M Target

Mentalization and the Changing Aims of Child Psychoanalysis

The interface of empirical work with child psychoanalysis at the Anna Freud Centre is part of the tradition of systematic study and research pioneered over many years by Anna Freud and her colleagues (A. Freud, 1962; Sandier, 1962; A. Freud 1965). George Moran initiated a program of work at the Anna Freud Centre, which, starting with the work on juvenile onset diabetes (Fonagy et al., 1991b), led us to ask fundamental questions about the nature of the child psychoanalysis, with important implications for technique. We acknowledged our debt by dedicating the lecture on which this paper is based to George Moran, whom we see as a worthy successor to Marianne Kris, both of them working within the tradition of Anna Freud. This article starts with observations that imply the need for a change in some aspects of our psychoanalytic model. Throughout child psychoanalysis is used to illustrate both the need for change and the character of the revision that is required. The authors, however, assert that, as is so of...

ATTACHMENT AND BORDERLINE PERSONALITY DISORDER: A Theory and Some Evidence

An attachment theory approach to severe personality disorder is described. Evidence is presented that suggests that representations of attachment relationships and attachment behaviors of patients with this diagnosis are commonly disorganized in character. It is argued that the capacity to develop mental representations of mental states in self and other (reflective function) develops in the context of attachment relationships and that disorganization of attachment undermines this process. Such disorganization can be associated with trauma but may also be linked to other biological and psychosocial deficits. Many of the clinical characteristics of patients with borderline personality disorder may be seen as consequences of disordered self-organization and a limited rudimentary capacity to think about behavior in mental state terms. The relevance of this model for the practice of psychotherapy with this group of patients is discussed.

Playing with reality: III. The persistence of dual psychic reality in borderline patients.

This paper is a contribution towards understanding the difficulties of severely borderline patients as they are uncovered within the psychoanalytic process. The authors aim to extend a model from previous papers, bringing a developmental perspective to bear on self-representation and self-organisation. This model rests on an understanding of the childs experience of psychic reality in both normal and neurotic people. The authors explore the relevance of these developmental ideas in thinking about severe borderline and related disturbances seen in adult patients, from the point of view of both understanding the pathology and considering technique. Illustrations are given from a case that helped to prompt the formulation of these states in terms of persistent, pervasive distortions of the experience of psychic reality. There is then an attempt to elucidate the difficulties of borderline patients in tolerating both separation and intimacy, consideration of the way in which bodily experiences may be used as an equivalent of mental experience or contact, and a discussion of the impact of disturbances in the experience of psychic reality on the analytic process.

Bridging the transmission gap: An end to an important mystery of attachment research?

Abstract The authors provide a context for this special section by arguing that the attachment relationships of infancy fulfil an evolutionary role in ensuring that the brain structures that come to subserve social cognition are appropriately organised and prepared to equip the individual for the collaborative existence with other people for which his or her brain was designed. Processes as fundamental as gene expression or changes in receptor densities can be seen as direct functions of the extent of understanding of mental states provided by the caregiving environment. If the attachment relationship is indeed a major organiser of brain development, it is even more important to understand the processes that underpin the transgenerational transmission of attachment patterns. The contributions of the papers in the special section to understanding the role of reflective function in the development of attachment and social cognition are reviewed, and the implications for the development of both theory and practice are explored.

Mentalization in adult attachment narratives: Reflective functioning, mental states, and affect elaboration compared.

Relationships between three measures of mentalization (reflective function, mental states, and verbal elaboration of affect), attachment status, and the severity of axis I and axis II pathology were examined. Seventy-three adults, both ex-psychiatric patients and nonclinical volunteers were administered the Adult Attachment Interview (AAI). Comparisons between the three measures indicate that they share some aspect of a core mentalization process and that each illuminates a specific component. Reflective function was the only predictor of attachment status. The number of axis I diagnoses is partly explained by attachment insecurity, but the capacity to generate high-level defensive mental states as well as increments in verbal affect elaboration further contribute to the model. Finally, increments in affect elaboration, as well as augmentations in high-level defensive activity and reflective function are all associated with decreases in the number of axis II diagnoses, over and above the contribution of attachment status and axis I pathology.

The Rooting of the Mind in the Body: New Links Between Attachment Theory and Psychoanalytic Thought

The relationship between psychoanalysis and attachment theory is complex indeed. A brief review of the psychoanalytic literature as it concerns attachment theory and research, and of the attachment literature as it pertains to psychoanalytic ideas, demonstrates an increasing interest in attachment theory within psychoanalysis. Some of the difficulties that attachment theory faces in relation to psychoanalytic ideas are traced to its links to the now dated cognitive science of the 1960s and 1970s. Today, however, a second-generation cognitive neuroscience seeks neurobiologically plausible accounts in which links with brain and body are seen as shaping mind and consciousness, which increasingly are seen as “embodied,” as emerging from or serving the needs of a physical being located in a specific time, place, and social context. This idea has also been at the core of much psychoanalytic thinking, which has historically affirmed the rootedness of symbolic thought in sensory, emotional, and enacted experience with objects. Now neurobiological advances supporting the concept of embodied cognition offer an opportunity to forge powerful links between the hitherto separate domains of attachment theory and psychoanalysis. Speculations about the nature of language are presented that emphasize the origin of internal working models (and of representations in general) in early sensorimotor and emotional experiences with a caregiver. It is argued that language and symbolic thought may be phylogenetically and ontogenetically embodied, built on a foundation of gestures and actions, and are thus profoundly influenced by the experience of early physical interaction with the primary object. Finally, the clinical and research implications of these ideas are discussed.

Efficacy of Psychoanalysis for Children with Emotional Disorders

OBJECTIVE This is the second report from a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre. METHOD Three hundred fifty-two children and adolescents were identified who met DSM-III-R criteria for emotional disorders or who had sleep or somatoform symptoms with marked emotional disturbance. Two hundred fifty-four were treated in full psychoanalysis, the remainder one to three times per week, for an average of 2 years. Outcome was indicated by diagnostic change and by change in overall adaptation, measured by the Childrens Global Assessment Scale (CGAS). RESULTS Of those treated for at least 6 months, 72% showed reliable improvement in adaptation, 24% still had some diagnosis at termination, and 15% still had an emotional disorder. Simple phobias were most likely to remit, and depressed children were least likely to return to normal CGAS levels. Children younger than 11 years were considerably more likely to be well at the end of treatment. Intensive treatment generally led to greater improvements, independently of age and treatment length. Certain disorders, and more severe pathology, required intensive treatment; 50% of severe cases showed no improvement in psychotherapy. Thirty-one percent of variance in CGAS change could be predicted, and greater than 50% when diagnostic groupings were examined separately. CONCLUSION Despite methodological limitations, the study identifies predictors of improvement (e.g., younger age, phobic symptoms, intensity and length of treatment) and shows that severe or pervasive pathology requires intensive analytic help.

The Efficacy of Psychoanalysis for Children with Disruptive Disorders

OBJECTIVE This paper describes a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre, and illustrates its usefulness by examining predictors of treatment outcome in children with disruptive disorders. METHOD 135 children and adolescents with a principal diagnosis of disruptive disorder were individually matched with others suffering from emotional disorders. Outcome was indicated by diagnostic change and change in overall adaptation (clinically significant improvement or return to normal functioning). RESULTS Improvement rates were significantly higher for the emotional than for the disruptive group. Within the disruptive group, significant improvement was more frequent among children with oppositional defiant disorder (56%) than those with attention deficit hyperactivity disorder (36%) or conduct disorder (23%). However, 31% of the children terminated treatment within 1 year. Of those disruptive children who remained in treatment more than 1 year, 69% were no longer diagnosable on termination. Fifty-eight percent of the variance in outcome ratings could be accounted for within this group. The crucial variables in predicting attrition and symptomatic improvement were found to be quite different in the disruptive and emotional groups. CONCLUSION Although the study has several methodological limitations, it does suggest demographic, clinical, and diagnostic characteristics of those disruptive children most likely to benefit from intensive and nonintensive psychodynamic treatment.

Predictors of outcome in child psychoanalysis: A retrospective study of 763 cases at the Anna Freud Centre

Under Anna Freuds guidance, the Anna Freud Centre developed a rigorous approach to the collection of child psychoanalytic data. Material contained in detailed diagnostic assessments and weekly written reports of 763 cases treated in intensive and nonintensive therapy has now been subjected to systematic study. This is the first, retrospective stage of a major investigation of child psychoanalytic outcome, carried out in collaboration with Yale University Child Study Center, New Haven, CT. The main findings of the work are reviewed. The study showed child analysis to be particularly effective for seriously disturbed children under 12 years suffering from a variety of psychiatric disorders, particularly those which involve anxiety.

The roles of mental representations and mental processes in therapeutic action.

In this paper we describe two models of the psychoanalytic treatment of mental disturbance. The first describes the mechanism by which the patient is helped to recover threatening ideas and feelings which have been repudiated or distorted as a result of conflict and defense. The second points to the therapeutic effects of engaging previously inhibited mental processes within the psychoanalytic encounter. The two forms of therapeutic action imply two distinct means available to the individual to deal with psychological conflict. They highlight different aspects of the psychoanalytic process and technique in child and adult psychoanalysis.