Coming Into Play: Discussion of Anne Alvarez: Luisa

What can you do when the task is to discuss a clinical presentation in which the presenter has already—and with such elegance—condensed a sophisticated and multifaceted framework, one that tacitly formulates so many of the relevant issues as they unfold in the work? Succinctly, Dr. Alvarez offers us links to Allan Schore and neurobiological psychology and, thereby, the perspectives of Winnicott and attachment theorists, along with Klein and developmental self-psychology. I suppose what a discussant may yet do is to play with the case in a conjectural way that could underline, and thereby amplify or extend, the clinical perspective as already richly implied by Dr. Alvarez.

I now might ask what you do, as therapist, when the task is to work with a patient who does not engage in play? And, when I think about play, I turn to Winnicott (1971), who wrote:

Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play. [p. 38, italics in original]

Luisa, as Dr. Alvarez presents her and their process, seems to me very much in need of making her way toward being able to play.

Luisa's relational world—the derivative of an attachment with her mother over-organized around projective–introjective exchanges—seems populated with subjective objects who have never yet become objects objectively perceived, and this set of objects has included her therapist. Such an internal world of subjective objects can be understood as the residue of a child's experiences with a maternal reflecting mirror whose own fears, compensations, and defensive projections tend to obliterate the child's articulate self-experience. Coates (1998) has written, “Such repeated experiences ca