Friday, January 22, 2016

A Good Enough Therapist

“Real isn't how you are made,' said the Skin Horse. 'It's a thing that happens to you. When a child loves you for a long, long time, not just to play with, but REALLY loves you, then you become Real.'

'Does it hurt?' asked the Rabbit. 
'Sometimes,' said the Skin Horse, for he was always truthful. 'When you are Real you don't mind being hurt.' 

Our weekly psychoanalytical seminar ended today with this reading from the famous children's book, The Velveteen Rabbit.  We are into our second pod and going through object relations.  We have read about Melanie Klein, Fairbairn, Bion, Ogden and now are reading Winnicott,  The famous British pediatrician who later took on psychoanalysis and was trained by Melanie Klein herself, is best known for his concepts of "good enough mother", "transitional objects" and was an avid advocate for mothers.  He introduces ideas such as "Ordinary mother and her ordinary love for her child" and talks about never interfering and undermining an able mother's ability to intuitively know how to take care of her child.  He boldly challenges the long held concepts of infant's aggression viewed in classical drive theory models and the original Klein object relation that focuses on the infant's fantasy.  He looks at aggression from a rather unique point of view of something vital to help transition from "object relation to object use." (Winnicott, 1969)  

The idea of a transitional space (Winnicott 1969) between the mother and child where play and creativity comes in play is the containing space for this aggression.  It helps the baby to be able to relate to the mother in his own time and manner.  For example a baby may bite his or her mother while feeding or even playing with her (those of us who have breastfed our babies can relate to this).  The biting is not simply an act of aggression related to his fantasy about the good breast or the bad breast, when you are in Winnicott's world.  It's rather necessary.  The baby is testing the limits of the mother's tolerance.  Of course the mother will react and will be in pain but it's what she does afterwards that matter.  If she can understand that the act doesn't mean that the baby is intentionally hurting her because he/she considers her bad, she will be able to experience the pain, show the pain and take the baby in her arms and feed him again.  The time old expression of children telling their parents, mothers that they hate them, is another example of a child's anger and rage towards the parent/mother in the context of whatever evoked that anger and the words came out.  What is a mother to do when the child does that?  I can tell you what she is NOT to do.  She has to allow the child to say this without shaming the child and not taking it personal because as hard as it is to hear that, the child is allowed to say that.  It will take a good enough mother to tell the child that she understand that he is angry and probably also hates her at that time for whatever it is that happened but she also wants to tell him/her that she still loves him/her and they can talk later.  

With time baby will learn that it hurts the mother when he/she bites but the mother still loves him/her and will continue to offer the breast.  The child will learn that it is okay to hate parts of his mother at some point but that doesn't mean that it ends the relationship.  The mother's ability to accept the child's true feelings without making it all about herself, promotes a true self that is nourished by acceptance and deep love.  Mothers who have not experienced the holding environment themselves, remain trapped in the inadequate transitional space with their own mothers; and are not be able to provide that safety to their own babies.  When they receive pain or harsh words from their children, they can't help but be threatened, defensive and enraged.  

A mother's ability to let the baby show aggression and experience that they may have hurt the mother without scolding, retaliating or shaming the baby, takes the baby beautifully into the object use phase.  This simply means that the baby learns to know the limits and powers of his/her part in a relationship and is able to hold on to trust and belief in the love of his mother.  That she can handle his/her personality and that he/she doesn't need to hide the true self in order to win and keep her love.  Baby is good enough for the mother as their true self and there is no need for the false self to appear.  

Children who grow up with narcissistic mothers or caregivers, turn into adults who don't have any idea of their "SELF".  Self is the basis of our existence.  

I will give you a simple example.  My supervisor explained the concept with this example today and as simple as this example sounds, it is the concept that matters.  Think about a baby who is playing by himself and is busy in his own world.  Now imagine a mother or caregiver who wants to interact with the baby at that very moment.  They baby keeps playing and ignores the advances because he is really interested in what he was doing.  The intrusion continues and continues to get intense, until the baby finally responds by looking at the mother or caregiver, or smiles and laughs in response to the whatever was going on.  Harmless, right?  Well not quite.  Of course once in a while, all of us have done this sort of thing with our own children or children in our families.  Now imagine this scenario many times a day for many days, weeks and months.  Repeated intrusions of the child's space, until the child gives up their activity to please the mother or caregiver.

Of course I do not mean that we should never initiate interactive play with the baby but rather that we be tuned into baby's need and give him space to be by himself, if he/she doesn't seem interested.  Now also imagine a child who can't be upset around his mother because the mother can't not take it personal and shames the baby into an apology or a child who is neglected and ignored because the mother's emotional needs overshadow baby's emotion needs.  Such children learn to hide their emotions and feelings to be the "good girl or boy" so the mother is able to tolerate them, love them and doesn't turn away.  Such adults never feel comfortable in who they truly are because they never had a chance to be themselves.  How could they?  They always had to hide their true self to be in tune with the mother.      

Think about the first scenarios and think about who is the real benefactor there?  If you said the child, I urge you to think again.  Are you thinking about it from the child's perspective?  May be you are looking at how the adult really wants to be with the child?  And you know what? You are right, the adult really really wants to be with the child and that is precisely what is wrong with this picture.  

The baby has to tend to the adult's need and give up their activity because the adult is relentless and needy until the baby gives in.  He can't be his true self, who wants nothing more than to play alone and be with himself at this point.  But rather has to respond to an external force and make up a false self to please the adult.  

This translates into therapy when the therapist provides the transitional space and allows the patient to be the true self, while he/she contains the rage, tears, loves, sadness and despair, without freaking out and shutting down.  When the therapist can push his/her needs aside and tune into the patient as a good enough mother may tune into her child, the patient learns that he/she can be their true self and that won't mean annihilation of the love object (in this case the therapist and the mother in transference) and a calamity of the childhood i.e. the loss of love of the object doesn't have to be reenacted.  Learning that there is an alternative to the calamity, may seem easy but that is the most intense part of the relationship with the therapist.  

Many adults and children who come to us to seek treatment and therapy, are still trying to find their real selves because growing up, they never had a chance to have a love as true and pure as the little boy who had the Scarlet Fever had for his fluffy soft toy rabbit.  The magic fairy of the nursery never came when tears rolled down.  For these patients the fairy can't arrive, until they can relive the nursery in their therapist's chair or laying on the couch; and feel that they matter more than they ever mattered to anyone before.  And that even when the Scarlet fever hits, they won't be cast aside and blamed for the misery.  The real test lies in being patient and present because the fairy will take it's time before she materializes.  I believe that the good enough therapist is the fairy indeed.  There is no magic dust but only the reality of what happens in the therapeutic alliance and transitional space that mends a broken heart.  Once that happens, people become real and unafraid.         

Because after all, as the Skin Horse said to the rabbit:

'Does it happen all at once, like being wound up,' he asked, 'or bit by bit?' 

'It doesn't happen all at once,' said the Skin Horse. 'You become. It takes a long time."

"Generally, by the time you are real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except to people who don't understand.”

― Margery WilliamsThe Velveteen Rabbit