Maria Rhode

Mirroring, imitation, identification: the sense of self in relation to the mother's internal world

The phenomenon of neonatal imitation, and the use of mutual imitation by mother and baby in the service of attunement, are considered in relation to psychoanalytic theories of mirroring, imitation and identification. Material from infant observation and from the treatment of two children on the autistic spectrum is discussed in terms of the suggestion that developmental imitation implies a perceived position of balance between the external baby and the mothers supposed internal occupant. This is seen as making possible introjective identification and assimilation, with the enrichment of the sense of identity, in contrast to the kind of imitation involving mimicry, in which adhesive or projective identification may be operative.

Sensory aspects of language development in relation to primitive anxieties

ords are not just symbols: they are sensory constructs with rhythmical arid musical properties. These two aspects of W language are perhaps most fruitfully integrated in poetic diction, which relies on the sound of words to produce a bodily and emotional impact just as their ineaning produces a mental impact. Clinical work, on the other hand, and particularly work with autistic children, allows 11s to study the disjunction between form and nieaning, or sound and sense. In norinal usage, as in the stages documented by developmental researchers (Schore 1994, Stern 1985, Trevarthen 199S), tlie rhythinical and musical aspects which Meltzer ( 1986) has described as the Song-aiid-Dance level provide a foundation for tlie semantics of speech. In contrast, children with autism will often experience words concretely rather than synbolically, as solnethirig that can be physically lost froin their mouth. They inay then attempt to deal with these fears by using the physical aspects of words in the service of self-soothing rather than of communication. I will begin with brief clinical vignettes showing this non-communicative use of vocalisation, and then move on to examples froin infint observation which illustrate aspects of the interplay between sound and meaning.

Whose memories are they and where do they go? Problems surrounding internalization in children on the autistic spectrum

Recent work in neuroscience has highlighted the contrast between ‘procedural’ memory for bodily experiences and skills, which is unconscious though unrepressed, and verbalizable, ‘declarative’ memory, which includes autobiographical memory. Autobiographical memory is weak in people with autistic spectrum disorder, who frequently turn to self‐generated sensations for reassurance that they continue to exist. The author suggests that, instead of internalizing shared experiences leading to growth, children with autism can feel that they add to themselves by taking over the qualities of others through the ‘annexation’ of physical properties that leads to a damaged object and can trigger a particular sort of negative therapeutic reaction. Clinical illustrations drawn from the treatment of two children on the autistic spectrum illustrate some ramifications of these processes in relation to the sense of a separate identity and the capacity to access memories.

Asperger's syndrome: A mixed picture

Diagnostic ambiguities surrounding Aspergers syndrome are discussed in a historical context; two main subtypes are distinguished according to whether coping mechanisms are predominantly obsessional or schizoid. A case is reported of a girl, later diagnosed with Aspergers syndrome, who originally showed many characteristics of autism, including echolalia. In the later stages of her treatment, she resembled borderline children in her anxious outpouring of florid fantasy. The transition from the first stage to the second was marked by a fantasy of the bodily projection of her mouth into the therapist. Drawings from the beginning of treatment suggested that the schizoid fantasies characteristic of the second stage were already present, although in unelaborated form. The case is discussed in the context of object relations theory and of historical controversies concerning the relationship of autism to childhood psychosis. It is suggested that the intimate psychodynamic knowledge of a child acquired during therapy can make a contribution to diagnostic classification.

The many faces of Asperger's syndrome

This is the first book on the psychoanalytic treatment of children, young people and adults with Aspergers syndrome. It includes multi-disciplinary contributions on psychiatric perspectives and psychological theories of the condition. There is an overview of relevant psychoanalytic theory, and chapters on Aspergers original paper, on first-person accounts, on assessment and on care in the community. Clinical case histories of children, young people and the first published account of work with adults provide the possibility of using psychoanalytic work as a means of diagnostically differentiating between sub-groups, as well as providing a detailed insight into the emotional experience of people with Aspergers syndrome.Both Editors teach on the Tavistock Clinic Training in Child and Adolescent Psychotherapy. They are widely published authors and have both given lectures and papers in the UK, Europe and the United States.

“Packing” therapy for autism

www.thelancet.com Vol 371 January 12, 2008 115 implementing sensitivity analyses stratifi ed for major risk factors. We agree that aortic pulse-wave velocity is an independent and informative risk factor. However, measurement of this variable requires special equipment and trained observers, which makes the technique more expensive and globally less accessible than recording the ambulatory blood pressure. For this very reason, we developed the ambulatory arterial stiff ness index (AASI). AASI refl ects the dynamic relation between systolic and diastolic blood pressure during the whole day, which depends on various haemodynamic mechanisms, including arterial stiff ness. AASI can be easily calculated from individual ambulatory blood-pressure recordings. In our hands, AASI correlates with several measures of arterial stiff ness, including aortic pulse-wave velocity, the central and peripheral pulse pressures, and the systolic augmentation index. AASI is a strong and independent predictor of stroke, especially in younger individuals. We assessed the independent contributions of aortic pulse-wave velocity and AASI to the stratifi cation of cardiovascular risk in our Danish cohort. In multivariate-adjusted Cox regression models including both indexes, AASI (standardised hazard ratio 1·68, p=0·01) but not aortic pulse-wave velocity (0·91, p=0·62) predicted stroke, whereas the opposite was true for the composite of all cardiovascular events (aortic pulsewave velocity 1·15, p=0·03; AASI 1·04, p=0·68). These fi ndings support our main conclusion that recording the ambulatory blood pressure during the whole day should become routine in the work-up of hypertensive patients in all settings where resources allow its implementation.

Short-term psychoanalytic psychotherapy for adolescents with depression: A treatment manual

Short-term Psychoanalytic Psychotherapy (STPP) is a manualised, time-limited model of psychoanalytic psychotherapy comprising twenty-eight weekly sessions for the adolescent patient and seven sessions for parents or carers, designed so that it can be delivered within a public mental health system, such as Child and Adolescent Mental Health Services in the UK. It has its origins in psychoanalytic theoretical principles, clinical experience, and empirical research suggesting that psychoanalytic treatment of this duration can be effective for a range of disorders, including depression, in children and young people. The manual explicitly focuses on the treatment of moderate to severe depression, both by detailing the psychoanalytic understanding of depression in young people and through careful consideration of clinical work with this group. It is the first treatment manual to describe psychoanalytic psychotherapy for adolescents with depression. The treatment approach described in this manual has been used in a multi-site randomised controlled trial in the UK, ‘Improving Mood with Psychoanalytic and Cognitive Therapies’ (IMPACT) and internationally. It is presented here as a treatment to be used in routine clinical practice and will be of interest to child psychotherapists, multi-disciplinary professionals in young people’s mental health, service providers, and researchers alike. After describing theoretical models of depression and presenting an overview of STPP as a treatment model, the manual details the specific stages of the STPP process for the therapist and adolescent patient. It then describes the nature and scope of parallel work with parents and gives a detailed account of the function of supervision.

The physicality of words: some implications of Donald Meltzer's writings on language

The author considers Donald Meltzers writings on language in relation to the testimony of poets on the role of rhythm, sound and the ‘shape’ of words in poetic composition as well as in the readers response. Observational and clinical material is offered to illustrate Meltzers concepts of the ‘Song and Dance Level’ of language and of the ‘Theatre of the Mouth’. Sibling figures and the Oedipal father are seen as important structuring elements of the childs capacity to produce words and sentences. It is suggested that mutism and the idiosyncratic distortions of words and of syntax can reflect the childs primitive anxieties and phantasies as well as serving as a magical attempt to control them. Convergences with other theoretical approaches are discussed.

Links between Henri Rey's thinking and psychoanalytic work with autistic children

(1995). Links between Henri Reys thinking and psychoanalytic work with autistic children. Psychoanalytic Psychotherapy: Vol. 9, No. 2, pp. 149-155.

‘Paralysed associations’: countertransference difficulties in recognising meaning in the treatment of children on the autistic spectrum

Children with autism can have a paralysing effect on the clinician’s capacity to associate freely: connections that seem obvious on reflection may be impossible to notice in the child’s presence. The author argues that this situation can be reached by more than one pathway, and that the degree of the child’s bodily and emotional cohesion is an important factor. Children may seek to immobilise the therapist’s thought processes through projective identification, whether to communicate their own experience of paralysis or because these thought processes are equated with a parental intercourse that produces a ‘baby’ (as described by Bion and Britton). Vignettes are offered to illustrate how the therapist may be nudged into overlooking this baby as well as a potentially growing part of the child that is identified with it, with important consequences for development. A second possible pathway appears to involve the much more primitive mechanism of adhesive identification, in which the child’s sense of continuing existence depends on sticking to the therapist’s surface and any movement can lead to a sense of bodily disintegration. In the clinical illustration, the therapist felt physically constrained and unable to recognise links in the material: it is suggested that this was in resonance with the child’s fear that movement, whether physical or mental, meant losing parts of his body and must be avoided at all costs. These levels can mask each other, and it seems essential to attend to both in order to avoid impasse or the overlooking of essential aspects of the child’s experience.