American College of Psychoanalysts — 2014 Fall Newsletter
Summary of Presentations at the ACP conjoint conference, in Paris on May 23-24, 2014, with the University of Paris 7-Diderot (Centre pour Psychanalyse, Medecine, & Societe), and A2IP (Association Internationale Interactions de la Psychanalyse) by David R. Edelstein, MD
Excerpts from Dr. Edelstein’s summary of Gilbert Kliman, MD’s presentation of Reflective Network Therapy and subsequent discussion:
It was impressive that this deep interpretive work could be done in 15 minute sessions on the classroom floor and could be so thoroughly integrated with the rest of the child’s interactive environment…One could observe in the video clips, in a way that was profoundly moving to the entire audience, the way that the child could develop mental representations and mirror the therapist’s ability to present such representations.
Gil postulates that the reflective network environment strengthens weakened neural networks between limbic and motor systems…Gil emphasized that there was a profound biological process occurring as the child took in, metaphorically, the ‘scaffolding’ of the mental representations provided by the therapist.
Gil and his colleagues have worked with more than 1700 children, 40% of whom had Autism Spectrum Disorder, and has slowly built and evolved an increasingly fuller understanding of this disorder and its treatment by using psychoanalytic techniques in the context of orchestrating and harnessing small social networks for the advantage of the individual child as well as the group. Gil described, eloquently, how he had undertaken the treatment of autistic children without using medication and how he views it as a hazardous experiment to turn quickly to medicating children.
Gil described, using extensive and very moving video clips, his treatment of a young boy with high level autism who had few words, was preoccupied with train schedules, was aggressive, repeatedly wore the same clothing, often howled and screamed, could not tolerate noise, could not allow himself to be touched, spoke in the low guttural voice characteristic of what had previously been labeled Asperger’s Syndrome, and was clumsy. Gil had sessions four times weekly, 15 minutes per session, with the child within the child’s school classroom. The Reflective Network Therapy aims for a synergistic combination of education with psychotherapy.
The child’s play is central in the construction of the sessions and during the sessions other children might interact with the child and with the therapist. The therapist begins the session by being attuned to the child and tactfully verbalizing his or her reflections about the child’s feelings and behavior, particularly the therapist’s thoughts about what the child is doing and thinking in the here and now of the classroom. In this way, the child’s resistances to education, refusal of affection, and inhibited or inappropriate enjoyment of socialization can be spoken about and often interpreted on the spot. Following the session, the child and the therapist both brief the teachers on the treatment. The parents are seen weekly by the teacher, being offered a 45 minute private guidance session, and monthly by the therapist. The teachers and the therapist also meet regularly to share observations. …
The network reflects about the child in predictable ways and the intersubjective reflections organize and semantically encode each participant’s theory of the child’s mind. Classroom peers are a vibrant part of this network and everything happens in the real-life space of the classroom. The sessions focus strongly on attunement and are often filled with entangled and metaphoric interactions with the children. Interpretations, often deep, are made on the spot. The rejection that children experience from their peers is spoken of directly, allowing little time interval between the painful wounds of rejection and interpretation. Every child in the classroom interacts actively with the school and the therapeutic network and each child receives daily feedback and has hundreds of sessions. This environment is the opposite of the secluded Kleinian approach.
Children experience a linear increase in IQ with this treatment, going up one standard deviation with twice weekly treatment and two standard deviations with four times per week treatment. Gil also finds that this treatment can be done for 1/6th the cost of behavioral analysis and is much more effective.
Gil noted that something unexpected and very growth-promoting happens when the network is initiated; strong affection can be brought out in these children. Gil conceived of the therapist as holding mental representations and sharing them with the child to ‘scaffold’ them and to help the child to mentalize psychological content. One could observe in the video clips, in a way that was profoundly moving to the entire audience, the way that the child could develop mental representations and mirror the therapist’s ability to present such representations. Gil was literally on the floor with the child and his engagement and caring was evident, and was felt by the child, and this served as an important support for the attunement on which the development of mental representations was based.
In no other method does the child’s treatment take place exclusively within the learning and play activities of his special and regular education classroom groups. There is no pull-out therapy. Parents are often present in the classroom and behavioral aides are hardly ever used.
Discussion:
Discussant Dr. Drina Candillis felt that Gil’s emphasis on a group framework is essential. Drina noted the importance of sharing psychoanalytic ideas with people who are not psychoanalysts and felt that Gil had done this effectively. Drina felt that the French approach focuses too much on symptoms as reflective of parental suffering and focuses too much on parental issues and that Gil’s work shows that this may not lead to an accurate understanding of the child.
Discussant Dr. Gisèle Apter stated: In France these [ASD] children attend one half day of school, then have group meetings, then parent meetings, then therapy. The therapy is much less frequent than four times weekly and the children do not do as well. Gisèle views the 15 minute session as a way for the therapist to stay engaged and to keep the child engaged and felt that longer sessions might be overwhelming for both the therapist and the child. Gisèle also commented that maintaining neutrality and giving medication are mistaken approaches and she strongly supported Gil’s efforts to be creative and inventive with technique.
Gil responded that suspicion of assessment with autistic children is often quite strong and may lead to resistance to studying the outcomes of treatment. Gil emphasized the importance of using extra-analytic outcome measures for scientific purposes as this can provide strong data. Psychoanalytic data, for example on defenses, may not be as useful and extra-analytic data can help our profession to achieve a better public image. Gil then pointed out that children often feel tranquilized by being thought about and that their pain at feeling isolated can be expressed in their howling. Gil emphasized that we can overcome genetic tendencies, gene expressions, through the use of Reflective Network Therapy.
Jerry Blackman commented that Gil’s technique ‘used interpretations upwards’ similar to Lowenstein’s technique, and was able to translate the child’s thinking into a less primitive form and to push verbalization, keeping children from retreating. Jerry also wondered if one might use conflict theory, with the concept of erotization in masturbation, and if one could view Gil’s patient as having sublimated. Gil responded that many meta-psychological theories are called out by his method and that he has greatly expanded his own “psychoanalytic IQ” by doing Reflective Network Theory.
Sophie de Mijolla-Mellor commented that the developments in Gil’s patient were not, in her view, sublimation but one could think of the child beginning to learn as the start of sublimation. She would use the term ‘symbolization’ rather than ‘sublimation.’ She quoted a French theory that the mother is the “bearer of language,” meaning that the mother names emotions and gives names to the roles and levels of interaction within the family. Sophie noted that, if that is not done, the child may have difficulty.
Gil responded that there have been studies which show that events which are discussed with the mother and the father are more readily recalled than those that are not, indicating that the “self” is built upon dialogue. Gil stated that he has produced workbooks on people’s roles in the child’s history so that children can know where they fit in; this helps children break free of repetition compulsions following multiple placements. Gil felt that the analyst is the “bearer of memory” and that this concept can be applied on a public health basis.
Drew Clemens described how Erna Furman at the Hannah Perkins program in Cleveland started a high school course on parenting and used Anna Freud’s developmental lines to study children in therapeutic schools. Henri commented that we need more parenting programs in schools.
Gil responded that he has observed IQ increasing more in his patients if the father is present in guidance sessions.
Harold Blum raised a question about the development of memory in these patients.
Gil commented that issues of infantile amnesia and the start of the ability to recover memories are later issues in the trajectory of development than developing mentalization and that little is known about this. Gil pointed out that the brains of autistic children may differ from those of normal children and that their genetics may differ. For example autistic children have been shown to often have a P10 gene that is linked with higher rates of cancer; the study of autistic children therefore has strong public health implications.