Being Alive

Building on the Work of Anne Alvarez

Judith Edwards

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317711070
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book is a celebration of the work of Anne Alvarez, an enormously influential psychoanalytic psychotherapist whose work on autism and severe personality disorders in children has been important internationally. This book: * brings together assessment of the influence of Alvarez's work across a range of child psychotherapy and related areas * evaluates how her ideas affect the most current developments in these areas * includes contributions from renowned psychoanalysts and psychotherapists from around the world. It will be of great interest to child and adolescent psychotherapists in training and practice, and also to clinical psychologists, psychoanalysts and psychiatrists working with autistic/severely disturbed children.

Part I

Mainly theoretical

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Chapter 1

Bridging the Atlantic for psychoanalysis

An appreciation of the contributions of Anne Alvarez

Neil Altman

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In the evolution of a field such as psychoanalysis there need to be both close-knit subcommunities with a common vision and commitment, and cross-fertilization between and among subcommunities. Subcommunities create the conditions under which people feel they are working on a common project, inspiring each other and feeling inspired and nurtured by one or more intellectual leaders. Synergy and enthusiasm develop as people, excited by a unique or novel point of view, spell out the view's clinical and theoretical implications. The very solidarity that creates a sense of community, however, can also give rise to onesidedness, an ingrown tendency. Cross-fertilization, promoted by people who cross borders between communities, creates the potential for something new, unexpected, creative.

Anne Alvarez is both a solid member of the Kleinian community, and among the most creative of border-crossers. As such, her work enriches us all. Her writing, firmly rooted in the Kleinian tradition, shows the influence of recent North American psychoanalytic thinking in the self-psychological and relational traditions. I like to think that this particular theoretical integration reflects a generative marriage, within Alvarez, between the cultures of her Canadian roots and her British life-of-choice. Alvarez has not only received and integrated these psychoanalytic and national traditions; she has also picked, chosen, and used that which is available in these traditions to express her own values and clinical commitments. England and the British Kleinian community must have felt like home to her, a place where she could be, or become, herself. But then Alvarez became her own kind of Kleinian. I would like to highlight two areas that stand out for me in her writing: (1) the analyst's use of self in the analytic process, and (2) the way Alvarez integrates, or transcends, a split in psychoanalytic thinking about the relative primacy of destructive vs. developmentally progressive factors in human psychic life, a split that had crystallized in differences between Kernberg's and Kohut's points of view about narcissism. I pick only two areas out of many I might have chosen in which Alvarez has been especially original, and in which she has made unique contributions reflecting who she is and what she has become. My reading of Alvarez's work, of course, will reflect who I am, the use that I, a North American analyst working in the relational tradition, have made of her work.

Use of self in the analytic process

The analyst as interpreter, container, and reclaimer

Alvarez's way of working with autistic and severely disturbed children is, to my mind, strikingly bold. Confronted with these most inaccessible of children, she refused to give up, refused to accept that behavioral modifications were the best that could be hoped for. She insisted on connecting with them, human being to human being. Using a Kleinian conceptual framework, Alvarez thought that the internal objects of these children must seem dead if they treat other people as inanimate objects. Interpretation, the standard Kleinian technique, seemed futile. So Alvarez developed the idea that the analyst must be “llive company” (Alvarez, 1992) for these children, must “reclaim” them for the human world by making active efforts to engage them, especially when the attachment to their withdrawal and their rituals becomes addictive. It is only too easy to respond to an autistic child's inaccessibility with a reciprocal withdrawal, to respond to their “deadness” with a reciprocally dead ritual of interpretation that has no meaning to the child. In my view, a large and crucial part of Alvarez's achievement with autistic children is the analysis and transcendence of countertransference that would otherwise lead us to abandon them or to join them in their deadness rather than seeking ways to help them join us in life among human beings.In claiming a place for this work in the psychoanalytic repertoire, Alvarez became a trail-blazer for the Kleinians in seeing the analyst as a “real” object for the child. She saw that the traditional, interpreting, analyst is not necessarily neutral and anonymous for the autistic child. To the contrary, the abstinent analyst positively confirms, or at least fails to provide a contrast with, the child's projected internal object. The analyst who reaches out, who actively seeks to engage the child, is more neutral than the more reserved analyst in the sense that such an analyst may have successfully transcended a defensive countertransference withdrawal, rationalized as proper technique. Not incidentally, the actively engaged analyst is more likely to help the child, as is clearly demonstrated by the many case presentations in Autism and Personality (Alvarez and Reid, 1999). So, for me, the more general question arises, how does Alvarez view the balance in the analytic process between the analyst's participation as a “real” external object, and as a more detached commentator on the person's internal world? Since Alvarez's clinical presentations are mostly of autistic and severely disturbed children, the following comments will apply specifically to these patients. I think Alvarez probably believes that a more traditional, interpretive, approach is more suitable for the relatively healthy patient, child or adult; however, her staking a claim within the analytic repertoire for her participatory stance as a “real” external object leaves open the possibility that such a stance may be useful at times, if not at all times, with any patient in analytic work.

Contemporary Kleinian thinking (e.g. Joseph, 1989) has recognized that interpretation is not always the best technical approach. Following Bion's (1961) idea that the analyst may need to function as “container,” the idea has gained currency that the analyst may sometimes need to “hold” the patient's projections until such time as the patient is able to reintegrate them. It has been recognized that to interpret too quickly can serve a defensive function for the analyst, in terms of the analyst's intolerance for the patient's projection. (Alvarez, 1997, cites Grotstein, 1981, who refers to this phenomenon as a “deficit in the object.”)

Two-person psychologies in the inner and outer worlds

Alvarez's work has thus been part of a general move in Kleinian thinking toward recognizing an expanded use of the analyst's self in the clinical situation. We now have the analyst as reclaimer and the analyst as container. As the analyst's participation becomes more of a factor, Alvarez invoked the concept of “two person psychology” (Alvarez, 1992) to describe her evolving view of the analytic situation. This concept, originating with the British middle group (Rickman, 1928; Winnicott, 1965; Balint, 1950), has been used extensively by North American relational analysts. In this literature, as relational analysts have struggled to integrate British object relations and American interpersonal concepts, a wide variety of ways of integrating one-and two-person factors have become available. Briefly, two-person perspectives have entered analytic thinking as follows: neo-Kleinian analysts have tended to apply two-person perspectives to the inner world by seeing the inner world as structured by object-relationships; a two-person perspective is applied to a lesser degree with respect to the outer world, e.g. the actual interaction between patient and analyst.¹ American interpersonal analysts tend to focus on a two-person perspective applied to the outer world of the patient with others, while relational analysts try to apply the two-person perspective to both inner and outer worlds in defining the field within which one attempts to understand and help the patient.² In a sense, traditional Kleinians apply a one-person perspective to the interpersonal field by seeing the analyst, through the patient's eyes, as the patient's internal object. Many relational analysts (e.g. Benjamin, 1995) invoke a two-person perspective in the analytic situation by emphasizing the analyst's separate subjectivity, as well as the interactions between subjectivities of patient and analyst, in the process of trying to understand the patient. What is at stake in the choice of these perspectives has to do with how we, as analysts, see the role of our subjective experience and our participation, interpretive or otherwise, in understanding and helping the patient. An interpretation, for example, can be conceived of as a detached commentary with minimal input from the analyst's personal subjectivity. Or interpretation can be conceived of as a process of intersubjective recognition, or as reflecting a process of containment and metabolization (Bion, 1988) of a projected psychic content or internal object. In both these latter cases the transformation of a patient's internal world depends on the analyst's active reception and transformation of an experience within her own subjectivity, followed by a communication to the patient which conveys the psychic work done by the analyst on that which the patient has projected.

The analyst as container holds and explores

Consider now how Alvarez views the role of the analyst's subjectivity. In much of her writing (e.g. Alvarez, 1999) she emphasizes two-person factors in the inner world rather than the outer world; for example, she refers, in speaking about projective identification, to projections into an internal object. She emphasizes the analyst's separate subjectivity in terms of the analyst's “holding and exploring” (1997, p. 755) within herself the patient's projections, rather than immediately attempting to return them to the patient via interpretation. Let us focus here on what exactly is entailed by such “holding” and “exploring” within oneself, and what sort of intersubjective analytic process is being described. If the patient sees the analyst as depriving or persecutory, the analyst may, on this account, have to allow that bad object to remain “out there” in the analyst, far enough away from the patient so that the patient can explore it. Alvarez (1997), using the “grammar of rightful need” (p. 766) advocates sometimes saying things like: “(You) must feel I should be sorry about not being strong enough to persuade (your) parents to let (you) stay (in analysis)” (1995, p. 178) to convey a recognition and to enact, in a sense, that from the patient's point of view, the analyst has been ineffectual in providing for the patient that to which he is entitled. Clearly, in making a statement such as this one, the analyst is containing the patient's projection of an ineffectual internal object.

But is the analyst also saying that she experiences herself as ineffectual from her own point of view in such a case? In the “as if” space of psychoanalysis this question is left open. One can only say “yes and no.” The question of the analyst's subjectivity touches on what Alvarez means when she speaks of “exploring” the patient's projection within herself. On the one hand, the phrase “within oneself‘ might seem to imply that Alvarez expects to find the patient's internal object in her own subjective experience to some extent, and in some way. One can imagine that the analyst, from a relatively detached perspective, could recognize that, from the patient's point of view, the analyst is ineffectual, while retaining a sense of being effective enough from her own point of view. Or, one could imagine that a sense of being ineffectual, from her own point of view, is part of the mixture of subjective experiences that the analyst is juggling at the moment. A particularly illuminating clinical example here is in Alvarez (1995). Alvarez, as analyst, has been unable to prevent her 4-year-old patient Tom's parents from pulling him out of treatment. She says to him that “he must feel that I ought to be sorry about not being strong enough to have persuaded his parents to let him stay” (p. 178). It is easy to imagine that Alvarez did, in fact, feel sorry that she could not persuade them to let him stay, even as she knows that she has done all anyone could do under the circumstances. Here, I believe, good use is made of her own distress and sense of helplessness to convey to the patient a powerful sense of recognition of the patient's experience.³ What follows is particularly illuminating. The patient orders the analyst to clean up the mess he has made in the play room. Alvarez decides to enact the part of the helpless victim, the slave, projected into her by Tom, because she feels that he “actually needed me to pick the things up, and to show him that I was willing to do it because I liked him, not forced to do it because I feared his tantrums. Also, he was finally engaging me in a joint activity, in however bullying a manner” (p. 178). Accordingly, Alvarez cleans up, all the while maintaining eye contact with the boy, in my reading so as to retain her sense of dignity, but more than that, to convey that she is, and is not, identifying with his sense of helplessness. Alvarez thus holds and explores within herself the sense of being helpless, while simultaneously functioning very effectively as a containing and metabolizing analyst by integrating the helpless feeling with her liking for the boy, and her understanding of what he needs at the moment. The balance seems to be right, since at this point the boy is freed up from his one-sided role as persecutor, as he is startled by a noise from upstairs and Alvarez is able to say that “he was afraid someone up there didn't like him bullying me like this” (p. 178). Alvarez thus seizes the opportunity to help the boy begin to integrate his own sense of empathy for himself as victim and misgivings about his defensive sadism (though still at a safe-enough distance).

How the analyst's subjectivity is inevitably implicated

Alvarez refers to this sequence of events as “what is really happening between the patient's self and his object” (1995, p. 179). The word “really” in this context generally refers to what is happening in external reality, but in referring to the patient's “self and “objects” Alvarez appears to be referring to what is “really” happening in internal reality. But to me it seems clear that external (from the patient's perspective) reality, in the form of the analyst's separate subjectivity, is also operative and clinically significant in a variety of ways that remain implicit in Alvarez's discussion of the case. I would add to her statement that this sequence of events is also what is really happening between the patient and his analyst. For example, the analyst must draw on her own experiences seeing other people as ineffectual or persecutory or deadened, in imagining the patient's experience of the analyst. She must draw on her own experience of herself in these ways. In this case, Alvarez conveys something of her subjective world in the way she enacts her identification with Tom in the role of helpless victim.⁴ In thus drawing on her own experience, the analyst's own life-experience would seem necessarily to color her sense of the patient's experience even though the analyst would, of course, be listening carefully and with objectivity, as well as subjectivity, as the patient describes or enacts her experience of the analyst directly or indirectly. It would also seem likely that ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Notes on contributors
• Foreword
• Acknowledgements
• Introduction
• Part I Mainly theoretical
• Part II Mainly clinical
• Anne Alvarez's published work
• Author Index
• Subject Index