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This is a very interesting paper for analysts who wish to explore the complicated and progressive process of ego structuring in their patients, and are working on finding ways of helping their patients to obtain stronger ego integration. How to help a patient in areas in which ego integration is lost, or has never been achieved? Which approach and interpretation to choose? This paper offers a clarifying distinction of levels of ego integration, and proposes for each level a different approach in technique.
Anne Alvarez is a child psychotherapist who has devoted her work to the understanding of the vicissitudes of the ego in extremely damaged child patients. She has written extensively on borderline and autistic conditions in children. This paper captures the essence of her thinking and summarizes a lifelong search grounded in first-hand experience. Alvarez postulates a self with an ego which progressively undergoes integration, and by doing so, she comes indirectly close to Fordham's (1985) model of the self. Alvarez is interested in searching for ways to reach patients whose ego functioning is impaired and whose capacity to integrate and internalize is almost nonexistent. Although this paper is based on work done with children, what Alvarez has to say is relevant for working with adult patients as well.
In her work with autistic patients, Alvarez came to realize that interpretations have to reflect the level of mental and emotional development of the patient. For example she realized that by saying to one of her patients who was in a state of ‘inflammation’ because of a train delay, which had caused the patient to arrive late at his session: ‘You must be very angry with the trains for coming late’ that she did not manage to reach the patient and his distress. She understood that her words did not have a representation in the child's internal world. In a similar situation, she later tried with: ‘You are very upset today’. The comment seemed to help a little, but it wa