Thinking with, and about, patients too scared to think: Can non‐interpretive maneuvers stimulate reflective thought?

Abstract

Patients incapable of higher-order (symbolic) thinking can often not tolerate evidence of the analyst's separate existence, particularly when that "otherness" becomes evident in the process of the analyst's reflecting upon and interpreting how the patient experiences or represents the analyst. The patient's intolerance of the analyst's efforts to think (reflect upon and interpret) renders the usual psychoanalytic maneuvers employed to stimulate reflective thought ineffective with such patients. Such patients have to learn to tolerate multiple perspectives before they can allow the analyst, or themselves, to think in the other's presence. The author presents two clinical vignettes that illustrate how the analyst's efforts to think about the patient were experienced by the patient as both intolerably distancing and as rejecting of an aspect of the patient's subjective reality. Working psychoanalytically with such patients requires the analyst to forego the use of narrow interpretations that elucidate unconscious meanings and motives in favor of alternate technical maneuvers capable of facilitating the development of symbolic thinking and reflective thought (insightfulness). These maneuvers include a demonstration of the analyst's willingness and ability to withstand (rather than "interpret away") how he is being psychically represented by the patient, without becoming destroyed by, or lost within, the patient's characterization of him. Beside modeling a tolerance of alternate perspectives of one's self, other non-interpretive maneuvers that help facilitate the development of self-reflective thought include: stimulating the patient's curiosity about the workings of his own mind by identifying incompletely understood behaviors or reactions worthy of greater psychological understanding, and insinuating doubt about the adequacy of the patient's explanations of such phenomena.

Shifting between Alternative Modes of Cognition: Can Free Association, in and of Itself, Prove Therapeutic?

“…Some analysts (Sugarman ; Tuch ) believe that the chief benefit of analysis does not lie so much in the imparting of information—i.e., in the patient's learning things about himself of which he had been previously unaware or only dimly aware—but instead involves alterations in ego functioning (increased frustration tolerance, a shift toward utilizing more mature types of defenses, an ability to regress in the service of the ego, etc.) and/or the acquisition of particular “portable” skills that the patient can take away from analysis and rely upon for the rest of his days.…”

The Use of Play to Promote Insightfulness in the Analysis of Children Suffering from Cumulative Trauma

“…This emphasis on the process elements of the mind arises out of the developmental fact that children cannot reflect on their own thoughts and mental life until they realize that mental states are constructed, and that these mental states motivate theirs and others' words and actions (Mayes and Cohen 1996). That is, children are helped to develop higher-order mental functioning and to grasp the constructivist nature of the mind (Tuch 2007) via analysis.…”

“…Promoting insightfulness involves facilitating child analysands' ability to make second-order mental representations of theirs and others' mental contents (Tuch 2007). This enhances self-object differentiation, separation-individuation, and reality testing (Sugarman 2003a).…”

“…It improves affect regulation and facilitates empathy (Fon-agy and Target 1996b). And it forms the basis of social functioning (Forguson and Gopnik 1988;Perner 1988;Tuch 2007). But the ability to make second-order mental representations does not begin to develop in normal children until between the ages of four and six (Mayes and Cohen 1996), and it culminates some time in adolescence (Chandler 1988;Tuch 2007).…”

Levels of analytic work and levels of pathology: The work of calibration

“…Botella and Botella describe the need for the analyst to carry out the “work of figurability” with patients whose memory traces are not representational but more like “amnesic traces” (2005, p. xix). More recently, Tuch (2007) has discussed how to facilitate the reflective function with pre‐interpretive work. Child psychotherapists Lanyado and Horne (2006) have explored a variety of ways of working in the transitional area with extremely damaged and acting‐out child and adolescent patients, and Blake (2008) has illustrated the importance of humour in relieving impasses with aggressive deprived adolescents.…”