LIVE COMPANY Children whose minds as well as bodies have been damaged by the intrusions of sexual abuse, violence or neglect, and others, quite different, who are handicapped by their own mysterious sensitivities to more minor deprivations, may experience a type of black despair and cynicism that require long-term treatment and test the stamina of the psychotherapist to the utmost. In Live Company Anne Alvarez reflects on thirty years' experi- ence of treating autistic, psychotic and borderline children and adolescents by the methods of psychoanalytic psychotherapy. Cen- tral to the book is the moving story of an autistic child's long struggle between sanity and madness, in which the author describes the arduous journey that she as therapist and he as patient made together towards new understanding and his partial recovery. Modern developments in psychoanalytic theory and technique mean that such children can be treated with some success. In the book the author outlines and discusses these developments, and also describes some of the areas of convergence and divergence between organicist and psychodynamicist theories of autism. Particularly important is her integration of psychoanalytic theory with the new findings in infant development and infant psychiatry. This has enabled her to formulate some new and exciting ideas relevant to working with very disturbed children and to speculate on the need for some additions to established theory. Anne Alvarez has produced a professionally powerful and enlightening book. drawn from her extensive experience as a child psychotherapist at the Tavistock Clinic, which will be of interest to all professionals involved with children and adolescents as well as anyone interested in madness and the growth of the mind. LIVE COMPANY LIVE COMPANY Psychoanalytic psychotherapy with autistic, borderline, deprived and abused children Anne Alvarez Routledge Taylor &Francis Cmup LONDON AND NEW YORK First publishcd 1992 by Routlcdgc 27 Church Road Hovc Cast Susscx BN3 2FA Simultancously publishcd in thc USA and Canada by Routlcdgc 270 Madison Avcnuc Ncw York NY 100 16 Rcprintcd 1993, 1996, 1998, 1999,2002, 2003 and 2006 'liansfcrrcd to digital printing 201 1 (C) 1992 Anne Alvarez Typeset in 10 on 12 point (iaramond by Falcon Typographic Art Ltd, Fife, Scotland Printed and bound in Great Britain by 'I:] I Digital, l'ads tow, (Cornx~ii~ll All rights reserved. No part of this book (nay be reprinted or reproduced or ~~tilireind any for111o r by any electronic, ~iieclianical,o r other means, now known or hereafter invented, including photocopying and recording. or in any information storage or retrieval system, without perniission in writing fi-0111t he publishers. Bi.ili,slz Li111,at:v( 'ulaloguit~git z P~~111ic1~lDion1lztr Alvarez, Anne Live company: psychoanalytic psychotherapy with autistic, borderline. deprived and abused children I. Title 6 18.9289 14 Lihraq*o /'C'otlgrc.s.s( blaloguitzg in Pzlhlic.a/iotz Dnltr Alvarez. Anne 1936- Live company: psychoanalytic psychotherapy with autistic, borderline, deprived and abused cliildren /Anne Alvarez. p. cm. 1. Autism Treatment. 2. Schizophrenia in cliildren Treatment. - - 3. Schizophrenia in adolescence- Treatment. 4. Borderline personality disorder in children Treatment. 5. Borderline personality disorder in adolescence Treatment. 6. Autism - - Treatment- Case studies. 7. Child analysis. 8. Adolescent analysis. I. Title. [DNLM: 1. Autism, Infi~ntilet herapy. 2. Child Abuse psychology. - 3. Psychoanalytic Therapy in infi~ncya nd childhood. 4. Psychotic - Disorders in infi~ncya nd childhood. 5. Psychotic Disorders therapy. - - WS 350.2 A473Ll RS506.A9A58 1992 61 8.92'8982065 1 dc20 - DNLMJDLC for Library of Congress 9140447 C'lP ISBN 978-0-415-06097-4(pbk) How, physically, could the infant mind identify persons? What features of their behaviour are diagnostic of them? Intentional behaviour has a number of features that are not shared with inanimate things, and so an intentional agent may be equipped . . to respond to others like itself.. Inanimate movement runs downhill, oscillates in simple ways, bounces, but it does not surge in self-generative impulses. Anything that tends to make unprovoked bursts of rhythm, like a spot of reflected sunlight, seems alive. This rhythmical vitality of movement is the first identification of live company. (Colwyn Trevarthen 1978) I have no doubt whatever of the need for something in the person- ality to make contact with psychic quality. (Wilfred Bion 1962) CONTENTS Preface ix .. . Acknowledgements xu1 Introduction: modern developments in psychoanalysis 1 1 The long fall 12 2 Vegetable life and awakenings 26 3 Becoming vertebrate 42 4 Growth of a mind: the function of reclamation 5 Reclamation and live company: normal counterparts in the caretaker-infant relationship 6 Making the thought thinkable: perspective on introjection and projection 7 The problem of the new idea: thought disorder and behaviour disturbance as forms of cognitive deficit 8 A developmental view of 'defence': borderline patients LIVE COMPANY 9 The necessary angel: idealization as a development 10 Clinical depression and despair: defences and recoveries 11 Some precursors of reparation in the hardened destructive child 12 Child sexual abuse: the need to remember and the need to forget 13 Beyond the unpleasure principle: play and symbolism 14 Wildest dreams and lies: aspiration and identification in depressed children 15 Autism: the controversies 16 Rites and rituals in autism: the use of the counter-transference. Robbie at 30 Appendix 1 Appendix 2 Bibliography Name index Subject index PREFACE This book is a record of my reflections on the experience of treating autistic, psychotic and borderline children by the meth- ods of psychoanalytic psychotherapy. Some of the children and adolescents I shall describe are psychotic patients who begin to get better, some are borderline psychotics who have been hovering on the brink; all, I hope, give an idea of the two worlds of sanity and madness, the fragility of the one and the ugly and seductive power of the other. Such patients can be helped by psychoanalytic methods, but the treatment is long, arduous, and almost always places considerable strain on the therapist. Yet there is growing consensus that this strain and burden is in some way central to the treatment. Children whose minds as well as bodies have been damaged by the intrusions of sexual abuse, violence or neglect and others, quite different, who are handicapped by their own mysterious sensitivities to more minor deprivations, may experience a type of black despair and cynicism far beyond that felt by neurotic patients. A therapist suffering from too large a dose of therapeutic zeal or of passionate belief in the therapeutic power of psychoanalytic explanation, may experience great disappointment when the child doesn't seem to feel helped by her remarkable revelations, and doesn't seem to change. I have had many such disappointments myself. The patient's terrors may be too overwhelming to be easily named, let alone explained; or his destructiveness or self-destructiveness may have developed, after perhaps years of practice, into high art. The psychotherapist has to be capable of being disturbed enough to feel for the patient, and at the same time sane enough to think with him, until the patient's own ego, his thinking self, grows enough to be able to do it for himself.