Building A Truer Self with Alex: A Dialogue between Authors about Clinical Case Material

Abstract

One of the challenges of psychoanalytic therapy with young children is finding more adaptive channels for the symbolic expression of bodily and feeling states expressed in motoric, sensory, or visceral forms. The following case study, written in the format of a dialogue between the first and second authors as the article was being prepared, depicts processes of psychic transformation in twice weekly psychoanalytically oriented psychotherapy with a 5-year-old boy as he tried to linguistically integrate and represent his negative feelings and anxieties. Initially his emotions were aroused in presymbolic form dominated by sensory and somatic experiences that were disconnected from objects, events and words. The authors each reflect on Alex's therapy experience as well as the specific kinds of therapeutic interventions that provided the opportunity for containing and transforming Alex's emotional life. They conclude that as Alex's threatening emotions were linked to objects and events in the play, a substantial emotional growth took place towards a shift to a greater capacity to comfortably maintain a “Truer Self.”

Notes

1. Discussant: These experiences speak purposefully to the diagnostic questions raised early in the paper. His all too easy sense of fragmentation when stormed by affect is consistent with the pre-oedipal child's still vulnerable clustering of experience before libidinal object constancy has been fully established. Therapist: In the initial stages of our therapy, much of the time, he felt he did not have an intact body. We had to go the bathroom and literally check in the mirror if his body is stable. For example, towards the end of one session, he was licking one of those lollipops that also color one's tongue and he said to me:

P:	=	Look at my eyes. What color are my eyes?
T:	=	Brown.
P:	=	We have to go to the bathroom.

So we went to the bathroom to look at the color of his eyes in the mirror. Every time he ate his candy, he asked me what color his eyes were and whether they had changed color. I had to tell him that his eyes will always stay brown as he was not yet convinced that his body was stable.

2. Discussant: This is thunderously good therapy! You are able to articulate and amplify his fears yet never to the point where he feels overwhelmed and abandons the play. Yet you are also attempting to provide a scaffolding for curiosity (Tuber & Caflisch, 2011) (“I wonder why”) to help him develop the ability to step back from his affects and create a transitional space from which to view his experience. Therapist: I was also trying to voice an internal life for him as much of his experience of his world was in the mode of action. I wanted to be able to reflect that as his feelings shifted, so did his identifications and consequently his actions.

3. Discussant: I love this validation of how tenacious angry feelings are!

4. Discussant: Once again you try and build a scaffold to hold on to as to just be overwhelmed by the affect he expresses. Therapist: Initially, I used to express all this in longer sentences that would alienate him due to his receptive language deficits. I remember you had given me a five-word limit! I was really challenged to use simple words and syntax and be quite precise in my speech. I started to rely on verbal repetitions that marked his state but also use slight modifications that could open up the space for further thinking (Halfon & Weinstein, 2013). Discussant: That makes perfect sense developmentally, cognitively and clinically.

5. Discussant: This is developmentally consistent with the early stage of affective development in the second and third year of life wherein affects are experienced as objects with physical properties rather than states of mind. Thus at this age, for example, a child is happy because she is smiling or angry because he is frowning and not because of an inner feeling state. Therapist: I do agree that this is a developmental arrest but I also think this is another example of the “alien self” of the mother that was projected into him. I do think part of the reason he was so desperate to remove his emotions was because he was forced to internalize her state of mind as part of himself. He deals with this “alien self” by externalization as he perceives the alien affects as outside his mind.

6. Discussant: Reminding him of the “as if” mode of play speaks to his inability to keep play as a transitional experience, making you resort to having to concretely reassure him that reality was different from fantasy. Therapist: I was reassuring both of us as the play literally felt quite scary to me at times … You may remember this from class, but with him I always had this question in mind: When is play too real and when is it transformative? I took my fear as an indicator to differentiate the two but I also have a tendency to just let things develop and it is sometimes hard to tell when it is therapeutic and when it is simply dangerous and too far. Discussant: This is such a crucial, yet often diminished notion: although play is the “gold standard” for childhood expression of authenticity, it is also simultaneously often on the brink of “madness”, of threatening to be come too real and thus toxic.

7. Discussant: Your beautifully attuned work with him thus permitted him to make the developmental leap from affects as objects to affects as states of mind that have meaning. This is the necessary conduit for later work that might link individual meanings from his past to affective states in the room. But this later potential attempt at “insight” would not be possible unless he could make this leap to affects as feeling states and not as objects that must be pried out of him. Your using pliers metaphorically is a brilliant means of enabling his concretizing of feelings to be used therapeutically to minimize their terror. Therapist: Yes, this developmental leap also changed the flavor of the sessions as they were not so action oriented anymore. In the initial sessions, I would literally get exhausted after every session because we were so invested in expressing ourselves through the body. However, as he developed the capacity to differentiate state from behavior, we could experience an emotion together, even perhaps talk about it without having to always express its behavioral demonstrations. I think this also opened up the mental space for both dyadic and triangular experiences, as he could start to think about his emotions in relation to others.

8. Discussant: What a special moment in this child's life! You were able to distinguish between a physical “look” (hurt) and an underlying emotional state (anger) and the child “gets it” and can then link the feelings together! This is the very basis for the capacity to make emotional meaning from experience and we are seeing it in statu nascendi! Therapist: I still remember the exact image of his face when he looked hurt. It really was a very touching moment for me.

9. Discussant: What is also so striking here from a developmental perspective on affects is that cataloguing one's feelings (“a boat for every feeling”) is a necessary precondition for the later integration of feelings, one with another. When feelings fully become mental states they become far more malleable and hence less terrifying. Placing his feelings in boats is an especially evocative bit of literal containment!

10. Discussant: Indeed, for once feelings are no longer literally persecutory objects, they can become under the reign of the domain of play (Tuber, 2012) and “good” feelings can be produced to combat “bad” ones.

11. Discussant: What an intense, brilliant evocation by the child of what it feels like to not to understand when the “other” he thought was permanent disappears and is replaced by malevolence. Once again Alex allows us to see what it is like when one is not yet capable of integrating contradictory and powerful affects.

12. Discussant: Here Alex tells us about the archaic fear Winnicott described as a fear of falling forever, a fear at a level of annihilation. Yet the fears are expressed in play, with words, transforming them into worries that can potentially be mastered rather than enactments that are re-traumatizing. Therapist: I again have that question in mind about when play is transformative and when it could re-traumatize. I do agree with you that in this case, this was not a mere traumatic repetition but what is the criterion to hold onto to be able to make the distinction? Discussant: I wish there were such criteria! Unfortunately, we are left with the fact that it can only be gleaned from what the child empirically demonstrates in the nature of his play and the degree of disruption certain themes evoke in his capacity to both maintain the coherence of the play and to stay with his affective experience without marked regression.

13. Discussant: This speaks to the reciprocal, intertwining nature of affects and object relations. The more his affects become states of mind rather than things, the more possible it becomes to experience both self and other as less fixed. The archaic anxieties associated with past painful experiences with others can then be mitigated by more benign representations of self and others so that, for Alex, his primitive separation fears become less terrifying.

14. Discussant: The delight and relief that you can be allowed into the child's domain, and his delight and relief that he can let you in on his terms speaks to powerful changes in his experience of affects that in turn allow him to experience both his therapist and himself with far greater benevolence than before his treatment began.