thought of as a dummy by her family and who came for consultation when the assumed genetic aetiology was questioned, the authors build upon Tustin's contributions on the context of togetherness and the crisis of two‐ness, and upon Eugenio and Renata Gaddini's on the precursor object. The mimetic phenomena enacted with an older brother and at the kindergarten are found to result from cumulative trauma at her contacting a loving but mind–blind mother. After an initial stage of transference autism, enactment in the session of the traumatic situation was the first step in surmounting her autistic pseudo–stupidity. Mimetic transference dynamics took place principally at the level of the gaze, leading to the unfolding of the work of two–ness to a differentiation from the analyst as psychic breast, on the road to symbol formation and personal agency.     

Infantile Trauma,Therapeutic Impasses and Recovery

Throughout his writings Ferenczi examines the role of the mother–infant relationship in healthy development as well as the difficulties that occur when that relationship is problematic. This paper using Ferenczi and Bion as theoretical background explores the clinical development of impasse in the treatment of hard to reach patients. These patients present special difficulty for analysis because they are not self reflective although they can be addicted to “processing,” which is in lieu of emotional connection. Impasse occurs when the analyst does not detect the mimicry involved in processing. The paper offers the idea of recovery, rather than repair, in that such patients have “gone missing” in infancy. Recovery of lost potential can be found in relationship with the analyst and with significant others.     

A falsifying adolescent

The author describes an adolescent patient who, while often speaking factual truths, maintained an aura of falsity in her life, and in two interludes of psychoanalytic psychotherapy, that functioned as a barrier to psychological insight. To match her falsity, the analyst at times modified his functioning as a "real" therapist and took on her personification of neglectful and false adults. Eventually, the analyst became an object that the adolescent could trust and rely on. In discussing the case, the author introduces and applies Bion's ideas regarding truth and falsity, and three variations of container-contained relationships-symbiotic, commensal, and parasitic-in the context of the case's relational perspective.     

When patients contribute to the choice of treatment.…

To explore an alternative solution more appropriate to clinical standards than random assignment, 42 mothers consulting for a functional (sleep, feeding) or behavior problem of their infant were given the choice between two forms of mother–infant psychotherapy (Psychodynamic or Interaction Guidance). Clinicians, blind to mother's choice, followed a systematic indication procedure and provided a therapeutic recommendation. Results revealed a very high agreement between mother's choice and therapists' recommendation. Examination of patient and pretreatment variables showed no major differences between the two groups resulting from a choice of treatment procedure. This procedure proved to ensure internal validity of the data and was also able to guarantee external validity. Discussion focuses on the methodological and clinical implications of the findings that support the consideration of the patient as an active participant to his/her treatment. © 1998 Michigan Association for Infant Mental Health     

The illumination of history

Formulations regarding the patient's history have not only played an important part in understanding the patient, but interpretations explicitly linking the present with the past have been seen as central to the therapeutic process. In this paper the author considers the role of historical reconstruction in bringing about psychic change. He emphasizes the therapeutic value that lies in the exploration of the way the patient's history is embodied in his internal object relationships, becoming manifested in the transference-countertransference relationship. The author presents clinical material which he suggests allowed the analyst to follow the way the patient's internal object relations, coloured by her history, became expressed and played out in the sessions. He suggests that, when these processes can be followed and addressed in the present, this may lead to a diminution in the underlying anxieties. This can thus promote psychic change by freeing the patient's capacity to achieve a sense of connection with her history, and to tolerate the meaning of what emerges, which illuminates both the present and the past.     

ON LOVE AND MELANCHOLIA IN MARGUERITE DURAS'S AUTOFICTION

In the Durassian melancholic atmosphere, past and present, fantasy and reality come together as one. This paper addresses the themes of love and destruction in Marguerite Duras's life that pervade her oeuvre, allowing us to discern a melancholic structure within her autofiction. Writing down her melancholia—the impossible mourning of a loved object—Duras captures nothingness and loss—in order not to die of love. In a constant exchange with her readers, she searches for herself and delivers herself to her readers. This renewable creative process of writing enables her to engage in an ongoing experience of identity reconstruction, in a way similar to the patient in psychoanalysis re‐creating his/her life's fiction.     

Trauma and the transference‐countertransference: working with the bad object and the wounded self

This paper focuses on the transference‐countertransference dynamics that manifest in work with those individuals who experienced severe early relational trauma and, in particular, childhood sexual abuse. The literature is surveyed from Davies and Frawley's (1992a) seminal paper through to more current trauma‐related and sensorimotor approaches, which deepen our understanding greatly. The rapidly shifting, powerful, conflicting and kaleidoscopic transference‐countertransference dynamics are explored in the light of these views and in relation to a lengthy clinical example. The author elucidates the dual‐aspect of the traumatic complex, whereby the abuser figure, which is disavowed by the patient, becomes manifest in prosecuting the analyst for the ‘wounds’ that the analysis evokes. The paper also explores the particular nature of the splitting processes, whereby pressure is put on the analyst to adopt an idealized role, in particular to act as a self‐object, in order to enable the patient to safely express and ‘be’ themselves in an attempt to make up for what was not possible in childhood; the analyst will necessarily fail in this task. In the context of powerful masochisto‐sadistic dynamics, the analyst's masochism is likely to be called up in the spirit of caring ‘humanity’ (another inevitable enactment), which can impede the progress of the analysis if not addressed. The extreme woundedness, intense affect and moral outrage associated with these dynamics are characteristic and compelling. Issues relating to disclosure, enactment and analytic attitude are also discussed.     

Infantile defences in parent‐infant psychotherapy: The example of gaze avoidance

Findings from parent‐infant observational research have stimulated the development of intersubjective models of psychotherapeutic action. These models have brought out the infant as an interactive partner with the parent. Conversely, interest in describing the individual psyche of the baby has decreased, especially the unconscious levels of his/her experiences and representations. In parallel, clinicians and researchers have been less prone to apply classical psychoanalytic concepts when describing the internal world of the infant. The author argues that this is inconsistent with the fact that psychoanalytic theory, from its inception, was founded on speculations of the infant's mind. He investigates one such concept from classical theory; the defence. Specifically, he investigates if selective gaze avoidance in young babies may be described as a defence or even a defence mechanism. The investigation links with Selma Fraiberg's discussion of the phenomenon and also with Freud's conception of defence. The author also compares his views on the baby as a subject with those suggested by infant researchers, for example, Stern and Beebe. The discussion is illustrated by vignettes from a psychoanalytic therapy with a 3 month‐old girl and her mother.     

Finding the depressed object in the obsessional: a clinical study

In this paper the author explores the clinical significance of the presence of a depressed internal object in a patient with marked obsessional features, dominating the patient's internal world and restricting relations in external life. After discussing important aspects of the contribution of Freud and later writers to the study of obsessional neurosis, the author provides clinical material that shows the patient's tormented relationship to a feared depressed object that was manifested in the transference. Developing her argument, the author suggests that if the analyst does not fully grasp the primitive anxieties of the underlying state of mind she can be prone to enter into an aggressive enactment with the patient's sadistic superego. This kind of enactment may arouse excitement and triumph in the patient, but actually confirms his doubts and fears about the capacity of his object to contain him.     

‘Black holes’: escaping the void

The ‘black hole’ is a metaphor for a reality in the psyche of many individuals who have experienced complex trauma in infancy and early childhood. The ‘black hole’ has been created by an absence of the object, the (m)other, so there is no internalized object, no (m)other in the psyche. Rather, there is a ‘black hole’ where the object should be, but the infant is drawn to it, trapped by it because of an intrinsic, instinctive need for a ‘real object’, an internalized (m)other. Without this, the infant cannot develop. It is only the presence of a real object that can generate the essential gravity necessary to draw the core of the self that is still in an undeveloped state from deep within the abyss. It is the moving towards a real object, a (m)other, that relativizes the absolute power of the black hole and begins a reformation of its essence within the psyche.     

Misrecognitions and the fear of not knowing

A form of pathological internal object relationship is described that timelessly perpetuates the infant's subjective experience of the mother's difficulty in recognizing and responding to her infant's internal state. The individual identifies with both the mother and the infant in this internal object relationship and experiences intense anxiety and despair in relation to his efforts at knowing what he is feeling and therefore of knowing who he is. Substitute formations are utilized to create the illusion that the individual knows what he feels.     

PROBLEMS OF INTERNALIZATION: A BUTTON IS A BUTTON IS—NOT

Analysts hope to help the patient internalize a relationship with the analyst that contrasts with the original archaic object relation. In this paper, the author describes particular difficulties in working with a patient whose defenses and anxieties were bulimic, her movement toward internalization inevitably undone. Several issues are considered: how does the nonsymbolizing patient come to internalize the analyst's understanding, and when this does not hold, what is the nature of the patient's subsequent methods of dispersal? When the patient can maintain connection to the analyst as a good object, even fleetingly, in the depressive position, the possibility of internalization and symbolic communication is increased.