The Metaphor of a Play: Origin And Breakdown Of Personal Being

Citation preview

The Metaphor of Play Third edition

In this updated revision of his earlier classic work, Russell Meares not only deepens our understanding of the essential role of play in development and in the clinical context, but also puts forth a compelling model of the fundamental functions of the self in the human condition. I learned more about the subtle yet profound mechanisms that operate in the deeper strata of the therapeutic encounter than any book I've read in the last 10 years. Allan N. Schore, Ph.D., UCLA David Geffen School of Medicine. Russell Meares has brought together a wealth of clinical experience and deep theoretical understanding in this book. His humane and sensitive approach to therapy comes through whether he is describing an infant playing or the enormous distress of a person haunted by past trauma. Frank Margison, Medical Director for the Manchester Mental Health and Social Care Trust Russell Meares, in a scholarly, creative and consistently lively manner, explores in this book the development and breakdown of the sense of self. Reading this book is to enter into conversation with an extraordinarily gifted thinker and teacher. Thomas H. Ogden, M.D., Supervising and Training Analyst, The Psychoanalytic Institute of Northern California Personality disorder can be conceived as the result of a disruption of the development of self. This thoroughly updated edition of The Metaphor of Play examines how those who have suffered such disruption can be treated by understanding their sense of self and the fragility of their sense of existence. Based on the Conversational Model, this book demonstrates that the play of a pre-school child, and a mental activity similar to it in the adult, is necessary to the growth of a healthy self. The three sections of the book: Development, Disruption and Ampli®cation and Integration introduce such concepts as the expectational ®eld, paradoxical restoration, reversal, value and ®t, and coupling, ampli®cation and representation. This highly readable and lucid presentation of the role of play in the development of self will be of interest not only to therapists but also to those interested in the larger issues of mind and consciousness. Russell Meares is Emeritus Professor of Psychitary at the University of Sydney and leads a programme at Westmead Hospital, Sydney for the treatment of, and research into, borderline personality disorders.

The Metaphor of Play Third Edition

Origin and breakdown of personal being

Russell Meares

First published 1992 as The Metaphor of Play: The Self, The Secret and the Borderline Experience by Hill of Content. Second edition published 1993 by Jason Aronson Inc. Third edition published 2005 by Routledge 27 Church Road, Hove, East Sussex, BN3 2FA Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York, NY 10016, USA Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Ø 2005 Russell Meares All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Meares, Russell. The metaphor of play : origin and breakdown of personal being / by Russell Meares.± 3rd ed. p. cm. Includes bibliographical references and index. ISBN 1-58391-966-X (alk. paper) ± ISBN 1-58391-967-8 (pbk. : alk. paper) 1. Borderline personality disorder. 2. Sel¯essness (Psychology)±Treatment. 3. Play±Therapeutic use. 4. Self-perception. I. Title. RC569.5.B67M43 2005 616.85©852±dc22 ISBN 0-203-01581-9 Master e-book ISBN

ISBN 1-58391-832-9 (Hbk) ISBN 1-58391-833-7 (Pbk)

2004020691

For Susanne

Contents

Foreword by Glen Gabbard Preface Acknowledgements

ix xii xiii

PART I

Development

1

1 Play and the sense of self

3

2 The secret

7

3 The self as double

15

4 I and the other

20

5 The role of toys

27

6 Two playrooms

30

7 Fragments of space and of self

41

8 Play, coherence and continuity

51

9 Value and ®t

62

PART II

Disruption

77

10 Body feeling and disjunction

79

11 Stimulus entrapment

88

12 Transference and trauma

97

13 Reversals

104

14 The expectational ®eld

114

viii

Contents

15 Restoration

126

16 Impasse: Paradoxical restoration

134

17 False self

143

18 The mask

149

PART III

Amplification and integration

159

19 A drive to play

161

20 Coupling, ampli®cation and representation

170

21 Empathy

181

22 Dissolving the trauma

190

23 A self-organizing system

202

Notes References Author index Subject index

211 227 245 251

Foreword

We live and work in an era in which the genome has entered the media limelight. The human soul has receded into the darkness. At a recent psychiatric meeting, I heard a distinguished colleague say that the in¯uence of parents is important, but it stops after the moment of conception. Patients now surf the Web for information about their psychiatric diagnosis and seek out the latest psychopharmacological agent that will alter their neurotransmitters in exactly the right way to make them feel less anxious, less depressed, less hypomanic, less shy, less impulsive, or less angry. The notion of interiority, a private space within the psyche that has long been cultivated by psychoanalysts, psychotherapists, theologians, and philosophers, is at risk of being trivialized by forces of genetic and biological reductionism in the ®eld of psychiatry. In this context, the third Edition of Russell Meares's The Metaphor of Play is most welcome. Going against the grain of our high-tech, quick-®x, and materialistic culture, he dares to contemplate the nuances of existence and the private domain of the self. This self evolves out of an intersubjective matrix of infant and caregiver and ultimately from the experience of play. Meares demonstrates a considerable catholicity of taste. In¯uenced by James, Janet, Jackson, Kohut, Winnicott, and others, he integrates diverse threads of thought into a coherent fabric that has his own personal stamp on it. To his credit, Meares does not fall prey to the trap of psychoanalytic reductionism. He thoughtfully incorporates recent developments in neuroscience into his overarching theory. Endel Tulving's work on the complexity of memory is one such example. In this new edition, Meares signi®cantly extends his understanding of trauma. This emphasis is fortuitous, as it provides a natural bridge between that which is most private and idiosyncratic and that which is ``hard-wired'' in the central nervous system and the neuroendocrine system. There is no better venue for the integration of mind and brain than the study of trauma. The ``expectational ®eld'' described by Meares as the imposition of an internal object relationship on current interpersonal relationships also re¯ects the existence of a powerful neural network in the brain involving

x

Foreword

representations of self and others and the physiological responses associated with those representations. These neural networks of self and object representations are pivotal to understanding the vicissitudes of relatedness and the complex mosaic of transference and countertransference in therapeutic relationships. In his description of reversals, Meares notes that in experiences where there is a disruption in connectedness between the self and other, the patient can adopt the position of the object representation and treat another person in the environment like the self representation in the network. The considerations of trauma that Meares introduces lead directly into the metaphors of play in adulthood. As he notes, play is really a speci®c type of mental activity. Although embarking from a different starting point, Meares arrives at a conclusion that is similar to the work of Bateman and Fonagy (2004) regarding the value of mentalization in the treatment of traumatized borderline patients. The integration of the psychic equivalence mode and the pretend mode is re¯ected in play. In some way, the process of play in development leads to a resilience of the self ± a capacity that allows trauma to be understood and processed. When the ability to play has been developmentally sti¯ed, there is still hope that the capacity to develop mental activity approximating play can be forged in the crucible of therapy. In Meares' view, this capacity becomes central to the healing process. The traumatic story can change if the patient can enter into the realm of imagination and alter narratives of self and other. Despite the ``hard-wiring'' of neural networks, new networks can be formed, and Meares emphasizes throughout that the self is not etched in granite. It is actually one of the numerous different forms of consciousness that is in a state of ¯ux throughout one's life. The self is acutely aware of how others respond, and it is in this context of connectedness that the self is reshaped. Meares has devoted his career to the seriously disturbed patient. Yet the reader will not be left with a sense of despair. Rather, this new volume presents a road map that ends with a powerful message of hope. Meares ®rmly believes that transformation is possible, even for the most severely damaged, through the efforts of a dedicated therapist. This book leads the way for those clinicians who share Meares' conviction and commitment to the most unfortunate of our brethren.

Reference Bateman, A., Fonagy, P. (2004) Psychotherapy for Borderline Personality Disorder, Oxford: Oxford Press.

Foreword

xi

Glen O. Gabbard, M.D. Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry Baylor College of Medicine Training & Supervising Analyst Houston-Galveston Psychoanalytic Institute Joint Editor-in-Chief International Journal of Psychoanalysis

Preface

The sense of a life going on within us, its ¯ux and feeling, its images, ``shape,'' and vicissitudes, is the main subject of this book. William James called this experience the ``stream of consciousness.'' It was what he understood as ``self.'' This central element of human existence was neglected by the scienti®c community for much of the twentieth century. It barely features in the mainstream psychotherapeutic systems. The Metaphor of Play is part of an ongoing endeavor, begun in the 1960s, to build a model of psychotherapy around the fundamental experience of what William James had called the ``duplex self,'' a form of double consciousness which is only one of the various forms of consciousness of which we are capable. In 1985 Robert Hobson called this approach the ``Conversational Model.'' Its central idea is that we are not born with a ``self.'' Nor does it inevitably develop in the way that our bones and other physical features grow. Rather, the peculiarly human experience of personal being emerges in the context of a particular kind of conversation. Outcome studies which validate the effectiveness of the model have appeared in recent years.1 The Metaphor of Play is complementary to my other recent work, Intimacy and Alienation. Both books have the same central theme, but each volume develops the elements in differing ways and degrees. The ®rst edition of this book was written during the period 1989 to 1991. This edition is considerably enlarged and revised. Eight new chapters have been added (8, 12, 14, 15, 16, 17, 22, 23) and three removed, with some aspects incorporated into the new chapters. Much of what is new in this book concerns trauma, a subject which became a major ®eld of inquiry only about 15 years ago. The notion of self as a self-organizing system is also introduced. The opening chapters are largely untouched. The book is addressed to three main audiences: ®rst, those who have a general interest in mind and consciousness; second, those beginning psychotherapy; third, experienced therapists who, it is hoped, will ®nd in this story things that are new and of interest.

Acknowledgements

A main background to this book was formed many years before it was written. My father, Ainslie Meares, was working with very ill patients while I was a medical student. One case was particularly inspiring.1 A young woman with an intractable psychotic illness recovered after some years, during which period she produced some remarkable symbolic paintings. The story of this relationship seemed to have within it elements of a therapy, the principles of which were not encompassed by the orthodoxies of the time. My father wrote about this and other similar experiences in The Lancet.2 He concluded that recovery seemed to be related to the physician's understanding of his patient. He considered that the main healing effect comes through the therapist's fostering a form of mental activity that is nonlinear, nonlogical, and that is found in states such as reverie. This state is broken into by moments of anxiety, so that the principal therapeutic task is to deal with these intrusions of anxiety in order to allow the healing kind of mental function to begin again. This approach describes the germinal centre of The Metaphor of Play. I was very fortunate, when I entered psychiatry in London, to encounter and then to develop a great friendship with the late Robert Hobson (1920± 1999). He too was working in a way that was outside and beyond the scope of the therapeutic theories and methods which were then most dominant and in¯uential. He was attempting to ®nd a way to help people who had failed other treatments and who would now be called ``borderline'' personalities. Our struggle together to grasp and express the essence of what was happening in those therapeutic relationships which resulted in bene®cial change went on for over three decades. The striving towards our goal was beset with dif®culties, particularly that of distance, but maintained by correspondence and frequent visits between Australia and England. I am immensely grateful to him for his warmth and generosity, for the stimulation and pleasure of our talks conducted in many places ± the Peak District, in pubs, at cricket matches ± and for the part he played in my life. It is to be hoped the memorial to him will be what he called the ``Conversational Model.''3

xiv

Acknowledgements

Another great friendship has been the third main in¯uence upon the evolution of the ideas expressed in Metaphor of Play. This is with Bernard Brandchaft to whom I am also immensely grateful, not only for the ideas, but also for the fun that arose during our time together. Like Hobson and me, he is concerned with patients with problems of intractable illness and with signi®cance of ``minute particulars,'' the shifts and nuances of the therapeutic conversation. His original ideas are particularly important in the areas of pathological accommodation (Chapter 17), unconscious traumatic memory, and the notion of impasse (Chapter 16). Many other conversations have been important in the development of my ideas. I can only mention a few of them. They include, in the area of psychoanalysis, Joseph Lichtenberg and Edgar Levenson; in child development, Michael Lewis; in memory research, Endel Tulving; in trauma, Bessell van der Kolk, Onno van der Hart and Paul Brown; and in the clinical neurophysiology, Evian Gordon, Lea Williams, and Allan Schore. Thomas Ogden has been particularly important. We began to correspond and to converse in 1984, after each had published on the spatiality of personal existence. His understanding of what I have been trying to do has given ``value'' to my endeavor. I have also valued the support of senior academic colleagues such as Basil James and the late Peter Beumont. The Metaphor of Play has been in¯uenced by many conversations, in Sydney, various other parts of Australia and New Zealand, with people who have been working to develop the Conversational Model. I particularly thank my colleagues in the Australian & New Zealand Association of Psychotherapy and those on the faculty of the Master of Medicine (Psychotherapy) course at Sydney University and/or training program; Joan Haliburn, Michael Williamson, George Lianos, Mohan Gilhotra, Leo van Biene, Tessa Phillips, Janine Stevenson, and Anthony Korner. Their constant efforts to elaborate, re®ne and de®ne the fundamental features of the way we work have provided the essential atmosphere in which the model can ¯ourish and develop. I also want to thank those patients and their therapists who have given permission for extracts from their therapeutic conversations to be reproduced. Mohan Gilhotra, Director of Mental Health Services for the Western Area of Sydney and also my agent Rose Cresswell, and my Italian colleagues Marco Monari, Antonello Correale and Francesco Andreucci, in different ways, have given invaluable support through their belief in the value of my work. I am grateful to my secretary Ru®na Fernandes for her dedication and her calm and cheerful demeanour in preparing the manuscript. She, like her predecessor, Bronwyn Maxwell, has been tireless in this laborious task. Finally, and most importantly, I thank my wife, Susanne, who provided the necessary creative environment in which this work could grow.

Part I

Development

Chapter 1

Play and the sense of self

Those who suffer a pervasive feeling of emptiness, who live as if on the surface, caught up in a ceaseless traf®c with the stimuli of the everyday world, are the main focus of this book. These people sense no core existence and are often without access to true emotions or an authentic feeling of being alive. Such disturbances of the experience of self are common. Indeed, people af¯icted with them make up the bulk of those who confront a psychotherapist in the modern age. Their severity ranges from a subtle and unobtrusive disturbance of personal being, to a severely disabling condition associated with repeated hospitalizations, suicide attempts and broken relationships. Until the 1970s, no major psychology could adequately explain the diminishment and fragility of the sense of existence that affect these people. In recent years, however, an understanding has begun to develop and is attracting increasing interest. In 1980, the most severe manifestation of the disturbance was of®cially given a name ± the borderline personality. The aim of this book is to show how these experiences, in both their lesser and more severe forms, can be understood, and how a way of treating them can be derived from this understanding. The main theme depends upon two paradoxes. The ®rst is that self, which is private, grows in the public domain. The second is that inner life, which we sense as insubstantial, is founded on physical things, such as toys and parts of bodies. Ideas about self and its origins were being developed in the United States about a century ago. James Mark Baldwin was one of the ®rst proponents of ideas about self. He belonged to a group of psychologists who sought to understand this experience and its evolution. William James was the leading ®gure in this school. Like his brother Henry, the novelist, William was intrigued by the phenomena of individual consciousness and by the problem of expressing, in simple language, their intricate nature. Others in this group included Josiah Royce, Charles Cooley, and George Herbert Mead in the United States; Pierre Janet in Paris; and Edouard ClapareÁde and others in Switzerland. They in¯uenced each other and also gained from philosophers such as Henri Bergson.

4

Part I: Development

Just before World War I, the American expression of this line of thinking was swept away in what has been called a ``radical behaviorist purge''.1 A new era arose, in which conceptions of man and mind were peculiarly mechanical. Such notions as self that could not be touched or measured were banished from the curricula of academic psychology as unscienti®c, leaving a vacancy at the heart of that discipline. The dominant psychodynamic theory of the time, ego psychology, formulated a notion of mind that was consistent with the images of the late industrial age. Ego was the ``psychic apparatus.'' This system of thinking included no notions of self until the late 1930s.2 These ideas seemed to be manifestations of something deeper, of a fundamental shift in the way those in the west conceived of themselves and of their relationship with others. This shift was re¯ected not only in psychology but also in the physical sciences, in political thinking, and in the dominant works of artistic expression. Casimir Malevic, for example, just before World War I, began to paint images that showed the fusion of man and machine. He was followed by a series of major painters, including Umberto Boccioni in Italy, and Fernand Leger and Francis Picabia3 in France, who portrayed man as a mechanism. Furthermore, the dominance of linear and geometric forms of painting over more random, wandering, and, in this way, more human forms of expression extended from Malevic through Mondrian to the Bauhaus School and on to the 1960s in New York with Frank Stella, Barnett Newman and Kenneth Noland. The ideas of James, Baldwin and their colleagues could not exist in such an intellectual atmosphere, which, for heuristic purposes but not entirely fancifully, we might date from 1913 to 1971. James died in 1910. His in¯uence waned soon after. Baldwin was forgotten. In Paris, Bergson's great books had all been written, and Janet, who before the war had seemed likely to become the greatest psychiatrist of his time was destined to become instead a footnote in the history of psychodynamic thought, his major works never translated. Only in Switzerland did the tradition live on. In very different ways, Ludwig Binswanger and Carl Gustav Jung pursued the problems of existence and self; Jean Piaget, who called Janet ``my Professor'' until the end of his life, conducted in¯uential studies on psychological development of the child.4 Nevertheless, in the United States, the rout was so complete in the ®eld of psychology at least, that when in 1972 Arnold Buss came to study the subject of private consciousness, perhaps the most fundamental fact of which we are aware, he found no single reference to it in the literature of psychology.5 The tradition began to revive in America in the 1940s under the in¯uence of Harry Stack Sullivan, who acknowledged his debt to George Herbert Mead. It was not until the 1970s, however, that the extraordinary situation discovered by Arnold Buss began to be recti®ed.

Play and the sense of self

5

The concept of self was welcomed beck to the scienti®c fold. At the same time, mother±infant interaction emerged as a major ®eld of study. It seemed an awareness had arisen that, in some way, self evolved through the child's engagement with the nurturing environment. The work of Heinz Kohut had arrived at his conclusions by a pathway very different from his predecessors, gaining his insights from clinical material. His explorations were paralleled in England by D.W. Winnicott, whose developmental approach was based on observations of children. This book belongs to and is indebted to this broad tradition. The second paradox upon which the book is based, that of self as substance, ®rst presented itself to me in a much more personal way. About 35 years ago, I encountered a young woman, Miss A, a waitress, ill-educated, and intensely shy.6 What she said was often puzzling and hard to grasp. Yet it was important, since she struggled to portray the reality in which she lived. One day she said something that seemed to be of fundamental signi®cance. She was ®nding, as she usually did, that it was very dif®cult to talk. She tried to explain: ``I suppose I'm scared that if I talk, there'll be nothing left to say. Say I told you all my thoughts, ideas, and whatsit, it'd be like me piled up beside us, with nothing left to say.'' Miss A seemed to feel that she was composed of a series of ideas and that should they be lost, she would cease to exist. It was as if she attributed concrete substance to her ideas and experienced her thoughts as the stuff of her existence. Their loss implied the threat of dematerialization. As a consequence, at our ®rst meeting, standing in a corner of the room, she told me that she did not want to speak. Subsequently, in groups she remained silent. For her, there would be no idle chatter, since conversation served only to reveal her inner world of ``thoughts, ideas, and whatsit.'' Miss A was aware that her sense of personal fragility had something to do with her relationships with others. She strove, in halting phrases, to describe this apprehension: ``If I began to speak ± it's too big ± like stepping on a merry-go-round ± no, it's like stepping stones across the sea ± having to go on to the end. The stepping stones are like situations, incidents more likely. I can't quite manage them. I scramble from one to the other. How I got from this morning to here was most unpleasant. I felt things were demanded.'' Her inner world of thought and emotions was constantly demanded in the encounters of daily life, when a part of herself was shown to another person and momentarily occupied a precarious existence outside her. She implied that to expose one's thoughts is to risk a kind of personal damage, through a faulty response of others. On another occasion she seemed to say that the sense of damage was like a wound to her physical being. The frailty of Miss A is not shared by everyone. Nevertheless, for most of us, there are threads of thoughts and images that are felt as intensely personal. They are valued and perceived as a kind of inner core. They have a creative potential and are also the locus of a sense of self.

6

Part I: Development

From where do such experiences come? At the heart of this book lies the idea that the play of the preschool child, and a mental activity similar to it in the adult, is necessary to the growth of a healthy self. Seen in this way, the play of the child is not mere diversion. It is vital to the evolution of mature psychic life.7 Play takes place in a space that is created by the atmosphere of another. The play space, part real, part illusory, provides the basic metaphor through which the experiences of Miss A and others who suffer disorders of self might be understood. The play of the very young child has peculiar characteristics that include the nature of the relationship with the other, the form of language, and an absorption in the activity that is similar to that of an adult who is lost in thought. The ®eld of play is where, to a large extent, a sense of self is generated. These and related developmental ideas make up Part I of this book. Part II of the book considers disruptions of this normal development. These frequently arise through the fragility of the play space, which is easily broken up by the faulty responses of others which do not ``®t'' the child's fundamental reality, which has its basis in feeling. These disjunctive responses have an alerting effect, causing the child to orient to the outer world. For a child who habitually lives in such a situation, the ®eld of play is never adequately established, so that there is little chance to elaborate those experiences that form the core of self. The individual is left with a sense of nothing much inside, no ``real me.'' A second and related form of disruption is more active, and can be understood as traumatic. A common kind of this experience is that which Miss A seemed to fear, that is, the sense of harm that comes with attacks upon the feeling of value which is at the core of self. In Part III, the ®nal chapters outline the therapeutic approach. The task of the therapist who works within this system is, ®rst of all, to establish, in a metaphoric sense, the ®eld of play.

Chapter 2

The secret

As soon as we try to understand how a disturbance in the sense of self might come about, we strike an obstacle. What is self? How can it be de®ned? These dif®cult questions must be given some kind of answer before we go on. An approach to the problem of conceiving so elusive and abstract an entity as self can be made in a negative way. Although it is hard to say what self is, we can say, without doubt, that it is distinct from not-self. This simple dichotomy provides a starting point. In making a distinction between self and not-self, we draw a line between not only our bodies but also a whole range of experiences, such as thoughts, feelings, and memories that are felt as one's own and as part of an inner world that is distinguished from an outer world. We are led to a fundamental idea ± self depends upon the concept of innerness. The development of this concept is shown through the child's understanding of secrecy. We are not born with a self. For some time, the child seems to conceive the boundary between his or her world of feelings and thoughts and the world of others as incomplete. Children seem to believe that those who are close to them will know of these feelings and thoughts, even their dreams. For example, one of Piaget's 5-year-old subjects is asked: ``Could I see your dream?'' ``No, you would be too far away.'' ``And your mother?'' ``Yes, but she lights the light''.1 Piaget wrote that ``it is indispensable to establish clearly and before all else the boundary the child draws between the self and the external world''.2 Despite the evident importance of the development of self-boundary, there has been little actual study of it. We do not know, for example, the age at which the concept is attained. Mahler and colleagues suggest that it is between 2 and 3 years of age;3 Piaget's ®ndings imply that it is considerably later, from 7 to 9. One supposes that the lack of data arises through dif®culties inherent in studying so subtle a notion as self-boundary. Pierre Janet, however, gave us a way of approaching the problem. Janet was the star of a school of psychiatry that was evolving in Paris towards the end of the nineteenth century. The story of his rivalry with Freud, his eclipse, and his death, which passed without public notice, is

8

Part I: Development

wonderfully told by Henri Ellenberger.4 He points out that Janet's hypotheses and clinical insights, many of them brilliant, have been lost, or are largely neglected following his fall from in¯uence. Among his ideas was the notion that the child's discovery of the concept of secrecy is an event of enormous signi®cance since it heralds the birth of an inner world. When the child learns that thoughts and ideas can be kept within himself and are not accessible to others, he realizes that there is some kind of demarcation between his world, which is inner and that which is outer. Seen in this way, a study of the age at which children know what it means to keep a secret may allow us to infer the age of self-boundary formation. We used Janet's idea in a study of 40 preschool children in Western Sydney, Australia.5 The children came from all socio-economic groups. The study depended upon the child's responses to a large colored photograph of two adolescents, called Cathy and Paul. Cathy was shown with her hand cupped to Paul's ear, as if she were whispering. The child was asked: ``What are Cathy and Paul doing?'' The questions that followed were designed to elicit the child's knowledge and use of the word secret, the content of secrets, those who were recipients of secrets, and those with whom one cannot share a secret. Another test consisted of the simple presentation of a moral dilemma in order to investigate the strategy of lying, which also seems to represent an understanding that a thought or idea can be kept hidden. The ®rst question to each girl in the study was: ``If Cathy was naughty, and her mummy asked, `Cathy, have you been naughty?' what would Cathy say?'' The same question was asked of the boys, except that it involved Paul. The taped interviews showed fairly clearly that most children older than 4 years of age understood the notion of secrecy. Of the 14 children younger than 4 years, only two had attained this concept. Of these two, one aged 3.5 years, was regarded as exceptionally advanced; the other was aged 3.11 years. Seven of 12 children between 4.0 and 4.5 years and 9 of 14 children between 4.7 and 5.9 years understood the concept of secrecy. The range of ages for attainment of the concept was from 3.5 and 5.5 years. The ®ndings concerning lying were complementary and surprisingly unequivocal. On no occasion did the interviewer introduce the strategy of lying as a possible response to the dilemma. However, 24 children spontaneously recommended such a strategy. One typical response was: ``She would say `George did it.' '' George being the child's brother. Lying, then, is normal in terms of the moral development of this age group, as Piaget6 had pointed out. Of the 16 children who did not lie, only seven told the truth. The predominant response of the others was to run and hide, as if the child believed that one cannot hide one's thoughts but can still hide oneself. Other responses of the non-liars included crying and asking to be cuddled. Understanding the strategy of lying was clearly age related. The mean age of the

The secret

9

children who lied was 4.6 years, and the non-liars 3.11. The strategy of lying was also closely related to the attainment of the concept of secrecy. Of the 19 children who did not understand secrecy, only 5 lied. (Three children could not be classi®ed in terms of the secrecy concept.) These ®ndings suggest that at the beginning of the ®fth year of life, the large majority of children know that it is possible to avoid getting into trouble, disapproval, or punishment by lying. The fact, however, that some children lie earlier than this may not necessarily indicate the achievement of the inner±outer distinction. Although the behavior of some children might have been based on the knowledge that their thoughts were not accessible to others, other children may have adopted the strategy through imitation of an older sibling. Therefore, the results of the secrecy interview are the more fundamental data in charting the emergence of a private self.7 Some extracts from the tapes illustrate the children's ideas about secrets and to whom they would tell them. Boy (4.0 years): What are Cathy and Paul doing? Telling secrets. What are secrets? You tell someone and they`re not allowed to tell anyone. Very good. What kind of things are secrets about? Presents. Like we got a Lilo* and it wasn't even anyone's birthday. Can secrets be about anything else? You can pretend things, like dressing up. Is that a secret? Yes, because I'm a boy and I'm wearing a dress. If that's a secret, whom can you tell? Jade, if you don't let her take the scarf, because she always wants them ALL! Who can't you tell? Daddy and Mummy because of the paint on my face, even if I wash it off they will be angry. Who else can you tell? Um, anyone but not if you don't like them, because they don't like me. Can I tell Miss Sweeney? Yes, she's the teacher, like you. I'll tell her, then Helen! Girl (4.7 years) What are Cathy and Paul doing? Telling secrets.

* A Lilo is an in¯atable mattress used for lying on the beach or in water.

10

Part I: Development

What are secrets? [Silence] What is she saying to him? [Silence] Do you know any secrets, then? Yes, I didn't invite Patricia to my party. Can I tell anyone? Anyone except Patricia. I know another secret. Boy George is a poofter.** Why is that a secret? Because it's a square (swear) word. What, poofter? Yes, a policeman will come and lock you up if you say it again. Who else can't you tell secrets to? Anyone who isn't your friend. What about mummy and daddy? I can tell them. What about Miss Smythe? No, she's the teacher. Isn't she your friend? No. Why did you tell me? Because you wear beautiful earrings, and so do I. Can you take yours off ? An example of a child who did not understand secrecy follows, girl (3.9 years) What are Cathy and Paul doing? Whispering. Why whispering instead of talking out loud? Because they're in a picture. Why do people whisper? To sound like the grass rustling. Do you know what a secret is? No. Do you ever know something that no one else knows about? No. These extracts show that what is held secret often concerns such intensely personal matters as gender identity and ideas about forbidden sexuality.

** Poofter is a slang term for homosexual.

The secret

11

Other responses described secrets that would bring shame to the individual should they be revealed. Examples included illegitimate pregnancy and being unable to swim. Such secrets might have been predicted. What was surprising, at least to the adult mind, was that the majority of secrets involved pleasant events and valued objects, such as birthday surprises and gifts. Some of these children had learned that such secrets could be used to exchange in the formation of alliances and friendships. A treehouse was an example of such a secret. It was a treat to be offered only to friends. Secrets were given only to those to whom the child felt very close. These children came upon a paradox. At the same time as they found that their personal worlds were distinct and separate from others, they also found a means of connectedness to others. The discovery of the notion of the secret brings about an immense change and an enlargement in the child's life. The child learns that through the emergence of a sense of privacy, groups can be formed. A shared secret unites people and, at times, gives them a common identity. They might become, for example, ``the tree house tribe.'' This is not so merely for children. The transmission of con®dences helps to develop social networks among adults.8 Many tribal societies depend upon systems of secrecy to hold them together. Jung, who observed this phenomenon, implied that it served an important developmental function. He wrote: ``The secret society is an intermediary stage on the way to individuation''.9 The attainment of the concept of secrecy brings another major change in relating to others. For the ®rst time, intimacy, of the kind that adults share, is possible. The child begins to know that secrets are disclosed in a developing dialogue with others who can be trusted to share and respect them. The secrets then become the coins of intimacy and the currency of its transactions. In contrast, a younger child's relationships with others do not involve exchange with another whose world is known to be different and not one's own. Rather, the small child lives in a single, personal universe of which the parents constitute a major part. They are close in that the child is devastated by their absence, but they are not conceived as having peculiarly individual wishes, feelings, or memories that differ from the child's. Flavell10 demonstrated this in a number of ways; for example, children were shown several objects (stockings, necktie, adult book, toy truck, and doll). They were asked to choose gifts for their parents, their siblings, and themselves. The 3-year-olds tended to give parents gifts they would like themselves, so that mother would be offered a toy truck. Some 4-year-olds, half the 5-year-olds, and all the children of 6 chose appropriate gifts. The attainment of self-boundary allows not only the formation of intimate relations, but also the feeling of empathy. Predictably, those who suffer severe personality disorder have de®ciencies in both areas. They tend to make non-intimate attachments and have relationships in which the others feel exploited. They also suffer what might be termed pathologies of privacy.

12

Part I: Development

Pathologies of privacy are shown in subtle ways. They are not obvious at ®rst contact, nor is the individual usually aware of them. One category of disturbance depends upon a precarious and ill developed sense of innerness. Since what is inner is minimal and unstable, it cannot be exposed to the risk of a faulty response or some diminishment at the hand of others. These people have grave dif®culties in telling others of their deepest feelings, their profoundest wishes, and their imaginings. In order to preserve a core of personal experience, which seems necessary to the sense of self, the individual develops strategies, often unconsciously, that hide this highly valued interior zone. These strategies may be complex, for the danger of exposure has to be balanced against the need for intimacy, in which revelation is required. An extreme resolution of this dilemma may be the use of false secrets as the currency of an intimate relationship.11 A second kind of pathology of privacy might be called psychic incontinence. The individual is rather like the child who does not yet conceive of an inner world. An example was provided by a young woman who remarked that she had dif®culty in expressing her feelings, except when she was using the telephone. Her therapist, however, soon found that she was expressive. She let him know immediately whatever she felt. He was not alone. Her workmates had learned so much of her feelings and of her intermittent despair, which sometimes led to self-mutilation, that they patrolled the restroom to make sure no harm had come to her. Her exasperated family were spared no details of her therapeutic sessions. In some ways, she was like a child who has no secrets. In contrast, it seemed that she did not like this state and in some part of her there was a wish to move beyond it. She hated it when her therapist put into words the emotion she was currently experiencing. Moreover, she disliked being looked at, as if the observer could too easily read her emotions. Her curious preference for telephone conversations now seemed less puzzling. In this way she could escape the feeling that others would inevitably know what was going on inside her. Although we have so far considered the importance of the concept of privacy in the evolution of intimacy, the child's attainment of this milestone brings with it other major changes, one of which can be inferred from the following story. A 5-year-old child in Victorian England discovered that his father did not know of a misdemeanor that the child had recently committed. With this discovery, a sudden realization swept over the youngster. Years later he wrote of the immense import of this experience:12 Of all the thoughts which rushed upon my savage and undeveloped little brain at this crisis, the most curious was that I had found a companion and a con®dant in myself. There was a secret in this world and it belonged to me and to somebody who lived in the same body with me. There were two of us, and we could talk with one another. It is dif®cult to de®ne impressions so rudimentary, but it is certain that it

The secret

13

was in this dual form that the sense of my individuality now suddenly descended upon me, and it is equally certain that it was a great solace to me to ®nd a sympathizer in my own breast. This incident from the autobiography of Edmund Gosse illustrates not only the importance of the development of an idea of secrecy for the achievement of a sense of individuality, but also that this individuality is dual. The dualisms that emerge with the concept of privacy are multiple. First, there is a distinction between subject and object in the social world; others are not merely parts of a personal universe. Second, there is a distinction between thoughts of things and those things themselves. Third, there is an awareness of a dualism in the inner world in which also subject and object are sensed. This idea is central to an understanding of the growth of self. It will be touched upon in later chapters. These changes are universal and part of ordinary psychic evolution. Sometimes, however, the attainment of the concept of an inner life brings with it a development that is peculiarly individual. It arises from the fact that those ideas, feelings, images, memories, and fantasies that make up the inner world are not all given the same value. Some, which concern things that are commonly sensed, are passed about in small talk and gossip. Others are highly valued and sensed as a kind of inner core. They may form the germ or seed out of which grows an individual life. This idea is illustrated by the story of Richard St. Barbe Baker, who achieved international fame for his work on the conservation of the world's forests. In a radio broadcast13 made at the age of 91, St. Barbe Baker described an occasion during childhood when, for some reason, he had wandered away from home into a neighboring wood. Although he was only 4 years old and lost, he was ®lled with a sense of the marvellous, as if he were in a dream. He came to a clearing, where he sat for a while. Sounds were ampli®ed so that the crack of a breaking twig was like the lashing of a cartwhip and birdsong sounded like organ notes. As he listened, he heard the tinkling of a brook, which he followed, and so found his way home. Although he went back to the same place the next day, he could not recapture the feeling of wonder and excitement. Nevertheless, the clearing in the forest now had signi®cance. He often returned to it. He said: Sometimes when things had gone wrong during the day, which wasn't infrequent, I used to escape from the house and go to the beechwood and I'd put my hands on the smooth bark. It was like my mother confessor. Everything seemed to be cleared up ± all the troubles of the day vanished and I went back to the house. I generally managed to slip in without being noticed by anybody. But one occasion my father caught me going into his study by the door through the conservatory. And he said, ``My dear boy where have you been?'' ``Oh, daddy, I've

14

Part I: Development

been out to see the stars. It's a wonderful night, come out.'' But I'd never give away my story, I'd never tell people where I went and I never gave away the secret of my mother confessor, my Madonna of the Woods. The soothing aspect of the secret, reminiscent of the effect of the mother, is evident in this story. Its whole effect, however, extended far beyond it. This incident became the germinal center out of which grew the direction and shaping of an entire life. The discovery and creative elaboration of such a ``generative secret,'' as yet unrealized and perhaps only dimly conscious, becomes an ideal goal towards which a therapy is aimed.

Chapter 3

The self as double

Although we may say that the birth of self comes with the discovery of what a secret means, this discovery is built on a past and on earlier, embryonic forms of self. We must know something of the nature of this history to understand disorders of self. To explore this development, it is ®rst necessary to describe self somewhat more completely. I approach this matter with the help of Australian philosopher David Armstrong. Armstrong writes in a clear and straightforward way. He asks us to consider the experience of the long-distance truck driver. I use his own words: After driving for long periods of time, particularly at night, it is possible to ``come to'' and realize that for some time past one has been driving without being aware of what one has been doing. The comingto is an alarming experience. It is natural to describe what went on before one came to by saying that during that time one lacked consciousness. Yet it seems clear that, in the two senses of the word that we have so far isolated, consciousness was present. There was mental activity, and as part of that mental activity, there was perception. That is to say, there was minimal consciousness and perceptual consciousness.1 The truck driver responded to stimuli, both meaningful and meaningless. Lest we doubt this, Armstrong goes on to describe the sophistication of the truck driver's activities while he apparently lacked awareness. He suggests that many animals may be operating by means of the two forms of consciousness assumed for the truck driver ± namely, minimal, involving some kind of mental activity, and perceptual, concerning the capacity to perceive. A complex neurophysiological apparatus is at work that deals with environmental events in an appropriate way. But there is no self in it. As Armstrong puts it: ``There is an important sense, we are inclined to think, in which he has no experiences, indeed is not really a person''.2 The truck driver functions like many animals and also like the infant, whose

16

Part I: Development

perceptual and organizational abilities are evident in the ®rst few weeks of life. For the truck driver to experience a sense of self, another kind of consciousness, which is presumably a later evolutionary development, is needed. Seen in this way, it is only likely to be found in few, if any, animals and at a relatively late stage in human development. This kind of consciousness is introspective consciousness. When the truck driver ``comes to,'' something happens that is analogous to a light going on in utter darkness. He begins to re¯ect upon his experience. Armstrong remarks: Introspective consciousness is bound up in a quite special way with consciousness of self. I do not mean that the self is one of the particular objects of introspective awareness alongside our mental states and activities. This view was somewhat tentatively put forward by [Bertrand] Russell in Problems of Philosophy (1912, ch. 5), but it had already been rejected by Hume and Kant. It involves accepting the extraordinary view that what seems most inward to us, our mental states and activities, are not really us. What I mean, rather, is that we take the states and activities of which we are introspectively aware to be states and activities of a single continuing thing.3 Armstrong concludes that ``introspective consciousness is consciousness of self''.4 The intricacies of Armstrong's argument will not be encompassed here. Nevertheless, a ®nal aspect from his argument is important. It concerns memory. Armstrong argues that the truck driver while in his unconscious state functioned like an infant in terms of memory. The various stimuli along the road presumably triggered certain kinds of memories that enabled him to respond appropriately. He was stimulus bound, living solely in the present. On his recovery of introspective consciousness, he had little recollection of what was happening while it was absent: ``It is tempting to suppose, therefore, as a psychological hypothesis, that unless mental activity is monitored by introspective consciousness, then it is not remembered to have occurred, or at least it is unlikely that it will be remembered''.4 Armstrong concludes his argument in the following way: The two parts of the argument now may be brought together. If introspective consciousness involved (in reasonably mature human beings) consciousness of self, and if without introspective consciousness there would be little or no memory of the past history of the self, the apparent special illumination and power of introspective consciousness is explained. Without introspective consciousness, we would not be aware that we existed ± our self would not be self to itself.4

The self as double

17

This idea is essential to my story. The notion of introspective consciousness implies a kind of spatiality of personal experience in which there is a sense of distance between consciousness itself and the contents of consciousness. There is doubleness in this experience that, as the story from the childhood of Edmund Gosse suggests, is not to be found in infancy. In the very beginning of life, we suppose that very many experiences are adualistic and have no self in them, in Armstrong's sense. There are probably times when the baby is, as it were, simply inhabited by sensation. An adult may imagine this adualism by using the memory of those rare occasions in which the intensity of experiences presses upon him or her as if to ®ll up all personal space. In extreme anxiety, for example, we are aware only of terror, a beating heart, tension in muscles, and other immediate sensations. There seems to be no distance between these experiences and our awareness of them. We cannot, as it were, stand back from them, look at them, and evaluate what is happening. In the same way, the baby is relatively stimulus bound, acting in a re¯exive way, as if in the grip of immediate sensation, with no perspective upon it. For example, the young baby grasps at everything, as if instinctively. For the baby, we might say that the doubleness of personal existence is found in the engagement with the mother. This subject is approached in the following chapter. Armstrong's argument concerning the doubleness of personal existence was anticipated by William James. In considering ordinary experience expressed in ordinary language, James found our consciousness to be ``duplex.'' We are aware of the things of the outer world and also the images and other elements of our inner life. There is a difference, however, between the awareness and those things of which we are aware. James describes this duality in the following way: Whatever I may be thinking of, I am always at the same time more or less aware of myself, of my personal existence. At the same time, it is I who am aware; so that the total self of me, being as it were duplex, partly known and partly knower, partly object and partly subject, must have two aspects discriminated in it, of which for shortness we may call one the Me and the other the I. I call these ``discriminated aspects,'' and not separate things, because the identity of I with me, even in the very act of their discrimination, is perhaps the most ineradicable dictum of commonsense and must not be undermined by our terminology here at the outset, whatever we may come to think of its validity at our inquiry's end.5,6 Although theoretically double, self is uni®ed. As James put it: ``Thoughts connected as we feel them to be connected are what we mean by personal selves.''7 Although the statement may not appeal to logicians, it is, nevertheless, what we mean.

18

Part I: Development

James and Armstrong lead us toward a self with more dimensions than one de®ned through the concept of secrecy or the sense of innerness. First, there is the pole of awareness or consciousness which is necessary to the experience. Second, other dimensions are suggested by the shape of inner life, which James compared with a bird's life, full of ``¯ights and perchings''.8 It does not go in straight lines. It is a capricious wandering thing, a ¯ux of images, ideas, and memories linked by affect, analogy, and other associations. We return to the form of this experience later in the book, since its precursor is a certain kind of play. It is of interest in passing that Einstein compared his thinking process during periods of creativity to play. He wrote: The words or the language, as they are written or spoken, do not seem to play any role in my mechanism of thought. The physical entities which seem to serve as elements in thought are certain signs and more or less clear images which can be ``voluntarily'' reproduced and combined. The above mentioned elements are, in my case, of visual and some of muscular type. Conventional words or other signs have to be sought for laboriously only in a secondary stage, when the mentioned associative play is suf®ciently established and can be reproduced at will.9 Einstein did not merely observe his thoughts. There is a sense of agency in his mental activity. The pole of consciousness that James had called the I moved the contents of consciousness about in an associative or combinatory play. A very important implication of this description is that consciousness is not merely passive, a simple searchlight, but active. A third characteristic of our inner life is the sense of its going on. Although there is memory in it, the memories are not ®xed, as if in their little boxes. Rather, there is an emancipation of memory in the present. James compared the feeling of constant change with the ¯ow of a river: ``No state once gone can recur and be identical with what was before.''7 This sense of ¯ow is often lost in those with disorders of self. The experience of stasis is accompanied by a diminished feeling of being alive. One of the results of successful therapy is the restoration of the feeling of ¯ow, the movement of inner aliveness.10 A fourth quality of inner life is its connectedness or unity. James declared that it ``does not appear to itself chopped up in bits''.7 Yet, such an experience, of being broken up in bits that do not connect, is an experience that those with borderline personality periodically suffer. Finally, the experience of inner life goes in a kind of container, an inner space, which, of course, is not real but a virtual space like that behind a mirror, which we perceive but know is not there. This space is not merely psychic; it includes the body. A body feeling and a background emotional

The self as double

19

state are with us all the time, although we may be barely aware of them.11 They remain as a background emotional tone, which at its most basic is simply positive or negative ± a vague state of well-being or an equally illde®ned sense of unease. Experiences of the spatiality of self, of the body, and of the background emotional tone are all altered, in an episodic fashion, in those with disorders of self, ¯uctuating with the form of relationship with the social environment.12 Anger, for example, closes one up. In contrast, in certain states of calm, there is a sense of opening up. These issues are discussed in more detail in later chapters. We now consider the nature of the original doubleness out of which eventually arises the doubleness of inner life and, with it, the sense of self.

Chapter 4

I and the other

We are not born with a self. However, the I, or the ego, is neurophysiologically given. At birth we have a rudimentary ego, which matures as the central nervous system matures. The self is merely a possibility, a potentiality that will arise through an appropriate engagement of the child as ``I'' with the mother and other caregivers. The nature of this engagement must be the starting point of an attempt to understand how self develops. The baby is born with the capacity to engage with others. This idea, that we possess innate, genetically encoded patterns or repertoires of behavior that are released by particular stimuli, seemed preposterous until the 1970s. Perhaps the most compelling evidence favoring the idea came from studies of birdsong. An intriguing example concerns the chaf®nch. This bird sings in the springtime, but it is only the male that sings. However, if the female is given androgens, she too will sing. If the male is given androgens in a season other than springtime, he also sings. The hormone concentrates in an area in the midbrain. It is assumed that the trigger of the hormone releases a repertoire of the behavior of singing, which is intrinsic to the nervous system.1 Triggers of a similar kind operate in the development of the engagement between the baby and his or her caregivers. Patterns of reciprocal communicative behavior evolve between mother and baby that depend upon appropriate responses to cues or signals, often quite subtle, that both partners emit. To participate in this potential engagement, the baby must be perceptually competent. The extent of this competence surprised many when the results of the studies of the early 1970s began to emerge.2 What is striking about the newborn's abilities is his or her awareness of the stimuli that come from people, particularly the mother. For example, newborns turn toward a voice coming from behind a curtain, moving their head and hands as if searching for the speaker and in a way that shows some coordination. The newborn shows a preference for his or her own mother's voice. Her characteristic way of speaking seems to have been learned while the baby was in utero. Moreover, in the ®rst few days the different syllables of speech, as well as their emotional tone, are discriminated by the baby.3

I and the other

21

The baby's ability to discriminate between mother and other people extends even to her smell ± at about the age of 2 weeks, the baby prefers mother's breast pad to that of another woman.4 At about the same age, babies prefer to look at their own mother's faces rather than the face of another woman, in this way appearing to show recognition of her.5 In addition to their unexpected ability to discriminate between such socially signi®cant stimuli as voices and faces, babies behave in a way that encourages responses from others. Perhaps the most powerful trigger is the smile. Smiling occurs in blind children who could not mimic such behavior.6 Babbling is also a characteristic of human infants.7 More complex forms of communicative behavior may also be part of the infant's genetic endowment. These include patterns of sucking during feeding. The infant sucks in bursts, which are interspersed with pauses of about 4 to 15 seconds, during which he or she tends to gaze at mother's face.8 The mother's eyes are particularly important. The baby's smiling, babbling, pauses during feeding, and other subtler behaviors are triggers to a set of responses on the part of the mother. Maternal behaviors, which we suppose are also genetically evolved, are released by these stimuli. The possibility that maternal behaviors, or parental behaviors, are part of our evolutionary heritage is again supported by studies of animal behavior. In certain animals, the hormonal activation that occurs during the gestation and birth of a baby stimulates characteristic maternal repertoires of behavior that are presumably encoded genetically like the chaf®nch song. For example, the pituitary hormone prolactin when injected into rats, whether they are male or female, causes them to begin to make nests.9 Nothing so speci®c has been shown for humans. Nevertheless, characteristic maternal behaviors do seem to be triggered by the speci®c stimuli given off by the infant. Klaus10 and others have described these behaviors. For example, at ®rst contact with their babies after birth, mothers behave in a stereotyped way. They raise the pitch of their voices, show an intense interest in eye-to-eye contact, and tend to touch their babies ®rst with ®ngertips to the extremities, then massaging the whole trunk and face. There is evidence that women may be more strongly programmed than men to respond to signals given off by babies. A neuro-imaging study showed diminished activity in the anterior cingulate cortex in response to both infant crying and laughing in women but not in men.11

The proto-conversation By the age of 2 months, the built-in behaviors of the mother and the child have meshed to a remarkable degree so that, in the 1970s, Trevarthen12 was able to describe what he called a proto-conversation. A reciprocal back-and-

22

Part I: Development

forward exchange between mother and baby is established, to which both contribute. Trevarthen describes the complex ``dance'' of the mother and the baby: In the second month infants become more precisely alert to the human voice and they exhibit subtle responses in expression to the ¯ow of maternal speech. They are frequently content to engage in expressive changes for many minutes on end by means of sight and sounds alone. . . . De®nite eye contact is sought by most infants about 6 weeks after full term birth. Once this orientation is achieved, and in response to a complex array of maternal expressive signals, many 4±6 week-olds smile and coo. . . Mothers align their faces with the baby, adjusting position to the least distance of clear vision of an adult, and making modulated vertical and horizontal head rotations. Their faces are exaggeratedly mobile in every feature and these movements are synchronized with gentle but rhythmic and accentuated vocalizations. All this behaviour responds to the infant's evident awareness and acts to draw out signs of interest and pleasure. The infants show intent interest with ®xed gaze, knit brow and slightly pursed lips and relaxed jaw, and immobility of the limbs. They exhibit an affectionate pleasure, closely linked to ®xation on the mother's face and responsive to her expression, with smiles of varied intensity, coos, and hand movements.13 Trevarthen called this kind of engagement primary inter-subjectivity. The behaviors of both partners are ®nely coordinated, creating a shared structure of activity, which gives pleasure to each but which neither could have generated alone. When the proto-conversation was ®rst described, some investigators doubted that it represented a true engagement. They suggested that the apparent interaction was really a series of reactions. This suggestion was dif®cult to counter using statistical and mathematical methods. However, Trevarthen and his colleague, Lynne Murray,14 devised a simple and very convincing way of demonstrating that what was going on between mother and baby was truly a shared structure of activity. Mothers and their 6- to 12-week-old babies were placed in separate rooms. The faces of each were televised and viewed by the other partner in the other room. Each baby fully interacted with his or her mother's image on the screen. Following this, the image of mother was temporally dislocated. The ®rst minute of interaction had been recorded and then replayed so that what the baby now saw was the mother earlier in the interaction. Although the baby was confronted by the same person whose face showed the same affection and interest, the baby was distressed and turned away. The baby was distressed by a mismatching between the mother's response and the child's moment-to-moment experience. It was as if the baby had an

I and the other

23

expectation of how the mother would respond and this was upset by the distortion of the image. The mother usually acts in a way that is so sensitively attuned to the baby's state that the baby may imagine the mother to be part of his or her personal system, something like an extension of the baby's subjective life. When the mother does not act in this way, the baby is dismayed. As James Mark Baldwin put it: ``To be separated from his mother is to lose part of himself, as much so as to be separated from a hand or foot.''15 Since the capacities of mother and child to make the engagement of the proto-conversation are genetically encoded, we might suppose that they have a neurophysiological basis. Our particular genetic endowments will provide us with nervous systems that differ in subtle ways. These biological differences might conceivably be re¯ected in different forms of mother±infant interaction. This possibility was investigated in a study of the form of an interaction of a series of mothers and their babies.16 Each baby after birth was examined by methods developed by Brazelton and his colleagues.17 The observations included the baby's orientation to social stimuli such as a face and a voice. These movements are presumed to be part of the innate neurophysiological capacities of the baby. Three months later, when the mother was not with her baby, she was tested in a room where a tone was periodically sounded. It had no particular meaning. Some mothers seemed fairly quickly to screen this irrelevant noise out of their consciousness since after a few soundings it excited no physiological reaction (in this case a fall in skin resistance). Other mothers, however, habituated much more slowly. These mothers, who showed more reactions to the noise, tended to have babies who showed relatively little social orientation. This type of mother±child pairing showed very rapid social cycling, that is, the periods of gazing at each other were relatively brief, being terminated by one or other of the partners averting his or her gaze. Following this, their mutual gaze would be restored to be once again quickly broken. In contrast, the pairing of mothers who habituated quickly and babies who showed clear social orientation produced a quite different form of interaction. This dyad characteristically gazed at each other's faces for long periods so that the cycles of gaze on/ gaze off were slow. We assumed that the different forms of interaction were normal for each pairing and that each partner was contributing to building up a pattern of interchange between the two that became characteristic of their engagement. We imagined a situation, however, in which the neurophysiology of mother did not match the baby so that she found it dif®cult to ®t in with her child. Such an experience may be extremely upsetting for the mother who might assume that she is not cut out for motherhood or even that the baby does not like her. If such a situation persists, a chaotic failure of synchrony between mother and child may arise, potentially disrupting

24

Part I: Development

the development of self. It is helpful for these mothers to know that, in an important way, they are not to blame for the dif®culty that, once its origin is realized, can be overcome.

Mirroring, imitation and the role of the other The mother's part in Trevarthen's proto-conversation and primary intersubjectivity is to provide a responsiveness that is attuned to the baby's state at that moment. This activity has been called mirroring, a term that is not quite accurate since it implies a simple re¯ecting back of the experience of the other. What the mother actually does is more complicated. The role of vision in these early interactions is central. The baby and mother, or other caregiver, have their eyes ®xed upon each other. The mother's gaze elicits responses from the baby, which the mother, in turn, responds to, matching something of the baby's expression. But this matching is selective. The mother is much more likely to respond to sounds that resemble the beginnings of language than nondescript crying noises. But what she utters, although resembling the baby's vocalization, is not echoic. The mother is not simply a mirror. In her responsiveness to her infant, she gives back some part of what the baby is doing ± but only some part and not all ± and also gives him something of her own. Stern18 points out that matching is not equivalent to imitation. Imitation, as he sees it, is static, nothing moves beyond it. On the other hand, matching is part of a dynamism. Matching responses of the social environment are an essential element of the development of self, not only in infancy but throughout development. Failure of these responses, particularly at critical points of development, such as adolescence, may lead to a disturbance in the sense of personal reality and diminished feelings of the rhythms and substance of the body.19 Although ``matching'' is not equivalent to imitation, where this word implies mimicry, something resembling imitation is central to the protoconversation. This imitative behavior is not con®ned to the mother's responsiveness but is mutual. James Mark Baldwin was particularly struck by the signi®cance of the child's imitations in the development of self. He wrote: ``My sense of myself grows by imitation of you, and my sense of yourself grows in terms of my sense of myself. Both ego and alter are thus essentially social, each is a source and each is an imitative creation.''15 This fundamental interplay, which is a necessary forerunner to the emergence of symbolic play, involves faces, facial expressions and imitation. Once again research ®ndings, particularly in the ®eld of neurophysiology, show that the propensity for humans to behave in the manner of the protoconversation is given to us as part of our evolutionary heritage. There are special areas in the brain which respond selectively to faces.20 There are also systems which subserve imitation, the so-called mirror-neurons.

I and the other

25

The Italian neuroscientist Giacomo Rizzolatti discovered mirror neurons almost by accident. He was studying pre-motor cortical function in monkeys. It was a hot day and he took time out to have an ice-cream. As he moved it to his mouth and started to lick it, he noticed the monkey's premotor cortex had become active. A series of experiments conducted by Rizzolatti and his colleagues led them to conclude that in the ventral premotor cortex of the Macaque monkey, there are neurons that discharge both during the execution of hand actions and during the observation of the same actions made by others. They suggest that mirror-neurons activation could be the basis of action recognition.21 The ®ndings also imply a further hypothesis. If actions of others trigger the activity of neurons relating to these actions in the subject, they potentiate the likelihood of the subject imitating those actions. The developmental signi®cance of mirrorneurons, however, has yet to be fully elucidated. The proto-conversation goes on in a state of positive affect and is mediated by facial expressions and vocalizations which express this feeling of pleasure. Kohut and Winnicott, in different ways, have emphasized the developmental signi®cance of a responsiveness which resonates with this feeling. Kohut saw it in terms of value. He focused on the mother's adoration of her infant ± an idealization of the child that is represented in the religious imagery that lies at the heart of western civilization. The joy in her baby that the mother feels is manifest on her face, showing the baby she or he is loved and valued. The Winnicottian conception concerned representation. Winnicott asked: ``What does the baby see when he or she looks at the mother's face? I am suggesting that ordinarily, what the baby sees is himself or herself. In other words the mother is looking at the baby and what she looks like is related to what she sees there.''22 As an example, a wriggling, excited infant, ¯ailing his arms and kicking his legs as he lies on a bed, is looking up into a beaming face. This face shows him what he is ± happy. And it evokes a further response in the baby. A kind of communication is going on that does not depend on words but on emotions and their expressions. The baby expresses his affective state in his face, body, and vocalizations. The mother responds to these expressions in a way that ampli®es and represents them, giving them form.23 In Chapter 20 in which the principles underlying the proto-conversation will be applied to therapy,24 its main elements will be seen as coupling, ampli®cation and representation. Affects are the coinage of the proto-conversation, the language of humanity before language eventually emerges, after a very considerable amount of development has occurred, during the second year of life. This language of emotion, like the process of engagement, is part of our evolutionary endowment. In a classic study, Darwin25 showed that we share a variety of facial expressions with the higher animals. He suggested that these expressions, which register such emotions as a joy, surprise, anger, fear, and disgust are not simply conveyed to us by the mannerisms of a

26

Part I: Development

particular culture, but are part of our physiological makeup. These forms of expression are not culture bound.26 Since the ®rst form of engagement with another is so largely dependent on affect, which provides the ``words'' of the proto-conversation, we have an ``affective core''27 to our lives that is shared by all humanity, so that even in a foreign country we are able to communicate, in a way. With those in our own social environment, we know that we are truly with another when the language of our discourse embraces emotional life. Affects are not only the words of the proto-conversation, but they are also central to those later relationships that we call intimate.

Chapter 5

The role of toys

The proto-conversation between the 2-month-old baby and the mother is between I and the other. There is no self in it. A third element needs to be found for self to evolve. This element is the world-to-be-manipulated. In a baby's earliest days, nothing else is as interesting or entrancing while the mother is around. Soon, however, the baby begins to take an interest in the things around him or her. These things include clothes, bottles, part of bodies, even the baby's voice, and, later, toys. The toys and other bits of the material world are all part of a triadic relationship with the mother and child. These things become the basis of self. It must be emphasized, however, that it is not the things alone that become the basis of self, but those things manipulated during an engagement of a particular kind with the mother and other caregivers. The triadic relationship between the baby as ``I'', the mother or other caregivers, and the things is extraordinarily complex. Our studies of 3month-old babies with their mothers and a small number of toys show that neither the baby's behavior nor the mother's is random.1 It is evident that the baby's interest in the toys is related to factors in his or her relationship with the mother. It cannot be conceived adequately as the child oscillating between two dyadic engagements of child±mother and child±toy. Rather, the mother participates in the child's play in a way that seems attuned to the infant's affect. The Newsons, in Nottingham, England, have produced some charming video illustrations of what is essential to this behavior. For example, the mother is playing with soap bubbles. She blows these bubbles into the baby's face, where they burst. The baby is startled and does not know how to respond. The mother laughs, so the baby laughs too, knowing now that this is fun. It is as if the mother shapes affectively the baby's experience. She, by her attunement, gives it a kind of meaning. It is tempting to believe that she could impose a reality, but in fact she cannot. If she laughs when it is inappropriate to do so, the baby becomes distressed. The baby's behavior, when he or she looks into the mother's face for some signal concerning the meaning of a situation, has been studied by

28

Part I: Development

means of a modi®ed visual cliff experiment.2 The babies were a year old. As the children moved out over the transparent ¯oor and saw space below them, they became apprehensive and looked toward their mothers. If the mother smiled and showed pleasure, the baby went on. If however, the mother had been asked to show facial fear, the baby turned back, perhaps showing some distress. The form of the tripartite engagement between I, the other, and things, which is the basis of play, changes with time. One striking feature concerns the child's increasing interest in the things. The ®ndings of our study showed that at 3 months, only 12 percent of the baby's gaze was directed at the toys that were placed between the baby and the mother. The same mother±baby pairs were studied again at 6 months. At this age, 60 percent of the infant's gaze was directed at the toys.1 This increases further when the child begins to walk. The parents tend to ``transfer responsibility'' for play to their toddlers.3 Nevertheless, the child's pattern of turning to the caregiver for a response that gives meaning continues, particularly in explorative situations. For example, when children of 1 to 1Ý years walk in a park with their mothers, they point at things while looking at her or bring them to her for inspection. Children in this situation ``have been shown to bring and show adults [parent or observer] what they ®nd interesting, and to do so often and continuously.''4 Soon, however, the trajectory of increasing interest in toys and play reaches the point where the child no longer seems to notice the parent. It was beautifully described by Piaget. The child chatters as he plays: What he says does not seem to him to be addressed to himself but is enveloped with the feeling of a presence, so that to speak of himself or to speak to his mother appear to him to be the same thing. His activity is thus bathed in an atmosphere of communion or syntonization, one might almost speak of ``the life of union'' to use the terms of mysticism, and this atmosphere excludes all consciousness of egocentrism. But, on the other hand, one cannot but be struck by the soliloquistic character of these same remarks. The child does not ask questions and expects no answer, neither does he attempt to give any de®nite information to his mother who is present. He does not ask himself whether she is listening or not. He speaks for himself just as an adult does when he speaks within himself.5 The picture Piaget paints of the child at play is the basic scene of this book. It provides the principal metaphor upon which an approach to the evolution of self is built and also from which a theoretical framework for the treatment of disorders of self can be derived. Here is the embryonic self. To understand this notion, we must return to William James, who had told us

The role of toys

29

that ``thoughts connected as we feel them to be connected are what we mean by personal selves.''6 Although a ¯ow of inner life may give adults a sense of existence, for infants this cannot be so. This is because, as we have already seen, the distinction between inner and outer worlds is not made, generally speaking, until the child is in the ®fth year of life. The child who does not yet conceive of a boundary of self does not distinguish in a mature way between thoughts of things, which are inner, and those things themselves.7 Rather, before the milestone of the private self is achieved, thoughts are mingled with, or even in the things. Thought cannot go on without them. For the child, then, things are necessary vehicles of a particular kind of thought, which is comparable with the ¯ux of inner life in an adult. For the adult, the inner life of images, ideas, and memories moves in the mind's eye against a space we know is not real space. It is a virtual space. It is as if inner experience is projected upon a metaphoric screen.8 For the young child, the arena upon which thought is displayed, in toys, is real. In only a partly ®gurative way we can say that the play space is the precursor of inner space in adult life. It is where experiences are generated that become the core of what we mean by personal selves. It must be emphasized that the whole scene is a precursor, including the enabling atmosphere provided by a parent. The eventual internalization of this scene includes a sense of the presence of the other. We now consider some of the characteristics of the play scene.

Chapter 6

Two playrooms

While the child is playing, he or she is generating a sense of ``what we mean by personal selves''. This play, however, is of a particular kind. Play is a complex subject and includes many different kinds of activities that are typical of various ages. Piaget1 distinguished three main categories of play. The earliest he called ``practice play.'' It is pre-symbolic, involving activities such as banging a rattle, performed for the sake of pleasure. Play of older children is often social and involves rules. We are concerned with a form of play that falls between these two age groups. Piaget called it ``symbolic play.'' It goes on between the ages of approximately 1Ý years and declines after the age of 4; that is, it occurs during that period of life before the individual has reached the stage of knowing an inner reality. Its emergence is not inevitable but depends upon prior periods of parental responsiveness which might appear inconsequential. Positive and negative affects follow different developmental pathways and involve different parental behaviors. If the baby is distressed, the mother does something to relieve the distress. If the baby is not unhappy she might offer a different set of responses which an observer may judge to be trivial. She seems to be simply playing around, amusing herself with her baby, doing nothing essential for the baby's development. Yet this kind of responsiveness, which is evident in the proto-conversation, is necessary. A recent study showed that ``maternal responsiveness to infant non-distress activities at 5 months, but not responsiveness to infant distress, uniquely predicted infant attention span and symbolic play.''2 Since the scene of symbolic play is a core theme in this book. It has several essential components that must be considered in some detail.

Magic and reality Symbolic play takes place in a curious atmosphere in which magic mingles with reality. Piaget3 pointed out that before the child conceives of a boundary to self, he lives in a largely personal universe in which his own mental life penetrates into his surroundings. This projection involves not

Two playrooms

31

only people, but also things. Flowers, clouds, the wind are given feelings and wishes that are similar to the child's, so that, for example, leaves wave in the breeze because they like it. The inanimate world is given the attributes of life. Children's animism is paralleled by a magical omnipotence. Since the boundary between themselves and the outer world is limited, children believe that they and other people can exert undue in¯uence upon it. For example, a 2Ý-year-old sways in front of a still pendulum, trying to make it swing. There is little gap between human wishes and their ful®lment. At this stage in human life, we believe we are immensely powerful. We believe that it is human activity that determines universal events. For example, a 4-yearold may believe that clouds move because we walk, and that they obey us at a distance. An alternative explanation is animistic. Because the clouds are alive, they follow us. This sense of power is reinforced by the ordinary mother, behaving naturally, whose sensitivity to her infant's experience causes her to respond appropriately. For example, when the child is in discomfort and the mother does something to relieve it, the child believes that her mother's response was due to her own wish. Also in very early life, when the objects of the infant's world have no enduring existence beyond her hearing or seeing them, the mother's comings and goings may be conceived as if the child has recreated her at each rearrival. Although this magical system of thinking involves a sense of power, it also has its terrors. The child is able not only to recreate the mother, but also to cause her to vanish. Remnants of magical ways of thinking are found in adult life and are manifest in all cultures. Examples include such practices as rainmaking rituals or sticking pins into images of enemies in order to harm them. Nevertheless, this kind of thinking has a particular immediacy in early childhood, making play exciting and even frightening. The world of play, however, is not only magical, but also real. The child uses physical objects, bits of the material world, as the elements of play. That these things are real is as important as the fact that they are vehicles of imagination, as Winnicott4 pointed out in 1953 in his classic description of the centrepiece of much of the child's play ± the transitional object. Winnicott's concept must be discussed brie¯y since it is fundamental. The transitional object is the child's special possession ± a doll, a teddy bear, a blanket, or something similar ± that is soothing, especially when the parents are not around. In the sense that aspects of the mothering function adhere to it, the transitional object symbolizes the mother. But that is not all it does. Aspects of the child's self are projected onto it, as if it were an extension of his or her own reality. The little boy or girl, from time to time, chatters to the doll or teddy bear. It is as if the child talks to himself and, at the same time, to someone else. In this situation the doll or teddy bear performs functions that it cannot have in reality. It is an illusion. But it is also real. Winnicott emphasizes the importance of the paradox that the

32

Part I: Development

same thing is both actual and an illusion. A ®nal and cardinal characteristic of the transitional object is that it is owned. Nobody in the family will dispute the fact that this object is the child's possession. The child's ownership of it provides a ®rst step toward the sense of ownership of an internal world. In people whose disruption of the development of self has been severe, such as those who suffer borderline personality disorder, it might be predicted that, since we are supposing that symbolic play is a necessary precursor to self, evidence of transitional behavior will appear during treatment of such people, as they improve. This indeed is the case. These behaviors are beyond the merely soothing.5 In our studies of the outcome of patients treated for borderline personality6 it was discovered by chance that a number of patients had started a diary during the period of therapy. This behavior, which had not been suggested to them, seemed to be unusual for people who, in general, belonged to the less educated and lower socioeconomic section of the community. An examination of this phenomenon showed that, at least in some patients, the writing of the diary had transitional features. One patient, for example, described her experience in the following way: ``I have decided to analyse why I write, as I often wonder about this. I think I know the answer. My writing saves me from myself. I am writing to you no more than I am communicating with my inner world. At times, I am not me. I am outside looking on, and yet not free either, but trapped, trapped by the immobility and inability to return to be me. In yourself it is brought together so I don't fragment. If all my communication is received by one person I can be held together.'' This young woman describes the anxiety-reducing effect of her writing ± it stops her from fragmenting. Yet the activity is larger than this. It involves something like an inner dialogue, as if she were speaking to another part of herself, as if to a double. At the same time, the sense of the therapist as you is omnipresent. But this ``you'' is part of the self-experience. ``In yourself'' could refer either to the patient or the therapist, or to both. This kind of observation led to the hypothesis that those patients who used diaries or other forms of writing during their treatment would have better outcomes than those who did not. This indeed was the case. About half the patients used diaries. Although they were just as ill at the beginning of treatment, according to DSM-III criteria, as those who did not, their improvement after 1 year's treatment was signi®cantly greater. This ®nding supports the idea that the discovery of the experience of transitional space and the emergence of an activity analogous to the child's symbolic play are helpful in overcoming a notional arrest in personality development, which was a consequence of chronic impingement in that period of life before, say, 5 years of age. In this group of people, transitional activity was manifest in writing. However, it was carried on outside the session. This may be the usual pattern. Nevertheless, it seemed likely that whole therapeutic process,

Two playrooms

33

not merely the writing, was imbued with a transitional feeling. This is illustrated by the following case history. The patient, Judy, who was in her thirties, had been admitted to the hospital on about 30 occasions for various reasons, including quasi-psychotic episodes, selfmutilation, and attempted suicide. She had a neglectful mother and a sexually abusive father. She was intermittently af¯icted with intense experiences of emptiness. During the ®rst weeks of therapy, she clutched a small bear. The therapist learned that as a child her precious soft toys were often capriciously con®scated by her mother. Now her bedroom was ®lled with such toys. After about a month of therapy, the bear began to be less prominent. It was soon relegated to a handbag and later left in the patient's car. After about 12 months, it was left at home.

The transitional nature of her experience during this time was also evident in her writing. Although she did not keep a regular diary, she made notes, which had a poetic, associational quality and seemed to include a consciousness of the therapist. Some months after the bear disappeared, Judy sent the therapist a gift by mail. It arrived one week before a two-week vacation. It was a small key ring ± a pink plastic bear with the ring like a padlock. The padlock, Judy later explained, was ``to keep safe and not throw (her) away.''7

Selfobject or fellow feeling Play goes on in a space in which there is neither inner nor outer and in which internal reality and external reality coexist. It cannot go on, however, if the child feels that he or she is alone. As the child plays and chatters, he seems to be talking to himself, or else as if there were little distinction between his thoughts or those of the mother. To the objective observer, the mother is being ignored. However, the awareness of the mother penetrates into the intimacy of every wish and thought. The child experiences her as an extension of his own personal world. Piaget used the phrase the life of union to describe that state when the other is conceived as part of the child's selfsystem. This experience is necessary for play to begin and to be maintained. The enabling climate provided by the other is not merely passive. The mother is not simply present if play is to go on. She must be attentive and responsive. Yet, at the same time, as in Piaget's description, she is not salient or intrusive. Rather, she ®ts in with the child's experience so that she becomes the atmosphere of it. A study of Sorce and Emde is consistent with this idea.8 They showed, in a study of 15-month-old children that the mother's emotional availability is essential to play. When the mother was

34

Part I: Development

not available (in this case she was reading the newspaper), the effects in play were striking. The infants were subdued, were less explorative, and stayed closer to their mothers. Their play was less advanced in that it tended to consist of passively touching or holding toys, without using them in ways that were functionally appropriate (e.g., stacking nesting cups) or thematically appropriate (e.g., pretending to talk on the telephone). To say that the caregiver ®ts in with the child's own reality is not to indicate a simple or single behavior. The way in which a parent does this will differ according to age. The mother whom the 3-year-old seems to ignore while playing is behaving very differently from the mother in Trevarthen's proto-conversation. She too is conceived as a part of the infant's self-system, but she is clearly salient and active. Nevertheless, she ®ts in with the infant's needs. In a major contribution, Kohut described a role of the parent in development of the child which resembles, but is not the same as, the resonating responsiveness of the other in the proto-conversation or the more complex and imaginative attunement shown by the parent at the scene of symbolic play. Kohut called this role of the other the ``selfobject'' function. His theory derived from clinical experience rather than developmental observation. In his work with a 25-year-old woman, Miss F, Kohut was struck by the way she responded to him. First, she could not tolerate his silence, nor would noncommittal remarks satisfy her. After he had remained silent for a considerable period, she would suddenly become violently angry. He learned, however, that she would quickly become calm when, in essence, he restated what she had been saying. Second, he learned that he could not go beyond this restatement and attempt, say, to impose his perception of meaning upon what she had been saying. Kohut described her response. She ``would furiously accuse me, in a tense, high-pitched voice, of undermining her; that with my remark, I had destroyed everything she had built up; that I was wrecking the analysis.''9 We might suppose that he had invaded an experience that was analogous to play. He broke it up by attempting to bring into it aspects of a reality that came from outside. Kohut began to realize that she needed him to ``be nothing more than the embodiment of a psychological function which the patient's psyche could not yet perform for itself; to respond enthusiastically to her narcissistic sustenance through approval, mirroring and echoing.''10 Kohut's ®nal de®nition of the selfobject highlights this person's ``functions in shoring up our self.''11 This de®nition leads to a consideration of the difference between the selfobject and the developmental experience of at-oneness. An example helps explain what I mean. A very good looking young man was af¯icted with experiences of emptiness and deadness of ¯uctuating intensity. At times when he felt very bad, he would dress in his most expensive and stylish clothes, then go out, alone, to the most

Two playrooms

35

fashionable bar in the city. There he would walk slowly to the bar and order a single drink. He would be aware of the whispers and the glances of the other customers as they noticed him and wondered at the identity of this person with the carefully slicked back hair and the appearance of a 1940s ®lm star. Their gaze was what he sought and what gave him, for a moment, relief from the pain of inner vacancy. They were selfobjects to him.12 It is important, however, that there was no connection, no emotional link, between this man and the other people in the bar. Their attention had an effect upon him like that of a drug. This was immediate and somewhat soothing, but nothing fundamental had changed. In the therapeutic setting it is sometimes necessary, particularly when working with damaged people, to hold the individual's sense of self together by the means that can be described as shoring up. However, responses that are analogous to those of the drinkers in the bar, whose apparent admiration transiently soothed the handsome man, have no role in fostering the maturation of self. The therapist who believes otherwise risks creating something like an addiction. He or she is placed in the position of having to repeat the behavior which the patient strives for. An impasse is reached and a pathology perpetuated. These observations are necessary since a minority of Kohut's followers who, I believe, have misunderstood him, are propagating a form of therapeutic behavior based implicitly, on the need for ``shoring up.'' A model could be taken from a literal reading of Kohut's sense that Miss F needed him ``to respond enthusiastically to her narcissistic sustenance though approval, mirroring, and echoing.'' This remark is consistent with Kohut's belief in the primary signi®cance of admiration, or the giving of value, in the developmental process. I, too, consider the value of fundamental import. However, such giving of value depends upon a crucial context. What is fundamental is not admiration but connection, some link to another person which will, in the case of the solitary man at the bar, mitigate his essential alienation, loneliness, and painful dysphoria. Such a connection will involve an attempt to understand and respond to the whole experience, not only the negative emotional state but also the positivity, the imagination involved in his playing out the part of a star. Who was the debonair and nonchalant ®gure he portrayed as he sauntered into that crowded room? Out of this understanding comes valuation. The idea that the therapist ``be nothing more than the embodiment of a psychological function which the patient's psyche would not yet perform for itself'' does not convey what is needed. Recent Kohutian theorists, realizing the dif®culties implicit in Kohut's description of selfobject function, are now preferring to talk of ``selfobject experience.'' However, I will use ``fellow feeling'' to refer to the developmental experience and ``selfobject'' to that situation in which the subject requires, even covertly demands, the ``shoring up'' responses described by Kohut. This is characteristically the case in those

36

Part I: Development

in the so-called narcissistic personality disorder that Kohut studied. The partners of these suffering people often feel, in a subtle way, exploited. In his characteristically condensed and somewhat gnomic way, Hobson wrote: ``I can only ®nd myself in and between me and my fellows in a human conversation.''13 A ``fellow'', the Oxford English Dictionary tells us is: ``One of a pair; the mate, marrow; a counterpart, match.'' The ``marrow'' is the ``innermost part; the vital part; the essence; the `goodness'.'' These words suggest something of the affective tone which ``fellow feeling'' implies. It is a consequence of a complex matching arising out of a mutual interplay between two people that has the quality of resonance. Out of this feeling of resonance between my inner, essential and highly valued experience and the responses of the other, there emerges the sense of myself. The state of fellow feeling, as in Trevarthen's primary intersubjectivity, is created by ``a shared structure of activity, which gives pleasure to each but which neither could have generated alone'' (see Chapter 4). During symbolic play, the ``fellow-feeling'' experience might seem to an observer to be no longer possible since the scene involves only one person. The child chatters as if alone, apparently ignoring the caregivers. But the observer would be wrong. A feeling of the ``atmosphere of communion'' permeates the play. It is as if the other is experienced as within the space of play, although objectively not there at all, perhaps in another room. This leads to the notion that in a state of ``fellow feeling'' the other is both real and illusory, in the same way that the transitional object is both real and illusory. They are parallel and related concepts. Although they are linked and have some similar properties, they must not coalesce. Where the mother becomes the transitional object, dif®culties arise in the child's development. This may be manifest in problems with aloneness that arise in the following way. We have seen so far that the particular form of mental activity manifest in play needs the enabling atmosphere provided by a caregiver who is responding in a certain way. However, children play when there is nobody actually present, for example, in their own rooms. We suppose that in this setting there is a sense of the presence of the other that the physical surroundings provide. The child will also play in less familiar surroundings. What helps to provide the requisite atmosphere in these circumstances is often the transitional object. Where the mother does not allow this situation to develop, but continues, for example, to soothe her child at every opportunity, her functions cannot eventually be transferred to the child. The child's ``capacity to be alone''14 is preceded by periods during earlier development when he or she acts as if alone in the presence of the other. The progression to the stage where the other can be away for long periods is impeded if the mother or other caregiver takes on the role of transitional object. Where this occurs, the child's going-on-being depends upon the actual presence of the other, and psychic life is not experienced as ``owned.''15

Two playrooms

37

Idealization and grandness The scene of play has a particular affective quality. Piaget's description of the child at play implies an activity of great pleasure. It suggests a particular feeling-tone that is dif®cult to describe. The feeling-tone gives a value to these experiences, which are the primary atoms of the evolving constellation of self. The feeling tone, however, is not con®ned to the child. The whole scene is imbued with this experience so that, together with the child, the person whose presence has created this atmosphere is ideal. Coupled with the sense of idealization is an awareness of power, not only of the omnipotent child, but also of the other who creates the enabling environment. Indeed, this person is conceived, so Piaget's anecdotes would lead us to believe, as if he or she has created the child's experience or, at least, contributed to its making: ``The small child receives from the adult the double impression of being dominated by a mind far superior to his own and, at the same time, being completely understood by this mind with which he shares everything.''16 Nevertheless, he conceives her as part of himself so that at times he reacts toward her ``as a glori®ed omnipotent alter ego.''17 Indeed, because of a limited conception of boundary between them, there are times when she is he, and he is she. Their relations are reversible. When he feels and acts the way he perceives her to be, he becomes like her. He is grand. The child's experience, then, is bipolar, one pole being associated with well-being and goodness, the other with power. This notion of the bipolar self was introduced by Baldwin nearly a century ago. It was taken up by Kohut and elaborated, in a different way, as a central part of this theory. Kohut called the two poles ``idealizing'' and ``grandiose.''18 Since the aim of therapy with those with personality disorder is to help the developmental process begin again at the point where it has been derailed or sti¯ed, these two poles of experience almost inevitably emerge as part of a successful therapeutic encounter.

Innerness and language The playing child is absorbed in the activity like an adult who is lost in thought. This observation leads to the form of the child's language when playing. A cardinal feature of the preschool child's play is an embryonic innerness. This is evident in the child's language. Piaget gives an example of a little boy, age 3, who is drawing in the presence of an adult. ``There, I'm drawing in this sheet. I'm making a funny man. What am I doing? It's a waterworks. Here I must draw the water. Now the water. I'll make a boat too. A little boat and an Indian, a man and woman, two men and a woman. Two men and an Indian. They've fallen in the water; you see.''19 The ``you'' to whom he speaks and whom he questions is himself. ``He speaks for himself just as an adult does when he speaks within himself.''20 However,

38

Part I: Development

the ``you'' is also the illusory aspect of the other which arises in a state of fellow feeling. In symbolic play, the feeling associated with the me±other is becoming internalized. The child's speech, which is apparently a monologue, is better described as a curious kind of conversation. This emergent innerness is an immediate precursor to that stage of experience that is maturely inner, when one's thoughts are truly one's own. The language is not for communication with others or for adaptive purposes. Rather, it seems necessary to the representation of self. The language of the playing child has a peculiar form. It shows abbreviations, it jumps, and it is not grammatical. It moves by analogy, resemblance, and other associations. An older child does not talk in this way. Piaget had assumed that, with maturation, this form of language, which he called ``egocentric'' since it was not designed to communicate, simply atrophies and disappears. The Russian psychologist, Lev Vygotsky, however, came to a very different, and in terms of this discussion, very important view. In brief, Vygotsky, argued that the egocentric monologue does not vanish. Rather, it is internalized to become inner speech. It has structure quite different from socialized speech. It is not ``speech minus sound'' but is an ``entirely separate speech function. Its main distinguishing trait is its peculiar syntax. Compared with external speech, inner speech appears disconnected and incomplete.''21 It is, to a large extent, ``thinking in pure meanings. It is a dynamic, shifting, unstable thing, ¯uttering between word and thought.''22 This resemblance depends upon a ``basic semantic peculiarity of inner speech ± the way in which senses of words combine and unite ± a process governed by different laws from those governing combinations of meanings.''23 Vygotsky called this singular way of uniting words an ``in¯ux of sense.'' ``The senses of different words ¯ow into one another ± literally `in¯uence' one another ± so that the earlier ones are contained in, and modify, the later ones.''23 This is a process very like the condensation that, as Freud had pointed out, is characteristic of dreams. In a less speci®c, somewhat poetic way, Winnicott repeatedly remarked upon the similarities between play and dreaming.

The ``real '' playroom The room or other space in which play goes on has qualities that are beyond the physical facts of the ¯oor, the windows, the toys. The other's presence as the ``fellow'' and the embryonic experience of innerness creates an atmosphere that is not only real but also illusory. At times, however, the child inhabits a playroom that is entirely real. From time to time, the child's play is interrupted by events around him, which alert him. What alerts him may include any of the myriad events in ordinary living, or changes in the enabling atmosphere provided by the other. He orients now toward the external world. The ®eld of play is broken and play stops. Of course, this is

Two playrooms

39

part of normal development. A different kind of engagement now occurs. The other person is now ``real,'' not a quasi-illusion but an object in the external world in relation to the child as subject. The child's language and concerns are, in this circumstance, clearly adaptive. He asks for things, inquires and responds. His experience, at this point, has lost whatever was inner in the play. His attention is directed entirely outward. His language is linear, logical, and directed toward reality. It has the form of what Freud called ``secondary process.'' This space is real. Here is generated the beginnings of the ``social me'' or identity. The child switches back and forth between these two modes of engagement with the nurturing environment, often very quickly.

Later developments The features of the two different languages used in these two forms of relatedness are summarized in Table 6.1. The young child's experience oscillates between two spaces, one of which is totally real and the other both real and unreal (or perhaps imagined or illusory). In these experiential spaces, different languages, forms of relatedness, and states of consciousness prevail. At about the age of 4, or later, if things go well, these two spaces become coordinated and link up, so that the child's conversation now resembles that of the adult, consisting of the interweaving of two main languages. Embedded in the linear language of social speech are the elements of another, non-linear language, which relates to inner life. A major shift, which will be further discussed in the following chapter, has occurred in the child's life. The development of both the social and inner domains is necessary to proper maturation, but one is very much more fragile than the other. The ``life of union,'' as Piaget called it, is interrupted not only by the ordinary circumstances of living, but also by failures of parental attunement, as noted in a later chapter. When family life is chaotic and intrusive ± a large number of borderline personalities have been victims of sexual or physical Table 6.1

The two human languages

Inner speech

Social speech

1. 2. 3. 4. 5. 6. 7. 8.

1. 2. 3. 4. 5. 6. 7. 8.

Non-linear Non-grammatical Analogical, associative Positive affect Non-communicative Inner-directed Proto-intimate Self-related

Linear Grammatical Logical Variable affect Communicative Outer directed Intimate Identity-related

40

Part I: Development

abuse24 ± and where parental failure of attunement becomes chronic, the play space is never adequately or securely established and the child is relatively deprived of circumstances in which might be generated the core experiences of what we mean by personal selves. The child is left with a sense of ``no real me'' and an orientation and dependence upon outer reality. He or she lives in a hypertrophy of the ``real'' (see Chapter 11). In summary, the child alternates between two kinds of experiences that go on in different spaces. Much of the time, the child is oriented to the outer environment, adapting to others and coping with the world. In play, however, there is no adaptation to reality. On the contrary, I am supposing, the child takes pieces of the external world and uses them in play to represent, and so to bring into being, the double consciousness of self.

Chapter 7

Fragments of space and of self

In the previous chapter we found the child living, alternately, in one of two spaces. The child of 2 or 3 years cannot live in both at the same time. Subtle differences in affect and more profound differences in attention and language show that, in a sense, he or she is a different person in each space. Seen in this way, the child's existence is discontinuous. The observations and inferences of Jean Piaget suggest that the younger the child, the greater the discontinuity. This idea leads us to a fundamental difference between the tradition out of which this book arises and the psychoanalysis of Freud and his followers. The eminent psychoanalyst, Charles Rycroft, expressed the difference clearly. He wrote: ``Janet believed that self is not a pristine unity but an entity achieved by integration of `simultaneous psychological existences'. . . contemporary psychoanalysis and psychiatry tends to take the opposite view: that the self is a pristine unity but uses defences which have the effect of dysuni®cation''.1 These opposing conceptualizations lead to differences in theories of treatment that are particularly evident in approaches to borderline personality disorder. My view, in the Janetian tradition, sees this disorder as a consequence of a maturational failure. The discontinuities of psychic life that characterize the condition are manifestations of this failure, rather than the operations of defences such as ``splitting'' and ``projective identi®cation.'' In this chapter, the early fragmentation and the subsequent slow integration of personal existence is brie¯y outlined.

Identity and the social me The idea of a personal existence that is in bits seems strange and counterintuitive. However, when we contemplate the dilemmas of adolescence, the state becomes easier to imagine. The adolescent is often a different person in relation to different people. He does not like his friends and his parents to meet because he cannot resolve the dif®culty of being one person with his parents and another with his friends. He might try to keep his friends apart because, in a lesser way, he ®nds a similar dif®culty. With his girlfriend, his

42

Part I: Development

sister, the schoolmaster, and the bus conductor, he is, in each case and in a subtle way, a different person. He is dimly aware that he is a collection of roles that do not quite go together. A principal task of adolescence, as Erikson pointed out, is the formation of identity, of a coherent sense of who one is in relation to others.2 This process begins early in life and is evident with the emergence of language. By the age of 18 months, the child has a vocabulary of about two dozen words. Six months later, the child's lexicon is about ten times greater, so that a child of 2 may know 250 to 300 words.3 It is clear that around 18 months an enormous change occurs in the child's development. For the ®rst time, the child comes to recognize him or herself as an individual with identifying characteristics that give him or her a particular place in a social system. Put another way, the ``social me'' emerges. During the same period, a self, the inner me, is being created in episodes of absorption in play. The beginnings of the child's behavior as a social being are shown in a number of ways. The ®rst, of course, is language. As we have seen, however, words are the means not only of communication with others, but also of representing a personal reality. The body also comes to be recognized in its social sense. At about 18 months, children begin to show evidence of recognition of their mirror images, that is, they come to see themselves as others do.4 This is inferred from observations of children's behavior when they see themselves in a mirror. When a rouge mark has been surreptitiously placed on the child's nose, the child of about 18 months and older tries to rub it off. He or she shows that ``this mark is not me.'' At the same time, the child shows by actions that ``I know this is me I am looking at.'' Although children who are younger than about 18 months do not seem to recognize their own image, they have, nevertheless, stored and integrated a great deal of complex information about the body that is not social but purely personal. For example, there is evidence that babies of 3 to 8 months have a quite complex body schema derived from internal sensation coming from such sources as muscle and joint. Children of this age can make suitable adjustments of their bodies when placed in a room where visual cues indicate that the room is tilted.5 This ®nding suggests that there is a large amount of information to which small children have access and use, but of which they are not conscious. Fluctuations in body feeling are part of the inner awareness of self. They usually connect, often in a subtle way, with outer manifestations of the same state, such as facial expression and bodily movement. In most cases, we ®nd a harmony between the inner sense of the body and what is shown socially. As we will see in a later chapter, however, in disorders of self there is often a dislocation between the persona,6 which is the mask shown to the world, and more personal experience. The persona, the outwardly displayed aspect of the person one is in relation to others, is elaborated to a

Fragments of space and of self

43

substantial degree between 18 months and 4 years of age. This evolution is shown in gender identity, which involves the adoption of a certain appearance created by hairstyle, dress, manners of speech, and motor activity. From these rather obvious features extend a range of subtler behaviors to do with characteristic forms of emotional expression and interpersonal transactions. These have become so developed by the age of 4 that a child brought up in a role con¯icting with his or her chromosomal gender has dif®culty in changing.7 Language and the persona are not the only changes in the child's life that show emergence as a social being. Michael Lewis has pointed out that emotions relating to social life begin to be expressed following the ®rst awareness of one's image as it appears to others. Although anger can be demonstrated at 2 months and anxiety at 6 months, emotions that modify and in¯uence our social relationships do not become manifest until much later. Self-conscious emotions such as coyness and embarrassment appear during the second half of the second year of life.8 Other socially signi®cant emotions such as pride, shame, and guilt begin to be displayed between 24 and 30 months.9 However, just as language and the body cannot be seen as entirely to do with the social world, these social emotions are also related to self. Shame, for example, is the result of exposure of something felt to be intensely personal. In summary, then, a range of developments in language, bodily awareness and emotional expression show that great change occurs in the child's life during the second half of the second year. In essence, they indicate the emergence of a social ``me'' that is related to, but can be distinguished from, an embryonic self.

Before six months During the second half of the second year, the social me and the self are beginning to evolve in different experiential spaces. The idea that experiences have locations leads to the proposition that experiences create or constitute the spaces in which they occur. This proposal implies that early in life personal space will be multiple. In the beginning, we suppose ``there is a juxtaposition of different and local spaces without inter coordination: a mouth space, a visual space, a tactile space, a postural space, and so on.''10 This fragmentation of personal existence can be inferred from studies such as those of Spitz. In a famous series of observations, Rene Spitz11 seemed to show that for the baby the world is in bits. He recorded the child's response to a mask. A baby of 2 months will smile at a mask with eyes but no mouth, or a scowling mouth. At a slightly later age, a congruent mouth is needed to produce a smile, but a pro®le excites no response. A somewhat older baby smiles at the pro®le. It is as if the child perceives pieces of the environment

44

Part I: Development

that are at ®rst quite small, like eyes, lips, and nose, but with development, is able to integrate them into large coherences. The discontinuity of early experience can also be inferred from studies of memory. The evidence suggests that in the ®rst few months, the infant has a recognition memory but has no capacity for spontaneous recall. As a result, the reality of the small baby is entirely constituted by experiences in the present. The baby does not conjure up images and feelings associated with those who are absent. All that it knows is happening now. Reality, to a large extent, consists of others and is consequently broken up by the comings and goings of various caregivers. Since these comings and goings concern different experiences, they occur in different spaces. A corollary to the original proposition now emerges. Not only do experiences constitute spaces, but spaces determine the existence of the experiences and the objects that are part of them. Each object and each experience has its own place, and this place identi®es it. When the object moves from that place, it is no longer the same object and ceases to exist. Piaget came across the idea in playing with his small daughter while she was sitting in bed: Jacqueline tries to grasp a celluloid duck on top of her quilt. She almost catches it, shakes herself, and the duck slides down beside her. It falls very close to her hand but behind a fold in the sheet. Jacqueline's eyes have followed the movement, she has even followed it with her outstretched hand. But as soon as the duck has disappeared ± nothing more! It does not occur to her to search behind the fold of the sheet, which would be very easy to do (she twists it mechanically without searching at all). . . I then take the duck from its hiding place and place it near her hand three times. All three times she tries to grasp it, but when she is about to touch it, I replace it very obviously under the sheet. Jacqueline immediately withdraws her hand and gives up. The second and third times I make her grasp the duck through the sheet and she shakes it for a brief moment but it does not occur to her to raise the cloth.12 Jacqueline's behavior is characteristic of a child of 4 to 5 months. She acts as if the object has no enduring existence after it disappears. Her behavior suggests that she conceives a personal universe that is not only in pieces, but constantly shifting. Since the disappearance of the object from its space means it ceases to exist, its reappearance is a manifestation of its recreation. Thus, objects have only a precarious permanence. The child believes that the things are ceaselessly being made and unmade. Furthermore, since the object constitutes the space in which it was experienced, the vanishing object leads to a dissolution of that experiential space: ``The notion of space at this stage is fragmentary since objects dissolve into nothingness.''10

Fragments of space and of self

45

Six months to 18 months The experiential world of the infant is, as it were, fragmented. There seems to be a multiplicity of objects when only a few are there. The idea that the position of an object in space is an essential part of its existence suggests that the child's environment is ®lled with objects such as ball-under-thearmchair, doll-attached-to-the-hammock, mother-at-the-window. Should the ball roll under a sofa, it becomes a different object ± ball-under-thesofa. If mother moves, she becomes mother-at-the-®replace. It is as if the world were like a cinematic ®lm that had been broken down into its individual frames. The child of, say, 4 months, conceives a single person as multiple. Thus the concept of mother is made up of a parade of many women, all of them recognizable but not directly connected. This somewhat outlandish hypothesis seems, at ®rst sight, dif®cult to test. Nevertheless, the ingenious Scottish psychologist, Tom Bower, has conducted an experiment that does just this. He described it in the following way: I shall describe infants who sat in front of an arrangement of mirrors that produced two or three images of a person. In some instances, the infant was presented with two or three images of his mother; in others, he would see his mother and one or two strangers who were seated so that they were in a position identical with the earlier additional images of his mother. In the multiple-mother presentation, infants, less than 20 weeks old, happily responded with smiles, coos and arm-waving to each mother in turn. In the mother-stranger presentation, the infants were also quite happy and interacted with their mother as one of many identical mothers. They do not recognize the identity of the multiple mothers in the special sense in which I have used the word ``identity'', that is, they do not identify the multiple images of the mother, as belonging to one and the same person. Infants more than 20 weeks old also ignored the stranger and interacted with their mothers. In the multiple-mother situation, however, the older infants became quite upset at the sight of more than one mother. This shows, I would argue, that the younger infants do identify objects with places and hence think they have a multiplicity of mothers. Because the older infants identify objects by features, they know they have only one mother, and this is why they are upset by the sight of multiple mothers.13 Bower's experiment suggests that around 6 months a considerable integration of the concept of mother has occurred. This change is paralleled by a difference in the way that the child behaves with physical objects. At about 6 months, the child no longer seems to think that an object is the same

46

Part I: Development

object as long as it is in the same place and that all objects in the same place are the same object. Nevertheless, object permanence ± the infant's apparent certainty that an object continues to exist despite its disappearance ± is not fully achieved until 18 months. The integration of the concept of mother and other caregivers that occurs at about 6 to 7 months is paralleled by some uni®cation of the concept (or representation) of self. This assumption depends upon the idea that for the baby every experience of the other is linked to an experience of him or herself. During the period of development when ``mother'' refers to a range of disconnected experiences, the baby's own experience consists of a similar and related range of multiple selves. If the concept of the other is uni®ed, to some extent at least, by about 6 to 7 months, we should expect a similar coalescence in the concept of self. This, again, is not an easy hypothesis to test. Nevertheless, Michael Lewis suggested a way to do it. Lewis and Gunn remark that by 6 to 8 months infants begin to realize objects have an existence of their own: ``If an infant knows that objects exist, he must also know he exists separate from the objects. It would be reasonable to assume that knowledge of others, self and objects develop at the same time.''14 Lewis uses this idea to explain the emergence of anxiety at 7 to 8 months. If anxiety arises as a response to a threat to the integrity of self, then it can only arise when the baby has some sense of himself as an entity and some ability to evaluate a threat to this entity. This argument gains support from observations of children who were observed on the visual cliff. Children of 5 and 9 months of age crawled out over a glass ¯ooring, seeing a space emerge below them. Both groups of children had their heart rates recorded while they did this. The younger group was quite aware of what was happening but seemed interested rather than alarmed. This was indicated by a drop in heart rate. The older babies' heart rates rose, an index of fear.15 Thus, the older children apparently sensed a threat to their existence, whereas the younger ones did not. The concept of oneself as an existent being at 6 to 7 months is a preliminary one. This can be inferred from the child's behavior with objects. If we follow the idea that knowledge of others, self, and objects develops at the same time, we suppose that how the child of a particular age conceives of physical objects will be related to, and will throw some light on, the child's concept of self at the same age. Evidence suggests that infants younger than 18 months continue to display a residual tendency to identify objects with places.16 Accordingly, we infer that a discontinuity of personal existence persists, at least to 1Ý years. Piaget, gives an example of this residual tendency. He describes Gerard, aged 13 months, who is playing ball in a large room: The ball rolls under an armchair. Gerard sees it and not without some dif®culty takes it out in order to resume the game. Then the ball rolls

Fragments of space and of self

47

under a sofa at the other end of the room. Gerard has seen it pass under the fringe of the sofa, so he bends down to recover it. But as the sofa is deeper than the armchair and the fringe prevents a clear view, Gerard gives up after a moment; he gets up, crosses the room, goes right under the armchair and carefully explores the place where the ball was before.17 Children a little older than Gerard no longer search for a hidden object in a place where it was previously found. They cannot cope, however, with invisible displacements of the object in space.16 At 18 months, this dif®culty is also overcome. At this stage, the child acts as if objects have a stable existence whether visible or not.

From transitional to cultural space This child's conception of permanence of objects has important implications for the stability of personal existence. During the period leading up to 18 months, we assume that the personal experience of the child has a somewhat shifting and fragmented quality. With the attainment of object permanence at about 18 months comes the idea that the space in which things are is relatively stable and enduring. The play space, then, is also relatively enduring so that experiences going on within it, which are the beginnings of self, have a certain stability. This zone of experience is embryonically inner ± the region of self. At 18 months, the child also enters a second zone of experience, which is outer and particularly social. Out of it develops, over many years, an individual identity. Until about the age of 4, the potentially inner zone is both inner and outer. It is transitional, in Winnicott's language. With the attainment of the concept of boundary of self, the two zones become, in theoretical terms, quite distinct, and inner space is formed. Whereas the scene in transitional space is actual and visible, the view upon this new location of a personal reality is metaphoric, no longer dependent upon things. The attainment of the sense of an inner world brings with it something else. By the age of about 5, the child distinguishes not only two main zones of personal experience, but also that inner and outer should connect. Consider the following story told by a 6-year-old: Once there was a child. He was very wild. His name was Kind. Every single person thought it was a terrible name for a wild person. One day when Kind was playing, he saw a little girl. She was crying, so Kind went to the little girl. The little girl said, ``Find a little doll for me.'' Kind said, ``No, I will not.'' ``You are not Kind to me,'' said the little girl. Kind began to cry and said, ``I will never be unkind again.''

48

Part I: Development

The author of this little story seems to conceive an essential reality of the boy, which is known only to himself and which is indicated by his name. His identity, or social me, is different. The little girl's response makes him realize the disconnection between the two zones of experience. People with disorders of self also experience a sense of desolation on becoming aware that they live in two separate domains and that the gulf between them seems unbridgeable. The conception of a distinction between inner and outer, which arises about age 4, in most cases also involves a coexistence of and coordination between the two which is quite different to the child's conception that seemingly holds sway during symbolic play, where there is essentially no inner reality and no outer reality, only a personal reality. The experiential change from transitional space to what might be cultural space18 is associated with an increased complexity of relationship with others. Consider the following extract from one of the children in our privacy study. Girl (5.2 years): What are Cathy and Paul doing? Don't know. Are they playing? Playing a game. How do they play? She tells him a secret. What's a secret? I don't know any, but I can make up one. Make up one, then! Um [whispers]. We're going to the beach tomorrow, we'll build a sandcastle, and when we knock it down, guess what's inside? Do I have to guess? Yes! Shells? No. Goggles and ¯ippers? No! Surfboard? Egg? No! No! I give up! Promise you won't tell? Yes. Inside the sandcastle is a princess! Can I tell anyone at all? No! If you could tell one person, who would it be? No one!

Fragments of space and of self

49

Can I tell your mummy? No nobody AT ALL! This little girl is showing an extraordinary complexity of mental operations. First, she lives in the public or social domain. She plays a game with the interviewer, acting out the essentials of the concept of secrecy in her whispering and in her command that what she tells must not be revealed. She also draws on private experience where she conjures up the image of the beach and the hidden princess, who, perhaps, is part of a larger fantasy that concerns herself. The child coordinates the public and private domains so that they are uni®ed and seamlessly connected. The story of the princess and the sandcastle shows that the child has acquired the means of linking frames of experience beyond the public and private. To these domains are linked those of present and future. As she plays out the secret in the present, she also projects it into the future ``on the beach tomorrow.'' She displays a remarkable uni®cation of various dimensions of existence. With this unity comes a sense of duration, a personal continuity. The princess image in this story suggests something further ± a development in the emergence of the symbolic function.19 Symbols are to be distinguished from signs. Signs belong to a collective reality: e.g., clouds are a ``sign'' of rain; an image of two legs walking is a ``sign'' of pedestrians crossing. Symbols, however, may belong to a personal reality or to the reality of an initiated group. Personal symbols may be created by the individual, for example, the child at play. Unlike the sign, which refers to a recognizable part of a shared sensory environment, a symbol may represent something unseen, such as a feeling or an idea. The princess in this story may symbolize the ``specialness'' of a particular child, perhaps the narrator herself. The toys used in symbolic play are used by the child alone, to represent a personal reality to herself. The child who tells the secret of the princess uses the symbol differently, as part of the interplay with another person. Schiller called the symbol creating function the play instinct and believed it to be the basis of culture.20 Exchange is a crucial element in the movement from transitional space to cultural space which follows the attainment of the concept of selfboundary. It brings with it a profound change in relating to others. In contrast to the child absorbed in symbolic play, who appears to be ignoring others and whose activity involves no interchange, the more mature child is now able to engage in a reciprocal form of relationship. It involves choice. The child is free to reveal, or not to reveal, something of a world that is private and personal. The act of showing another that which is usually secret has the effect of an offer, inviting a similar act in return. This manner of interrelating is a fundamental aspect of intimacy. Friends are more likely than parents to be the recipients of secrets, and the ®rst partners in intimate relatedness.

50

Part I: Development

Friends and siblings have now become more important in the child's life. Dunn and her colleagues studied the change in children's relationships with their mothers and their older siblings on a longitudinal study of 47 families.21 The period studied was between 33 months and 69 months of age. Mother±child interaction decreased and sibling interaction increased markedly over the period. The children's use of re¯ective commentary, indicating dualistic consciousness, increased while egocentric moves decreased with both mothers and siblings. The child's increasing interest in peers and the development of friendships manifests a third form of pair bonding found in human life ± af®liation. Af®liation involves companionships and alliances.22 To af®liate is ``to adopt as a member of a society'' (OED). The later developing forms of pair bonding do not displace the earlier system of attachment. Rather there is coordination between and reorganization of the forms of pair bonding. An analogy can be made with the development of memory. Memory is made up of a number of ``modules'' of different types of memory. The last type of memory to develop, the ``episodic,'' depends upon re¯ective consciousness (see Chapter 12). Its evolution brings increasing possibilities to human life and an ampli®cation of personal existence, but it does not take over from the other forms of memory. Rather, in ordinary consciousness all modules of memory are active and coordinated. In the same way, a particular relationship, say a marriage, may combine intimacy, af®liation and attachment. However, both episodic memory and intimacy, which depend upon an awareness of inner states, are fragile relative to earlier evolved and developed modules. The child's new knowledge of the concept of exchange is re¯ected in play. After the age of 4, games with rules begin to be played. Such games, which are more clearly seen after 7 years of age,23 involve not only alliances and exchanges, but also combat, agreement, and other transactions. In contrast, the play of the child in the transitional period has no rules except that the things with which the child plays must be recognized as his or her own. To conclude, this chapter concerns the growing coherence of self. In the beginning of life, self is discontinuous, this experience going on as if in multiple places. By 18 months, considerable integration has occurred so that the child's existence is in two main spaces. One of these is the public domain where the individual's identity emerges. The second space is both public and private ± the play space ± in which is generated an embryonic self. By about 4 years of age, the play space becomes private. A new way of relating to others evolves in which private and public zones of experience are coordinated. With this milestone arises not only a further sense of coherence and unity of self, but also an enhanced awareness of temporality and personal continuity.

Chapter 8

Play, coherence and continuity

The progressive uni®cation of consciousness shown most clearly in infancy, and brie¯y described in the last chapter, is not given to us as a matter of course. It must be realized. In some people, this realization is impeded. On the other hand, in ideal circumstances the process goes on throughout life. Although it is a fundamental aspect of psychological maturation, we know very little about the way in which the distinct and separable facts of ordinary existence are integrated into larger wholes. In this chapter I suggest that play, or a playlike activity of mind, may be a crucial element in linking together discrete ``atoms'' of potential consciousness into larger or ampli®ed states of awareness.

States of discontinuity The people whom Pierre Janet studied and treated showed what he called a failure in ``personal synthesis.''1 These were people whose personal development had been upset by the adverse circumstances of their early lives. The most extreme form of failure of ``personal synthesis'' that Janet described was that of multiple personality disorder, or dissociative identity disorder. In this condition, the individual lives as if in a number of separate compartments, each of which is occupied by a different subpersonality, and in which not all these ``parts,'' as the subject frequently calls them, are aware of the other parts. About 90 percent of people af¯icted with this disorder have suffered childhood sexual abuse.2 This is a level higher than any other diagnostic group. Dissociative identity disorder is relatively rare. However, minor disturbances of ``personal synthesis'' are common. They are subtle, not evident behaviorally, but described by the subject. One woman, for example, told Janet that she could not dance and watch the other dancers' costumes at the same time. Janet showed other disconnections in the psychic lives of his patients which were not immediately apparent. One of these became evident when he asked his patients to read from a book. They could do this without dif®culty. He then asked them to read and also to tell him about what they

52

Part I: Development

had read afterwards. This extra task caused great dif®culty and distress, as if they had disconnected the capacity to read from another capacity, that of understanding. These two functions performed in different processing streams, which, although usually coordinated, are separable. Disturbances of personal synthesis, in dissociations of both the larger and the barely detectable kind, may depend upon a relative failure of aspects of pre-frontal cortical function necessary to a higher, or more extensive, coordination between various systems of brain function.3 However, that simple explanation is unlikely to be suf®cient in itself since the late developing elements of brain function, which involve the pre-frontal cortex, are likely to be ``sociogenetic.'' The world of others is necessary for their proper maturation.4

The gamma hypothesis How does ``personal synthesis'' come about and why does it fail? These are two of the largest questions facing neuroscientists in the present era. In recent years, the potential fragmentation of consciousness has been made spectacularly apparent with the advent of neuro-imaging techniques. They show that we do not perceive the world around us in the manner of a camera. Our brain does not take in the stimuli coming from the environment as if they were connected, all of a piece, in a single image. Rather, it processes tiny bits of what is sensed in separate neurophysiological streams. The puzzle of how these fragments are brought together to form a coherent whole has been called ``the binding problem.'' The complexity of the problem can be illustrated most clearly in evidence concerning the visual system. The identity of the object is processed separately from the space in which it is located.5 Moreover, the color, the depth, and the movement of the object are all treated separately6 in multiple processing streams.7 At a ®ner level, one set of neurons is dedicated to orange-red colors, another to objects with high-contrast diagonal left to right.8 Similar fragmentation processing in the sphere of language is equally remarkable. At the most microscopic level, vowels and consonants are processed by separate ``modules.''9 While a larger level, so also are speech and prosody. In the case of music, melody and rhythm are dealt with by different modules.10 In recent years, the hypothesis has been advanced that the binding together of different processing streams, necessary to our having a single perception, is due to a biphasic pulse of electrical activity, called gamma, which has a frequency of about 40 Hz, passing through the brain in a synchronous manner immediately following the presentation of a stimulus.11 Enthusiasm about the hypothesis has led to proposals that gamma activity is the basis of human consciousness. However, the integration of consciousness is likely to occur at a number of different levels and scales. It

Play, coherence and continuity

53

is not unreasonable to suppose that several mechanisms are involved. The gamma hypothesis is insuf®cient, in my view, to encompass the kind of coordination, or linking up, in psychic life with which we are concerned. The integration ascribed to gamma is instantaneous, involving the ``binding together'' of processing streams the moment a stimulus is presented. Although gamma is disturbed in borderline personality disorder, this disturbance seems insuf®cient to explain the discontinuities of psychic life in those who suffer this disorder. The problem of personal coherence in the evolution of personality is a larger one, extending over larger tracts of time. Moreover, coherence is not a static event when viewed developmentally. In the process of psychological growth, existing coherences are brought together and recon®gured into new and more ample constellations of psychic life. I am suggesting that play, or more particularly the kind of mental activity underpinning symbolic play, is necessary to this ampli®cation. This idea was anticipated by a German poet and philosopher, Friedrich Schiller.

Schiller's proposal The issue of ampli®cation is crucial in psychotherapy and to an understanding of psychological maturation. How ampli®cation comes about remains a mystery and our ideas about the matter are mostly, but not entirely, speculative. Schiller put forward an important proposal, which in¯uenced Jung, and which is amenable to a limited form of scienti®c testing. He suggested that play is the means towards psychological growth. Schiller distinguished between two principles governing human existence. He called them ``form'' and ``matter.'' ``Form'' is essentially the conceptual apparatus, the organizations of memory. ``Matter'' is sensation. ``Form'' is changeless. It is very like the kind of mental life which Janet described in his patients and which he called ``subconscious ®xed ideas.'' They are repeated throughout the individual's life with ``mechanical regularity,''12 even the same words being used to describe them. The actions relating to the ideas are similarly unchanging. For example, ``the subject takes the same number of steps, does not modify his gait in any way, even though the external circumstances have much changed.''12 ``Matter'' is the antithesis of form. It is ceaselessly changing. The individual whose existence is at the dictate of ``matter'' is constituted by it. Existence is simply each sensation as it impinges upon the subject. Consequently, the sense of personal being is without continuity. It is made up of different and disconnected bits of sensory data which successively present themselves: ``Man in this state is nothing but a unit of quantity, an occupied moment of time ± or rather, he is not at all, for his Personality is suspended as long as he is ruled by sensation.''13 If an individual's sense of existence were to be dominated by the principles of ``form'' and ``matter,'' and by those principles alone, he or she

54

Part I: Development

would show the features of a most extreme kind of personality destruction. Nothing would change. Stimuli from the world of ``matter'' would be given the same repetitive meanings by the categories of ``form''; time would not pass; and the individual would live in an eternal present made up of a series of disconnected instants. Such a hypothetical individual would live an extreme form of borderline existence. Since ordinary living is not like this state, there must be something else which mediates between Schiller's theoretical poles of ``form'' and ``matter.'' There must be a third principle which allows change to occur. This principle is play. Schiller believed that this function, or ``drive'' as he called it, is essential to the creation of humanity. He wrote: ``Man only plays when he is in the fullest sense of the word a human being, and he is only fully a human being when he plays.''14 In my view, it is a particular kind of play, symbolic play, which operates as the third principle. Many animals play. Karl Groos15 suggested that the purpose of animal play was a rehearsal of adult function. A kitten, for example, pounces on leaves in the same way that an adult cat seizes its prey. Children also play, at times, as if preparing themselves for adult roles. Little girls' play with dolls resembles the function of maternal care. But symbolic play does not appear to have such a purpose, unless the child were to become a theatre or ®lm director. The child is gazing at a scene which he or she is in the process of creating. This gazing is the forerunner of the metaphoric inward gazing which comes with the emergence of the re¯ective function, and the awareness of an inner life. Schiller made clear that ``contemplation (or re¯ection)''16 is a necessary element in the individual's becoming free of an existence dominated entirely by the principles of ``matter'' and ``form.'' Symbolic play displays more than an embryonic re¯ective function. Imagination is involved. In an associative state of mind, the child uses the things of the world in his or her own way to tell a quasi-symbolic story which has a personal signi®cance. This early imaginative activity is the precursor of a more mature imagination, which is freed of the actual material things which the child needs for representation. Schiller put it like this: ``From this play of freely associated ideas, which is still of a wholly material kind, and to be explained by purely natural laws, the imagination, in its attempt at a free form, ®nally makes the leap to aesthetic play.''17 We are led from Schiller's thesis and from a consideration of the main features of symbolic play, to the view that personality development, and an ampli®cation of psychic life, depend upon the capacity for re¯ection and also upon an associative, imaginative movement of mind. Seen in this way, psychological maturation resembles the higher levels of scienti®c and artistic creativity. A description of the state of mind in scienti®c creativity is given by the great biochemist, Sir Hans Krebs:

Play, coherence and continuity

55

I cannot explain how ideas arise in my mind but I know that they do not come entirely out of nothing. They arise when I hover over a subject more or less day and night. By night I mean that I dream, or think half-consciously about things in a very leisurely fashion.18 The word ``hover'' implies a wandering gaze over the pieces of a puzzle, viewed more in a drift of thought than in a logical and linear way. The outcome, in favorable circumstances, is the creation of new whole, a larger coherence made out of smaller previous unconnected bits. Coleridge, in his lectures on Shakespeare, also described the process of ``hovering'' in creative imagination.19 Mozart described something of his own creative state. Small fragments that he starts with are gradually brought together, so that the thing grows: I spread it out broader and clearer, and at last it gets almost ®nished in my head, even when it is a long piece, so that I can see the whole of it at a single glance in my mind, as if it were a beautiful painting or a handsome human being; in which way I do not hear it in my imagination at all as a succession ± the way it must come later ± but all at once, as it were. It is a rare feast! All the inventing and making goes on in me as in a beautiful strong dream.20

Dreaming The comparisons between dreaming and creative power made by Krebs and Mozart lead to the possibility that dreaming and symbolic play, and also forms of mental life which resemble these activities, have a similar function in creating personal coherence and continuity. Winnicott has suggested, in a poetic way, that play resembles the dream. The resemblance can also be inferred from Vygotsky's description of the language that accompanies symbolic play, in which elements of the child's monologues run into each other, ``in¯uence'' each other, in the manner of condensation, which Freud had seen as characteristic of the dream process. The descriptions of Winnicott and Vygotsky suggest that play and dreaming can be conceived as part of the same biological system and as having similar biological functions. However, the purpose of the dream is by no means clear. Most attempts to investigate the function of dreams have focused on paradoxical, or rapid-eye movement (REM), sleep. Although reviews of the subject21 show that there is no single generally accepted theory, a proposal put forward by Greenberg22 is consistent with my argument. He suggests that dreaming has a largely integrative function, connecting up personally adaptive and associative information. Greenberg23 cites a number of studies, in both animals and humans, that support his proposal.

56

Part I: Development

The linking together of previously disconnected elements of experience depends, both in play and in the dream, on more than associational ties. It involves a storying element that is crucial in binding into a new coherence data from disparate spheres of human experience, including, for example, the natural environment, forms of relatedness, feelings, morality, personal attributes, wishes and hopes. This function can be inferred from studies of memory in relation to REM sleep. In one study, subjects were given three kinds of material to remember before going to bed: a list of 62 words that could be categorized, ®ve sentences that were syntactically correct but nonsense, and a prose passage. Some subjects were deprived of REM sleep, or an equal amount of nonREM sleep. All the subjects were tested in the morning. The only signi®cant difference between them was that those deprived of REM sleep remembered less of the prose, that is, the material connected in a meaningful sequence.24 In a second study, the subjects were asked to remember a story. They were then deprived of either REM sleep or a speci®c aspect of non-REM sleep (S4). Recall accuracy following REM deprivation was signi®cantly poorer than following S4 deprivation.25 These intriguing ®ndings provide support for the notion that at least one of the functions of dreaming is to bring together and give coherence to the vast array of sensory data that impinge upon us every moment of the day. The shaping principle is given by the structure of narrative. That a form of this narrative structuring might be involved at the higher levels of scienti®c creativity is implied by the wonderful description given by the mathematician Henri Poincare of his own mathematical discovery. This classic essay could be quoted at length. However, a small portion of it is relevant here: A mathematical demonstration is not a simple juxtaposition of syllogisms, it is syllogisms placed in a certain order, and the order in which these elements are placed is much more important than the elements themselves. If I have the feeling, the intuition, so to speak, of this order, so as to perceive at a glance the reasoning as a whole, I need no longer fear lest I forget one of the elements, for each of them will take its allotted place in the array, and that without any effort of memory on my part.26 Poincare seemed to be saying that the higher levels of scienti®c creativity depend upon a structuring of data analogous to the structuring of events, personages, feelings and so forth involved in the process of narrative.

Forms of feeling The story or stories, that underpin and make coherent and individual life are of a particular kind. They are made up of the feelings, imaginings and

Play, coherence and continuity

57

memories which accompany the actual events. They are sometimes things which are held closest to our hearts, which may never have been expressed, and which, in some cases, are barely expressible. The telling of these ``interior'' stories is necessarily done symbolically. They emerge in a conversation ideally based on ``shared symbolical attitudes.''27 The idea that personal cohesion involves the evolution of a narrative of self, in which feelings and re¯ections, shown in memory and imagination, are essential, leads us to the view that both feeling and the capacity for re¯ection upon inner events, i.e., the experience of dualistic consciousness, are necessary to personal cohesion. It was William James who put forward the somewhat revolutionary idea that our sense of relations between things and events, and so, our experience of cohesion, depends upon feeling. He remarked: ``Few writers have admitted that we cognise relations through feeling.'' Furthermore, ``intellectualists have explicitly denied the possibility of such a thing.''28 Although an intellectual, cognitive, or rational relationship might also link things or events, it is the feeling which is fundamental. I want to extend his idea into the sphere of human relations. Although the idea seems obvious when we consider the relationships between people, its importance is sometimes obscured in the practice of psychotherapy through an emphasis upon meaning. A certain traditional theoretical background might in¯uence the therapist to make responses that give privilege to meaning and relatively to neglect subtle aspects of feeling that are the basis of the relationship. Connection, which above all is based on feeling and which is the basis of maturational change, is put at risk. James considered the relationship between things and events in terms of language. As an example, James used the words ``Wait!,'' ``Hark,'' ``Look,'' uttered on successive occasions. ``Our consciousness is thrown into three quite different attitudes of expectancy, although no de®nite object is before it in any one of the three cases.''29 ``We have no speci®c names for these different states except the words, hark, look, and wait.''29 He went on to imply that every word we know has about it a penumbra of associations, a shape into which it sits in the manner of a mould, like the white form that remains on the page after a black image has been imprinted upon it. As we search for a forgotten word, we know, in a nebulous way, that we are trying to ®nd a word which ®ts a metaphoric empty space in the memory system. Words are rejected because they do not feel right. This feeling, James suggested, involves rhythm. We search for the word which ®ts this particular rhythm. The sense of ``rightness'' when we come across the word we are after has a feeling in it. ``The only name we have for all its shadings is `sense of familiarity'.''30 Although James does not say so directly, his argument implies that relation comes through a linking up, or coordination, between these ``moulds'' of feeling and rhythm. Out of the linking comes something new. An example is provided by considering the word ``table''

58

Part I: Development

which, so he says, has a ``static'' meaning.31 If ``table'' is linked to another word or words, a faint feeling arises of which we are usually unaware, in the manner of poetry. If, for example, we speak of a ``table mountain,'' or a ``table of results,'' or a ``dining table,'' in each case the subliminal, barely detectable feeling will be different. Perhaps in the ®rst instance it is exhilaration, in the second deadness, and in the third pleasure. The therapeutic process involves attempts to discern, express and ``play with'' the ¯uxes of feeling that underlie the words and their meanings which are the currency of ordinary and familiar conversation. An important aim seen in this way approaches that of art, as Suzanne Langer understood it, i.e., ``as the creation of expressive forms to present ideas of feeling.''32

The amplified image and coherence The basic element of narrative is image or scene. But the ``interior'' narrative of which we have been speaking is, to an extent, unrealized, not only hidden from others but unknown to the subject. Its central images must be discovered and, in creative interplay, ampli®ed. The ability to organize large amounts of information into complex yet coherent images is one of the most signi®cant and powerful capacities of the human primate. We possess a multiplicity of such images, many of which operate unconsciously. Some remain relatively ®xed, as in the case of trauma, but others evolve in an engagement with the world and through conversation not only with others but also internally. Certain of the images serve as lietmotifs for an entire life. Howard Gruber, a renowned expert in the Piagetian theory, believes that most people have about four or ®ve such images. Perhaps another 50 or 100 operate so as to elaborate the main themes of the central images.33 He implied that psychological growth comes through an enlargement of these main organizing systems. This is evident in his description of them. He called them ``images of wide scope.'' The evolution of the image depends upon assimilation: An image is ``wide'' when it functions as a schema capable of assimilating to itself a wide range of perceptions, actions, ideas. This width depends in part on the metaphoric structure peculiar to the given image, in part on the intensity of the emotion which has been invested in it, that is, its value to the person.34 The ``widening'' might involve the assimilation of con¯icting images, leading to a changed organizing structure. Sometimes this process cannot occur and development is stuck. This is very like a dilemma which is often discovered during the therapeutic conversation. Once again, the creative process in science provides an analogy for the resolution of this impasse.

Play, coherence and continuity

59

The emergence of quantum theory at the beginning of the twentieth century caused a period of unease and perplexity among scientists. Max Planck had proposed in 1900 that radiant energy emitted from hot material was made up of bits, or quanta, of energy. The development of the theory led to a questioning of the whole edi®ce of classical physics. Fundamental notions of time and space, of cause and effect, of matter and motion, were under threat. The new theory led into a zone of abstraction where visualization was no longer possible. The theory could not be portrayed by a picture or mechanical model.35 Werner Heisenberg's elaboration of the theory, he admitted, had the disadvantage of not being depictable ``in terms of the familiar concepts of space and time.''36 His concept of unvisualizable particles and discontinuities profoundly disturbed Erwin SchroÈdinger who was ``repelled'' by Heisenberg's theory and its ``lack of visualizability.''37 He proposed, instead, a wave theory in which continuity was maintained. Heisenberg found the wave theory ``disgusting,''38 although it appealed to Einstein and Planck.39 Two contradicting and opposing models or images had now been formulated. An impasse had been reached, creating tension and confusion. The con¯ict was resolved rather as it might be in the therapeutic situation, by visual imagination. Niels Bohr had been a leader in taking quantum theory into the regions of unvisualizability. Yet this new direction was painful to him. He had a visual imagination and a lifelong interest in art.40 In particular he was impressed by an aspect of modern art epitomized by the work of Picasso ``face and limbs depicted from several angles . . . That an object could be several things, could change, could be seen as a face, a limb and a fruit bowl.''41 In 1927, Bohr proposed that the wave and particle theories, rather than being contradictory, were ``complementary pictures'' of the same phenomenon. Which picture one saw depended upon the way one looked at the phenomenon, that is, upon the manner of experimental observation. His complementarity principle combined and resynthesized the two opposing themes into a larger image or, as Gruber would put it, into an image of wider scope, able to process the apparently con¯icting data. Through the use of visual imagination Bohr had been able to bring cohesion to the broken theoretical ®eld by the creation of an ampli®ed organizing image. It emerged from intense and highly charged conversations with his colleagues, particularly Heisenberg.42 This story provides an analogy, or metaphor, for certain aspects of the therapeutic process which are touched upon in Chapter 16.

The narrative as conversation The image is not neutral. Feeling is central to it, as shown in the responses of Heisenberg and SchroÈdinger to each others work. Gruber makes the

60

Part I: Development

point that the organizing image is imbued with feeling and is given value. In the thematic evolution of those organizing images, which determine the unfolding of an individual life, there is an interplay between not only the contents of the organizing structures but also their emotional bases. In his essay on scienti®c creativity, Gruber wrote: ``I hope to draw together these two ideas, the interplay of different scienti®c moods in scienti®c thought, and the notion of images of wide scope.''43 Gruber used the story of Charles Darwin to illustrate his thesis. He identi®ed two main images which were basic to Darwin's thought. The ®rst is evident in the ®nal paragraph of The Origin of Species, which begins: It is interesting to contemplate an entangled bank, clothed with many plants of many kinds, with birds singing on the bushes, with various insects ¯itting about, and with worms crawling through the damp earth, and to re¯ect that these elaborately constructed forms, so different from each other, and dependent on each other in so complex a manner, have all been produced by laws acting around us.44 The image of the ``tangled bank,'' of the natural world viewed at a moment in time, was accompanied by delight, a feeling which had ®rst been generated in early life. The second image, which arose later, was associated with another kind of pleasurable feeling. This image was of the irregularly branching ``tree of nature.'' It introduced the time coordinate into the instantaneous image of the ``tangled bank,'' which was not ®xed but changing over thousands and millions of years. In Darwin's words: ``Organised beings represent a tree, irregularly branched . . . As many terminal buds dying as new ones are generated.''45 Over many years, Darwin played around with his tree diagram, which is the only diagram to appear in The Origin of Species. It was modi®ed and elaborated in an iterative way, not only with the observed facts of the natural world, i.e., with such scenes as the ``tangled bank,'' but also in a kind of interior conversation. His drawings are reminiscent of the child in symbolic play. The images were sustained and their elaboration fostered by the feelings that were central to them. As Gruber pointed out, scienti®c creativity is not merely ``a variety of problem-solving.''46 There is a ``mood'' associated with it which includes the feeling of ``rightness'' noted by William James. The images underlying Darwin's development of the theory of evolution resemble, and were related to, those of the narrative of self, which is not ®xed, but shifting and ¯uid, made of many chapters and themes, which are potentially intertwined, and which are constantly evolving and reshaping over months and years. Although the trajectory of a person's development can be recounted as a story, it is better understood as a conversation. The other is always sensed within it, as in symbolic play. This necessary

Play, coherence and continuity

61

background feeling is additional to the moods associated with the organizing images themselves. It seems likely that this background feeling was strongly developed in Darwin's life. Darwin's marriage to Emma Wedgwood gave him what his psychoanalytic admirer, John Bowlby,47 would have called a ``secure base.'' Darwin kept her ``beautiful letter,'' written after their marriage, for the rest of his life, reading it again as his death approached.48 During their life together Darwin would become uneasy when he was separated from her,49 and he would have ``a horrid sinking feeling'' on leaving home.50 His entire wellbeing, his biographers believed, depended upon his wife and daughters.51

The complexity of cohesion The origins of the sense of cohesion and continuity of personal existence are, at present, not understood. However, disparate sources of evidence, such as stories of scienti®c creativity, philosophical explorations, neurophysiological studies, and clinical observations give glimpses of what might be involved. The issue is clearly complex. However, these sources suggest certain of the requisites for a feeling of cohesion and continuity. They include the capacity for re¯ection; a positive emotional tone; an associative or playlike state of mind involving memory and imagination, particularly of visual kind;52 certain kinds of brain activities; the background sense of the other in which there is ``fellow feeling.'' These are all apparent in the scene of symbolic play which can be regarded as the embryonic form of the heights of creativity achieved by such individuals as Niels Bohr and Charles Darwin. Symbolic play suggests a further element necessary to the experience of wholeness of personal being. A story is being told which has some of the features of a conversation. It is not a chronicle of the simple facts of existence. It is an imaginary or ``interior'' story. The imaginary life, if things go well, slowly unfolds. It is as ``real'' and gives meaning to the chronicle of facts to which it is necessarily linked. Self then is a ®ction. It is ®ctitious in the sense that it does not exist except as a re¯ection of the activity of dynamism. It is a process never at rest, so that self too is never ®xed, never a thing we can point to and say ``That's a self.'' Second, it is a ®ction in that, in essence, it is a story. The ordering and sequencing that is necessary to the story might be ®rst seen in the play of the proto-conversation. This interplay is the necessary forerunner to symbolic play and the small stories which accompany it. In their dynamic movements, they show the earliest elements of the ``narrative of self'' which is constantly being woven throughout our lives. Schiller remarked that with this kind of play we become human. Janet expressed a similar view from a different perspective. He wrote: ``Narration created humanity.''53

Chapter 9

Value and fit

Miss A, the shy waitress encountered in Chapter 1, could not tell her story. Her inner life of feelings, ideas, imaginings, memories and so forth was experienced as having value. To speak of these things was a risk. The wrong response from others would cause their value to be lost. That which she sensed as the core of herself would be diminished or worse. The danger was that devaluation would af¯ict upon her a feeling of hurt and damage akin, in its pain, to physical harm.1 How does this sense of value arise? The question is a crucial one, since an unformulated, wordless background, we might almost say ``unconscious'' feeling of personal worth, to which in general we pay little attention, is at the heart of personal existence. It is lost, to varying degrees, in the overwhelming majority of those who seek therapeutic help. The loss is generally catastrophic in those people who suffer what is currently called the borderline condition. Their persisting dysphoria and sense of personal worthlessness is often concretized as badness, incompetence, even ugliness. In this chapter, a ``matching'' hypothesis is put forward for the origins of value. I suggest that responses from others which ®t or resonate with immediate states of feeling and imagining have an effect, often quite subtle, of evoking a positive emotional tone, a state of well-being of which the individual is usually only dimly aware. An accumulation of these moments leads to a relatively enduring positive feeling about oneself, out of which arises a judgement of value. Put another way, it leads to the growth of selfesteem.

The puzzle of self-esteem Despite our intuitive feeling that we know what it is and how it might arise, self-esteem is not well understood. The results of the large amount of research in the area have been disappointing,2 presumably because the subject has a somewhat intangible quality, dif®cult to de®ne. In¯uential de®nitions of the term are discrepant, as if different entities are being described.3

Value and ®t

63

A prominent view is that self-esteem is an idea, a ``cognition,'' whereas the main thesis of this chapter is that self-esteem has its primary basis in feeling, out of which ``cognitions'' arise. The dif®culty of conceiving the notion of personal worth or self-esteem is made more apparent when we consider the matter in terms of the difference between self and identity. These two aspects of personal existence are separable, although they are usually linked up and merged. The former looks in; the latter looks out. Much current research focuses on identity. The most famous of attempts at conceiving self-esteem came from William James4 who formulated the following equation: Self-esteem =

success pretensions

This equation can be seen as the origin of much research into the subject. The equation suggests that achievement is necessary to self-esteem, an idea which may be culture bound, relating to adult westernized urban life. The equation also leaves out fundamental issues. Where does the need for success come from? How did the value given to certain pretensions, or aspirations, arise? A person's central feelings about him or herself are likely to be found in interpersonal experiences that occurred early in life, including those that do not depend on the use of language. We need to discover a source more primitive and archaic than the congruence, or lack of it, between an individual's aspirations and their actual ful®llment. The Jamesian equation does not help us understand the more basic self-esteem that is growing before pretensions are recognized. Indeed, the Jamesian approach may underlie the almost conscious strivings of those in whom success is used in an attempt to overcome a basic feeling of low personal worth through highlighting the role of identity, the show given to the world. A main dif®culty about the Jamesian equation, and of research implicitly based upon it, is that it leaves out emotional life, which is surprising in view of James's insistence upon the centrality of feeling. He wrote, for example that ``individuality is founded in feeling.''5 Another well-known approach to self-esteem derives from Charles Cooley6 and his notion of the ``looking-glass self.'' He believed others provide a mirror for us that tell us who we are. Re¯ected appraisals are imitated and incorporated as one's own. In a series of studies, Susan Harter has systematically applied the views of James and Cooley to an investigation of self-esteem in young adolescents for whom, as Erikson pointed out, identity is a central issue. Harter operationalized the James and Cooley de®nitions. For the Jamesian construct she identi®ed ®ve domains in which self-worth might be judged. They are: scholastic competence, athletic competence, peer social acceptance, behavioral conduct and physical

64

Part I: Development

appearance. For the Cooley construct, she chose parents, teachers, classmates and close friends as those most likely to make signi®cant appraisals. It was found that the contributions of the two constructs to global self-worth were relatively independent. However, they interacted and compounded. In the Jamesian area, the domain of physical appearance was the most important for adolescents. Examinations of Cooley's construct showed that the support of parents and classmates was the biggest contributor to self-worth. Although research of this kind appears to focus on identity rather than self, the distinction is to some extent an abstraction since these poles of personal existence connect. Harter's research shows that those who felt good about themselves in general judged their physical appearance positively. Moreover, although the James construct might be more about identity than self, the reverse appears to be the case for the Cooley construct. This is consistent with the ®nding that the constructs were relatively independent. Items on the Cooley construct ``tapped the extent to which the subjects felt that others treated them like a person who matters, felt that they were important, listened to what they had to say, liked them the way they were, cared bout their feelings, etc.''7 These are behaviors likely to be important in the maintenance of self. Research ®ndings such as those of Harter, her colleagues and others in this ®eld are interesting and important, but we are still left with puzzles. One of these is a discrepancy sometimes found between an individual's judgement of self-worth and objectively observed facts. Adolph Stern remarked upon this in his pioneering, and perceptive, description of the borderline condition: Not a few of my patients have become successful in their chosen ®elds of endeavour, have acquired excellent general and professional educations; not a few have pre-possessing physical and psychological characteristics ± but none of their accomplishments, nor the sum of their accomplishments, in the least in¯uences them in their judgement as to their being inferior people. A close approach to this picture is the delusional self-depreciation of the melancholic.8 Such people suffer a persisting dysphoria, of varying degrees of intensity, which is additional to feelings of emptiness and deadness. For them, a sense of personal value does not arise simply as a response to a matching between goals and achievement. A contrasting story is that told by a 40-year-old American writer: He started writing plays in his twenties, when he lived in New York, and found almost instant success and fame. While still quite young, he married an entrancing young actress who had a part in one of his

Value and ®t

65

productions. Five years later, the couple moved to Los Angeles, leaving their friends and families in the East. Film scripts proved lucrative, and he bought a house on the ocean at Malibu, where they still live. Meanwhile, his wife's initially promising career began to fail. She started to drink heavily. His own career now began to falter. The critical acclaim he had once received turned to lack of interest, even contempt. He, however, had faith in his abilities and had recently invested a large amount of his own money in a ®lm for which he had written the screenplay. It had failed badly. He had discovered in the last few weeks that, as a consequence of this failure, he would probably lose his Malibu home and be left with very little else. In addition to this disaster, his wife's drinking and their consequent rows had escalated over the last few months. One night she announced her decision to return to the East Coast in the hope of reviving her career. Divorce seemed inevitable. The following morning he walked on the beach, his life in ruins. He was aware of a sense of strangeness and of feeling quite alone. He also began to realize that, despite all, he did not feel hopeless, despairing, or personally worthless. With everything stripped away, with apparently nothing left to live for, he experienced, as if within his chest, a kind of brightness and warmth, which he said was ``something like the sun.'' The sensation was nothing more than that, diffuse and without words or images. He knew then that he would not collapse and would be able to keep on going. The writer's awareness of a metaphoric warmth within him that gave him strength brings to mind James's oft repeated remark about the feeling of ``warmth and intimacy'' which is experienced at the heart of personal being. It is with this dif®cult-to-describe state of well-being, ``something like the sun,'' that the rest of this chapter is concerned.

Hedonic tone The writer's unusual experience seemed to be a concretization, or representation in bodily terms, of some core resource, some ultimate reservoir of optimism and well-being that could be called basic self-esteem. His story suggests that the heart of self-esteem is a feeling-tone, which might perhaps be called ``hedonic tone.'' This feeling tone in my view leads to the judgement of value. Jung anticipated this idea when he wrote: ``Feeling informs you through its feeling tones of the values of things.''9 Before looking for possible bases for the feeling-tone that gives value, we must consider the contribution of Harry Stack Sullivan to an understanding of personal worth. Sullivan's psychology depends upon three biological principles. The ®rst is the principle of communal existence ± ``the living

66

Part I: Development

maintain constant exchange through their bordering membranes with certain elements in the physico-chemical universe around them.''10 In the human, this universe includes the social and cultural. The organism may be in equilibrium or in relative disequilibrium with the environment. Sullivan conceived this equilibrium or otherwise in terms of the infant's needs, which at ®rst are mainly physico-chemical. (It could be argued, although less clearly, that they are always physico-chemical.) These primary needs include obvious physico-chemical requirements such as oxygen and glucose, but also such needs as contact. The mother's absorbed observation of her child results in a perception of the infant's needs. This perception induces ``a tension experienced as tenderness and as an impulsion to activities towards the relief of the infant's needs.''11 Seen in this way, mother and baby are the two parts of a communal existence in which inbuilt signals in one trigger inbuilt responses in the other. Need is, in a broad sense, disequilibrium in this dyadic system. The next aspect of Sullivan's psychology is relevant to self-esteem. He introduces two polar constructs that relate to states of equilibrium or disequilibrium. They are absolute euphoria and absolute tension (terror): ``Euphoria may be equated to a total equilibrium of the organism''12 and tension to disequilibrium. Sullivan was particularly concerned with the tension called anxiety. This ``appertains to the infant's, and also to the mother's, communal existence with a personal environment.''13 His emphasis was on the need to be rid of anxiety. He makes the important point, however, that the ful®llment of this need is not accompanied by euphoria. Rather, ``the relaxation of the tension of anxiety, the re-equilibration of being in this speci®c respect, is the experience not of satisfaction, but of interpersonal security.''13 Sullivan's system mainly focuses on the origins of low self-esteem. The needs of the child, which are central to it, involve the tender emotions. The child has a need for tenderness and expresses this need through a display of emotions that in the adult are those of intimacy. A response such as mockery, contempt, or simple lack of interest devalues the intimate emotions, and the child is hurt in a way that feels like damage to the physical self. When the child lives in a situation where the exposure of the innermost feelings is dangerous, he learns to hide these emotions. He develops a pathology of privacy. Moreover, he learns that the social environment is made up of enemies. Although he lives among them, he is an isolate. There is no one who connects with that which is tender in him. He has undergone what Sullivan called ``the malevolent transformation.''14 Where the disjunctions of this kind are great and repeated, a prevailing attitude of hatred will develop, and with it low self-esteem. Sullivan's main thesis concerns the disaster of the social environment failing the growing child's need for tenderness. The contrary theme ± the evolution of positive self-esteem ± is not developed. Yet the seeds of it

Value and ®t

67

are there. Self-esteem must arise through an equilibrium with the social environment in which euphoria is generated. What might this equilibrium be? The ``dance'' between the mother and baby, which is established by the age of 2 months, is the earliest example of this equilibrium. This engagement gives great pleasure to both mother and baby. Consider once again the following description from Margaret Mahler and colleagues ``in which the 5±8 month old, surrounded by the admiring and libidinally mirroring, friendly adults, seemed electri®ed and stimulated by the mirroring admiration. This was evident by his excited wriggling of his body, bending his back to reach his feet or his legs, kicking and ¯ailing with the extremities and stretching with an exaltedly pleasurable affect.''15 The baby shows he or she feels good. So do the adults. Their responses and body movements, in an escalation of emotion and bodily expression, ®t in with each other. Mothers and other caregivers characteristically act in this way, naturally and without thinking about it. This is the kind of equilibrium from which come the moments of well-being that together make up a core of self-esteem. Kohut's ideas were similar. He even used the word ``equilibrium.'' In his technical writing, Kohut would have seen the joyous wriggling of the excited infant as his exhibitionistic display and the pleased adult's responses as ``mirroring the child's narcissistic-exhibitionistic enjoyment.''16 This kind of language, to my mind, obscures the humanity of Kohut's intuition, which is found in his spoken words. Like Sullivan, Kohut saw the baby triggering in the mother a particular response, which meshed with the baby's state. The response is a kind of irrational adoration, which he called ``baby worship.''17 The baby's state is perhaps a delight in the self: Whatever the baby does is responded to by the gleam in the mother's eyes, by her warmth, by her enthusiasm. Her self-esteem is heightened as she feels at one with the excited and exhibiting baby. It is this kind of equilibrium, though on a much more silent level, that we are striving for all our lives.17 It is necessary to emphasize the importance, not only developmentally but also therapeutically, of the response of the other to moments of aliveness, however muted, and to the emergence of positive feeling which, in the characteristic subject affected with a disorder of self, has been crushed. Traditional theory and practice have neglected the feeling-core of healthy selfhood.

The effect of fit The interplay between mother and child of the kind described by Mahler and her colleagues is truly reciprocal. Both partners are given pleasure in

68

Part I: Development

this engagement which involves the sense of ®t. A puzzle now arises. Why is the baby electri®ed? How does the sense of well-being arise? Nothing has been done to the baby. He has not been held or fed. There seems to be nothing actually going into him, as if it were a drug, which stimulates him. How can the mother's face induce a state of well-being? It is merely a collection of visual stimuli, which can have no obvious physical effects. We must now consider further the notion of ®t. Henry Miller describes the following experience: It's as though I had no clothes on and every pore of my body was a window and all the windows open and the light ¯ooding my gizzards. I can feel the light curving under the vault of my ribs and my ribs hang there over a hollow nave trembling with reverberations. How long this lasts I have no idea; I have lost all sense of time and place. After what seems like an eternity there follows an interval of semi consciousness balanced by such a sheen, cool as jelly; and over this lake, rising in great swooping spirals, there emerge ¯ocks of birds of passage with long slim legs and brilliant plumage. Flock after ¯ock surge up from the cool, still surface of the lake and, passing under my clavicles, lose themselves in the white sea of space. And then slowly, very slowly, as if an old woman in a white cap were going the rounds of my body, slowly the windows are closed and my organs drop back into place.18 This extraordinary account is of a response to music, that is, a mere collection of auditory stimuli. How could a sequence of noises provoke so profound an effect? Neurophysiology cannot be left out of an answer to this question. In 1954, Olds and Milner19 discovered that electrical stimulation of certain parts of the brain of animals had a powerful effect. The animals would perform tasks to the point of exhaustion to gain such stimulation. This ®nding inspired considerable popular interest. The area that was the most strongly rewarding, the lateral hypothalamus, came to be called the pleasure centre. Its function in humans and in our ordinary living can only be guessed at. It seems important, at least in my view, in the development of personal value. We now return to the experience of Henry Miller. Music must trigger systems in the brain that are responsible for emotions. It follows from this assumption that there is, intrinsic to the central nervous system, the equivalent of a series of neuronal templates, which, as it were, recognize particular broad con®gurations of stimuli and, as a consequence of this recognition, emit a neurochemical response that determines mood, attention, and other mental states. Scherer and Oshinsky20 have made pioneering studies that support such an idea. Using a Moog synthesizer, they investigated the effect of different patterns of auditory stimuli in inducing emotions. By altering seven acoustic parameters, they were able to

Value and ®t

69

show that there was considerable agreement among judges for the moodpromoting effects of particular arrangements of tones. The moods included anger, surprise, sadness, and happiness. The mother in the proto-conversation is using her voice in a particular way that may have an effect like music. She is also visible. It seems likely that information about faces is genetically encoded. Fantz was a pioneer in this area, and his studies have become very well known. His work suggested that the form of the human face is the most signi®cant visual stimulus of all those we encounter. For example, he found that babies only 2 to 6 days old paid more attention to a disc with human features painted on it than to other stimuli of similar shape and size.21 Although other investigators have not been able to replicate some of his ®ndings, and Fantz himself was forced to modify his original position,22 there remains the strong possibility that the human being is pre-wired to respond to patterns of stimuli resembling faces and that, furthermore, the patternings of these responses are also pre-wired. Darwin had made this suggestion in 1872. He believed certain repertoires of facial expression are part of our innate endowment. Lewis23 was able to show that a preference for face-like patterns is shown at least during the ®rst quarter year of life. The work of Spitz has made clear that the eyes are the most important feature of the face, at least until 2 months of age. The infant smiles at a mask of eyes but no mouth. Smiling in response to a face seems a central element of the kind of mother±baby interaction described by Mahler and her colleagues. How can this pattern of stimulus and response evoke pleasure? We must begin with the smile. A blind baby, who obviously cannot imitate, will smile. At ®rst, such a smile may seem random, but it is soon evident that the baby is smiling appropriately in response to such stimuli as the mother's voice.24 This apparently simple observation implies that the particular pattern of facial muscle contraction which makes up a smile is innate and somehow written into the brain. The pattern is triggered by only a narrow range of the multitude of stimuli enfolding the child at any moment. An important trigger for babies who are not blind is the smile of another. It seems reasonable to assume a connection between the part of the brain that determines emotional states and the system in which is encoded the behavior of a smile. This assumption gains some support from the work of Ekman.25 He and his colleagues have conducted a series of fascinating studies on facial expression. In one of these, subjects were instructed in the laboratory to contract, one after the other, a number of facial muscles, so that the culmination was a recognizable emotional expression such as hate or surprise. When the subjects were asked afterward what emotion they felt during the experiment, most of them named the emotion that was appropriate to the expression that had, as it were, been constructed for them, as if some kind of feedback effect were operating. While the actors made these facial muscle movements, their autonomic nervous system activity was

70

Part I: Development

recorded. Following this, they were asked to relive certain affect states, again while autonomic activity was recorded. Reproducing the facial muscle patterns evoked more clear-cut autonomic changes than reliving the emotion. Beebe and Lachmann comment on the interesting implications of this ®nding: The implication is that by contracting the same facial muscles as perceived on another's face, the onlooker can literally feel the same autonomic sensations as the other person. Reproducing the expression of another (for example, in mirroring) can produce in the onlooker a similar state.26 Ekman's ®ndings are consistent with the idea that, at least for the behavior of smiling, there is a reverberation among a feeling of pleasure, the behavior of smiling, and the perception of another's smile. The baby smiles, the other smiles back; the baby feels pleased and smiles more broadly; the other smiles more broadly, vocalizing at the same time; the baby is now excited and wriggles and waves; at a certain peak of excitement either or both partners (usually the baby) break the engagement for a while, allowing the excitement to wane; then the cycle may begin again. This, in broad terms, describes the cyclical behavior of mothers and infants, in which the behavior of each partner in¯uences the behavior of the other, so that their pattern of activity is shared. There is a ®t between the responses of the other and the experience of the baby. So far, we have only touched upon value as it arises in infancy, yet it is clear that it goes on developing and changing throughout life. It is dynamism, to use Sullivan's word. How does `®t' occur in the adult? We are concerned with something more complex than the reverberation between mother and child. The adult's smile, for example, is a more complicated signal than that of an infant. To follow the implications of Sullivan's thinking, value must involve the sense of what is intimate ± the tender emotions. The experience of wellbeing arises with another. It comes when the match between response of the other and what one feels and knows is so good that it brings with it a muted form of elation. There is a receptivity to and a harmony with the sensory environment, and things get ``inside.'' This experience occurs in an intimate relationship and involves the totality of self, including the body. Jean Rhys describes it: I am tuned up to top pitch. Everything is smooth, soft and tender. Making love. The colours of the pictures. The sunsets. Tender with colours when the sun sets ± pink, mauve, green and blue. And the wind very fresh and cold and the lights in the canals like gold caterpillars and

Value and ®t

71

the seagulls swooping over the water. Tuned up to top pitch. Everything tender and melancholy ± as life is sometimes, just for a moment.27 From such descriptions we learn the parameters of well-being that contribute to the feeling of personal worth. There is a heightened sensation, a feeling of bodily smoothness, of ¯ow, of the intensity of the moment. The state of union described by Rhys is not necessarily associated with sexuality. Nevertheless, a sense of living a shared experience that is mutually understood, brings with it an emotional state that necessarily involves the body. Bertrand Russell described a rare and unusually intense response to such an encounter. Of his ®rst meeting with Joseph Conrad, he wrote: We talked with continually increasing intimacy. We seemed to sink through layer after layer of what was super®cial, till gradually both reached the central ®re. It was an experience unlike any other that I have known. We looked into each other's eyes, half appalled and half intoxicated to ®nd ourselves together in such a region. The emotion was as intense as passionate love, and at the same time all-embracing. I came away bewildered, and hardly able to ®nd my way among ordinary affairs.28 Russell's use of the word ``intoxicated'' implies a state involving chemistry and brings to mind the description of the electri®ed infant. How can mere words bring about such a state? This question is very like those asked about music and the human face. It seems that a resonance between inner and outer evokes a heightened sense of existence, a particular feeling tone. A mechanism that matches between sensory data and patterns encoded memorically or by other means must trigger this emotional state. Paul McLean, who named the limbic system, suggested how it might come about. McLean observed that the hippocampus and amygdala are essential to perception and are also connected to the hypothalamus and other parts of the brain involved in emotion. He suggested that all sensory input is funneled into the hippocampus and related areas. Their connection with the neurological systems underlying feeling states suggests at least ``one possible mechanism by which the brain transforms the cold light which we see into the warm light with which we feel.''29 Here then is a hypothetical basis to the nature of ®t and for a preliminary explanation of the profound effect of the precise and delicate ordering of auditory stimuli that we call music. It also gives us a way of understanding a feeling of self-esteem that is ``something like the sun.'' It might evolve through the individual having lived enough of his or her life in a social environment that allows ordinary perception to be transformed into ``the

72

Part I: Development

warm light with which we feel.'' McLean's words bring us back to the Californian scriptwriter who, as a last resource, felt something within him of brightness and warmth. The ®t we are talking of has involved the realm of the intimate and those experiences that are central to self. Yet this notion is very different from the vast literature on the subject of self-esteem, which focuses on goals, aspirations, and achievements. We come to the importance of a sense of agency. In considering the resonance between a psychic life broadly made up of thinking, feeling, and willing and the circumstances of the outside world, we have so far neglected the component of willing. Yet the awareness of one's willing being brought to fruition by one's action is one of the more fundamental matches between inner and outer that a child can experience. Charles Cooley was one of the ®rst to comment on the signi®cance of action, which, as it were, mirrors the wish: Self feeling appears to be associated chie¯y with ideas of the exercise of power, of being a cause . . . the ®rst de®nite thoughts that a child associates with self-feeling are probably those of his earliest endeavours to control visible objects ± his limbs, his play things, his bottle and the like. Then he attempts to control the actions of the persons about him, and so his circle of power and self-feeling widens without interruption to the most complex of mature ambition.30 Jerome Kagan however, distinguishes between the child's apparent pleasure in simple motor activity and what he calls ``mastery smiles,'' which emerge during the second year of life. They re¯ect the child's pleasure in accomplishing planned tasks. The smile ``follows prolonged investment of goal-directed effort ± which serves a previously generated plan.''31 On the face of it, one can become one's own mirror simply by acting, by demonstrating, in a concrete way, a concordance between the wish and its ful®llment. This, indeed, is the basis of some therapeutic approaches to selfesteem. It is also the basis of the striving for high scores in the success/ pretensions ratio used by some individuals as a means of overcoming a basic feeling of low self-esteem. It is a common observation that this is not generally achieved. In my view, the road to mastery begins with a basic feeling that arises when those emotions and ideas that are felt as peculiarly personal are responded to in a way that gives them value. George Brown and his colleagues found that in a relatively deprived South London suburb, self-esteem seemed to depend upon the amount of access to social supports and con®ding relationships.32 The sense of mastery that arises through a sense of connectedness with another is the necessary precursor to action. Virginia Woolf described this feeling. She wrote: ``With regard to happiness ± what an interesting topic that is! Walking about here with Jean for a companion, I feel a great mastery over the world.''33

Value and ®t

73

The following clinical anecdote illustrates how responses from another, which match with one's personal and inner reality, are necessary before the environment can be acted upon in a way that further engenders the feeling of personal value: Marguerite's life was characterized by an almost total failure of mastery. She entered treatment with the speci®c complaint that she was unable to cope with the ordinary chores of day-to-day life. Her house remained in chaos despite her efforts to keep it tidy. She was not able to recommence her occupation as a draftswoman, although her two children were now in school. She remained at home in a state of helpless apathy. Her parents had been incarcerated in a labor camp in the last part of World War II. She was born soon after in Europe. For about 5 years after the war, the family lived in various refugee camps and other temporary dwellings. It seemed clear that the patient's mother had been traumatized, was distracted, depressed, and presumably unable to give adequate attention to the child. After they arrived in Australia, both her parents worked, sometimes leaving the 5-year-old child alone in the house. The time of her life before Australia was never mentioned during her later development. Despite these deprivations, the patient managed to train herself for a professional life. During her twenties she lived relatively uneventfully, working steadily. She married rather late, in her thirties, and had two children. Her husband was a commonsense kind of man, a carpenter. To the outside world, he would have seemed a perfectly reasonable companion and spouse. It appeared, however, that he consistently responded to her in a way that failed to recognize her own reality. This was illustrated by his behavior after their house had been ¯ooded. This had occurred during a vacation and was caused by the husband's having made renovations that did not meet municipal standards. Since his carelessness would have disquali®ed their claims for insurance, he invented another story, that the insurance company accepted and which showed that the ¯ood was caused by the patient's ineptitude. It was said that she had failed to turn off a tap before leaving for their holiday. The husband then retold this ®ction to their friends and acquaintances as if it were fact. They joked with the patient about her stupidity. This event was emblematic of an existence in which her own inner states found no echo or resonating response in the outer world of others. For about 15 years, she sought treatment, usually of a behavioral kind, for an inability to cope with her life and for a chronic low-grade depression. Nothing was successful. She entered the current treatment, conveying a desperate, yet resigned, helplessness. In a monotonous, somewhat querulous voice, she catalogued her endless failures, her hopelessness, and her boredom. The main

74

Part I: Development

therapeutic approach depended upon attempts to put into words, in a speculative way, what seemed to be her immediate personal reality. The therapist learned to eschew all interpretive behavior. The patient was able to explain that her inner states involved feelings that determined her behavior which, on this basis, seemed perfectly comprehensible. Responses that attempted to give meaning to her states in a cognitive way made her experience seem unreasonable and even stupid. She would relapse into her zone of apathy, depression, and helplessness. The therapist's second main contribution to the therapeutic conversation was to give appropriate responses to spontaneous emotional expression. After about 6 months, she seemed remarkably different. There were times when her demeanor had vitality and energy. During sessions her spontaneous laughter conveyed a sense of pleasure. Moreover, she spoke of days during which she experienced joy. The particular session that is relevant to this discussion occurred the day before the patient had to confront a dif®cult task. She tried to describe how coming to therapy was going to help her meet her responsibility and to overcome the dead weights that seemed to drag her down. The description was dif®cult because it involved something intangible. She spoke of the need ``to touch base again.'' This experience had the effect of, as she said, ``lifting me out.'' This state of being lifted contrasted with her more usual experience of being ``a lone planet by myself.'' She said: ``I'm given permission to exist here. That person says you're okay. You can join the human club. If I don't have that connection, I'm spinning off on my own in space.'' The therapist picked up the phrase about the human club. The patient laughed, as if enjoying the conversation. ``Yes, I've got a membership ticket.'' Following this, she said: ``I feel sort of a loss, of my, you know, my self-esteem, that I get so churned up over it [i.e., tomorrow's task]. It's quite funny when you think about it [laughs, then sighs]. You know, a person of value doesn't . . . someone with dignity or integrity doesn't do that to themselves, get churned up over such a little thing. It's sort of demeaning. I feel I demean myself to make such a big thing about it.'' In essence, the patient describes a general sense of disconnectedness, of being ``a lone planet.'' With the therapist, she achieves a sense of connection, of touching base, out of which arises a feeling of being lifted, which involves energy and positive feeling. This will enable her to have suf®cient mastery to act capably the following day. She realizes that for someone with good self-esteem, a feeling of mastery and being able to cope is not a problem. In contrast, from the negative point of view, she sees that lack of mastery has a feedback effect, diminishing a sense of personal value. It is of interest that the therapist has not

Value and ®t

75

used the words ``value'' and ``self-esteem'' and has little theoretical interest in the subject.

In summary, basic self-esteem consists of an almost inexpressible feeling that arises in relation to others whose responses ®t. This feeling involves warmth and value. The hedonic tone produced by ®t presumably has a neurophysiological basis, which as yet can only be speculated upon. Although self-esteem is not an idea, ideas arise from it. One of these ideas is mastery and from it comes plans for action and their ultimate ful®llment. The match between the plan and its enactment in the external world provides another kind of ®t. The evolution of personal value throughout life is a dynamism, involving reverberations between a core sense of positivity and well-being and the responses of others to expressions and actions that one feels as peculiarly personal. Those that match the central experience of inner life add to a feeling of personal worth.

Part II

Disruption

Chapter 10

Body feeling and disjunction

The experience of ®t or connectedness in being with another involves subtle bodily feelings, such as an enhanced sense of the body's rhythms, of its smoothness, ¯ow, and spatiality. In this chapter, we approach the contrary state, in which connectedness with the other is lost and the sense of self diminished. We return to the notion of the two playrooms. The playing child feels good. Alerting stimuli break up this state, however brie¯y. Something happens that is not part of or related to the child's thought processes and feeling and that causes him or her to become conscious of something else. Mundane events cause the child to direct his or her attention away from playing and toward this event. The change is accompanied by subtle alterations in affect and bodily function. The child's face may show interest, and there is a desynchronization of the electroencephalograph, a fall in skin resistance, and often a slight drop in heart rate.1 Thus changes go on in the body while, at the same time, there is a shift in emotional tone. The intermittent interruption of the patterns of play does not always come through nonhuman stimuli. Sometimes the alerting is due to the kind of response made by the other who provides the enabling atmosphere of play. As the child plays, he or she is continuously making and remaking a personal reality. When the parents show the child that they are not part of this reality, that their experience is somehow outside that of the child rather than within it, alerting occurs and play stops. The parents' inaccurate, insuf®cient or, in other ways, inadequate attunement to the child's reality might seem minor to an observer or may not even be perceived. In essence, however, it does not ®t in. It seems ``estranged'' from the immediate reality of the child.2 This awareness of the ``strangeness'' of an element of the perceived environment is part of the fundamental means of our coping. It needs to be discussed in further detail. We live in an environment that is largely predictable, expectable, and familiar. Much of our behavior in dealing with this environment is automatic. We pick up cups, turn door handles, and walk up stairs, taking little notice of what we do. If however, the cup seems unusually heavy, the door

80

Part II: Disruption

handle turns too far, or our footfall on one of the stairs sounds different from the rest, our attention is aroused. These things are strange. A neurological mechanism is constantly operating during waking life matching perceptions against memories, including very recent memories of past experience. This matching leads to a judgement of familiar or strange. What is familiar may be screened out, so that it does not reach consciousness. The capacity to screen out what is familiar and not relevant is necessary to our ordinary coping. We could not manage our lives if every one of the myriad atoms of potential sensation surrounding us impinged upon consciousness. We could not read a newspaper in a train or listen to a conversation at a party if all the potentially audible sounds were heard. We suppose, in ordinary development, that the parent is often experienced as part of the familiar environment, by responding in a way that is consistent with the child's continuing reality. The parent, however, is far from irrelevant. His or her familiarity is not screened out. Rather, the parent's activity is not salient. The child does not particularly attend to the parent in the same way that she does not notice the movements of her hands as she dresses a doll or picks a ¯ower. If, however, something went wrong with this movement, the child would immediately notice it. In the same way, the mother not responding and staying stock still would seem strange, even frightening. In a state of fellow feeling, the other may be both active and non-salient. Those with disorders of self frequently experienced a chaotic family life in which alerting stimuli repeatedly impinged upon them, preventing the development of self. An equivalent disruption, however, can occur when there is no obvious disturbance in the family. Severe disjunctions between the child's immediate personal reality and the response of a caregiver will impact upon the child like a loud noise. Chronic alerting can be a consequence of ongoing failures in parental empathy. Where the parental environment is repeatedly and habitually unattuned, the child is constantly alerted, breaking up the ®eld of play. The child is now consistently oriented outward with little chance of developing a sense of self. There is nothing much inside, no ``real me.'' There is also, for some people, a persisting feeling of estrangement. Those affected with disorders of self are peculiarly sensitive to the other's failures of attunement. Indeed, a vulnerability to the sense of disjunction between one's own reality and the response of the other is a central feature of the borderline syndrome. The effect of such a disjunction varies in intensity. We now consider, in more detail, the nature of a disjunction. At this point, it is necessary to emphasize that disjunctions are necessary to normal development. We have seen that, in a metaphorical sense, the child of, say, 2 or 3 years, inhabits two playrooms, one real the other partly illusory. He or she oscillates between two states of being with the other. Where one or the other of these experiences is de®cient or lacking,

Body feeling and disjunction

81

development is impeded. Just as the child needs the parent who is attuned to his or her personal reality, the child also needs experiences when the other is not felt as part of this reality. These experiences help to establish the concept of self-boundary, since they bring into the child's awareness an outside world that contrasts with the world that is inner. A hypothetical parent who was always perfectly attuned to the child would create a psychotic. Disjunctions, in this sense, have a positive value. It is clear, however, that it is much easier to trigger the state associated with alerting than the state that depends upon ``fellow feeling.'' The latter condition is fragile, easily lost early in development and in those with disorders of self. These people have little access to a zone that is potentially inner. Their existence involves a hypertrophy of the real.

The affects of trauma We may divide disjunctions into those of a positive kind and those that have a negative affect. Let us start with the former, using ordinary experience. Someone says, ``Have you seen L'Atalante?'' You are interested, curious. You reply, ``What is L'Atalante?'' Attention is outer directed, towards the questioner as object. The language is linear, logical, and goal directed. At the same time, however, this is no loss of inner experience. It remains as a background. The negative disjunction also precipitates an experience of the other as salient, a form of attention that is outer directed, and a language that is linear. Its effect, however, is different in two important ways. First there is a diminishment of the sense of interior life. The greater the diminishment, the more nearly the experience can be called traumatic. A second difference from the positive disjunction is affective. The question about ``L'Atalante'' excites a positive emotion ± interest. The negative disjunction, on the other hand, produced negative affects. There are, I believe, three main categories of negative affective change, often intermingling, which are triggered in somewhat different ways. They are loss of vitality, anger and anxiety. Each has its own mechanism. We consider them in turn. The ®rst category of response can be understood in terms of the system of resonance, described in the previous chapter. Its failure leads to experiences that are the opposite of those produced by a feeling of oneness with another. There are changes in the sense of vitality, of the unity of being, and of personal spatiality. Connectedness with the other is associated with enlivenment, as in the example of the baby who was electri®ed. A disjunction is followed by a sense of deadness, a loss of vitality, conveyed perhaps in the tone of voice, even in the body, which might sag as if in dejection. Furthermore, when we feel in harmony with another, there is a sense of unity of being and of ¯ow. Both these experiences are lost with disjunction. There is a breaking up of experience. The conversation may have a

82

Part II: Disruption

desultory, fragmented quality that may approach incoherence. There is a sense of loss of bodily rhythm, of stasis, and of nothing happening, the opposite of ¯ow. In addition to these changes, there may be an alteration in the experience of personal space. When we feel at one with someone else, there is a sense of personal expansion. This, too, is lost with disjunction. Instead, the feeling is of constriction. In extreme cases, one's experience of self no longer corresponds with the dimensions of the actual body. The individual may feel shrunken or sticklike.3 One woman, who was both sensitive and verbally adept, described this curious state in a number of ways: ``I feel the essence of me has shrunk. My body feels tiny. When I look out of my arms seem grotesquely large but only because I'm diminished. I know my body is really the normal size, but. . . .'' These states of personal constriction were accompanied by boredom, deadness, and dissatisfaction. She eventually discovered that they seemed to be related to her feeling cut off from her husband, her children, and her therapist.4 In extreme states of anxiety and disconnection from the other, the disturbance of body experience may be so severe that the body may feel as if it had ¯oated outside itself, so that the individual may sense himself or herself as above the real body, near the ceiling perhaps and looking down. Such experiences, which may occur in sexual abuse, can be sometimes reproduced by the subject as a form of defense. Out-of-body experiences of this kind may sometimes be found in temporal lobe epilepsy and related to damage or dysfunction in the area of the temporo-parietal junction. In a report of six such cases, the out-of-body experience could be reliably evoked by electrical stimulation of this area in one of these cases.5 An explanation for the psychologically induced forms of out-of-body experience can be inferred from the observations made at the beginning of Chapter 8. Our experiences are processed through a vast number of different processing streams which are usually coordinated. In states of terror they may become disconnected, an aspect of the phenomenon of dissociation, as described by Janet. The position of the body in space, its appearance, its tactile sensation, its relationships with external space, and its relationships between parts of itself are all processed separately. In addition, there are representations in the brain for past, present and future states of the body.6 In dissociation, these processing systems become relatively disconnected.7 Out-of-body experiences do occur, although rarely, during the therapeutic conversation. One patient, for example, would see her head lying on the ¯oor. A further bodily experience, however, is very common. It occurs when the disjunction is felt like an attack upon ``the secret.'' It has an effect analogous to a physical blow. The behavior of the other, which seems to damage the integrity and value of those feelings and ideas that are precariously held as a core of self, is felt as an assault. There is an immediate ¯are

Body feeling and disjunction

83

of anger, a lashing out, which is sometimes called narcissistic rage. Alternatively, instead of lashing out, the individual may slump as if actually hit.8 This response can again be understood in terms of the ideas expressed in Chapter 2. When we expose those experiences, fantasies, ideas, memories, and feelings that are peculiarly personal and intimate, highly valued, and sensed as part of our core, there is a chance that the responses of others may invalidate, damage, or devalue this central aspect of self. Exposure risks the experience of shame. In extreme circumstances, shame is devastation, associated with loss of a sense of personal worth. The repeated in¯iction of what can be called ``attacks upon value'' leads to the formation of a complex of traumatic memories which, in the typical case, are largely unconscious. They are stored in a memory system which, in Janet's understanding of it, is ``dissociated.'' He called this complex a ``subconscious ®xed idea.'' It is adualistic; rather like the experience of Armstrong's truck driver, described in Chapter 3. The re¯ective function is lacking. This system of mental life often remains dormant until triggered by some event in the environment, which resembles, often very slightly, the original trauma. The ``subconscious ®xed idea'' now intrudes into the ordinary dualistic consciousness of going-on-being, perhaps completely obliterating it. William James described this incursion, referring to ``whole systems of underground life, in the shape of memories of a painful sort which lead a parasitic existence, buried outside the primary ®elds of consciousness, and making irruptions there unto.''9 The trigger for the irruption into the therapeutic conversation is apparently inadvertent. For example, a therapist attempting to enter into the experience the patient was describing said, ``You must have felt ashamed.'' The patient became enraged, interpreting this response as meaning that her behavior was shameful and that the therapist, in drawing attention to it, had shamed her once again. (The possibility that what the therapist had said was not accidental is considered in Chapter 14, ``The Expectational Field''.) The unconscious traumatic memory system is constructed by the feelings associated with the trauma. The more severe the trauma, so it seems, the greater becomes the contribution of the affect to the construction of this form of psychic life. Carla described her entry into this state, in which she inhabited a reality which differed from that of her ordinary existence. Immersed in it, she felt attacked and persecuted. Since this reality conformed neither to that of other people nor her own perceptions when not in this state, she conceived it as a form of madness. Indeed, she seemed anxious to have others af®rm that what she endured during these episodes was a mini-psychosis. While in the midst of this experience she was cut off from ordinary consciousness, so that she was unable to process the experience. She said: ``I can't work on anything . . . I can't see through it.''

84

Part II: Disruption

Carla, like the person who was shamed, was not able to relate her perceptions of the other and of herself to a past while in the grip of traumatic memory. She was unaware that what she was living out was, in fact, a memory. Rather, she believed that her experience was a product of the present, and caused by the individual whom she now confronted. She had ``transferred'' what happened in the past into her current relationship. A third category of trauma concerns abandonment, or fears of abandonment, loss and separation. The affect, in this case, ranges from anxiety and emptiness to something which approaches the sense of annihilation. The experience can be understood through a consideration of the effect of separation upon one's feeling of existence. In ordinary circumstances our customary feeling of going-on-being cannot be removed. In childhood, however, it is precarious. The idea was anticipated by Descartes. Where William James had concluded that our sense of existence depended upon the ¯ow of inner life, Descartes (1637±1641) went beyond him. He conceived a possible end to this sense of existence. He wrote: ``I am, I exist: this is certain; but for how long? For as long as I think, for it might be, if I ceased to think, that I would at the same time cease to exist.''10 His remarks suggest a threat. Yet the removal of thoughts in adult life is unimaginable except in some kinds of psychotic terror. In infancy, however, it is possible. How thoughts may be removed can be understood, once again, by considering the child's play. As the child plays, his thoughts are in the things with which he plays. Their removal means, at the same time, a removal of the thoughts connected with them. In this sense, thought is substantial. It is now possible to understand to some extent the apprehensions of Miss A, the shy young woman described in Chapter 1. She too conceived thoughts as substantial so that to express them carried with it the feeling that she was losing parts of her physical self. Her experience may have been like that of the 2-yearold who screams when his toys are taken away. Emptiness is the result. Going-on-being can be threatened in a second way through the absence of the other who provides the atmosphere in which it can occur. The child or the person whose sense of self is frail is now in the situation imagined by Descartes. Existence is under threat. A fear of something like annihilation arises. For the individual whose development of self has been disrupted, quite small breaks with the other who is experienced as necessary to existence bring a tremor, a sense of unease, a fear that is like teetering on the edge of a void. Although I have tried here to make distinctions between forms of interpersonal trauma, such distinctions are, to a large extent, abstractions. All interpersonal traumas involve, in varying degrees, alienations, devaluations, and isolation. For example, the failure of resonance is not only devitalizing, but also suggests to the person who has not been ``heard'' or ``recognized'' that he or she is of little value, not worth responding to. Furthermore, since

Body feeling and disjunction

85

he or she has now lost contact the other, a distancing is evoked analogous to actual separation. Anxiety rises. Kohut's Miss F provides an example of the effect of the other's failure of responsiveness which goes beyond deadening. Miss F, it will be recalled, would become angry due to the therapist's silence. It is reasonable to suppose that his silence activated an unconscious traumatic memory system relating to parental unresponsiveness, speci®cally, a depressed mother.11 Not only is the silence diminishing of a sense of aliveness, it is also devaluing. There is, in this silence, the sense of being attacked.

Therapeutic disjunction In the clinical situation, most important disjunctions are often apparently inadvertent. Their detection and exploration offer signi®cant opportunities for therapeutic change, as will be seen later in Chapter 22. However, disjunctions may also result from the therapist's training and theoretical background. An obvious example, no longer common, is of the therapist who adopts the blank screen stance of classical psychoanalysis. Another, more common, involves therapeutic responses that are designed to show the ``meaning'' of the patient's remarks, behavior, feelings, and fantasies. These are often helpful where they show an understanding of the patient's experience. Where they are disjunctive and rejected by the patient, the therapist may conceive this response in terms of resistance. Repetition of the therapist's view of the patient's reality, and the meaning of this experience, may lead to an undermining of a fragile sense of existence. The therapist may have in¯icted upon the patient a state of estrangement and depersonalization.12 Disjunctions, however, usually come about in more subtle ways, such as tone of voice, gaze, and the way in which words are used. A particular kind of grammar, for example, an excessive use of pronouns or of questions, sets up a situation in which the therapist places him or herself in the role of object in relation to the patient as subject, which blocks or disrupts the feeling of ``being-with.'' Finally, however, and this is most important, therapy usually begins in a state of disjunction. Those with disorders of self usually live in a state of chronic disjunction. Since the person must be seen as part of a larger organism that includes others, the therapist begins to feel something of the bodily unease, the disconnectedness, of the patient. The therapist may not be quite aware of this disconnectedness since the conversation may seem unremarkable, concerning subjects that seem relevant and important. Nevertheless, the therapist may begin to ask questions, to use technical words, to make intellectual contributions to the encounter. The sense of disjunction is compounded. Both partners are caught in a reverberating situation in which the behavior of each cannot be understood alone but

86

Part II: Disruption

includes their effect upon each other. This entrapment is further explored in later chapters. The danger of this situation, if unrecognized, is that it has consequences that may be acted out beyond the boundaries of the therapeutic situation. The patient, now affected with a painful emptiness, takes steps to alleviate it. This may take a symbolic and apparently self-destructive form. The following is an example of such an attempt. The patient was a 35-year-old businessman who had been given the name of Bertram but called himself Burt. He presented with a vague depression that was akin to a chronic sense of dissatisfaction with life. He was af¯icted by a sense of deadness and emptiness and had low self-esteem. Burt was tall and strongly built. His voice was menacing at times, at others, petulant. His demeanor was tense. His story soon revealed disturbances consistent with the diagnosis of borderline personality. It also showed a person of considerable courage and persistence in that he had overcome the adversity of a very disadvantaged childhood and had become an engineer in a senior position in a construction company. He was in charge of large projects and a hard man. Other aspects of his life were less functional. His second marriage of two years was failing, partly as a consequence of his compulsive promiscuity. During sessions, he characteristically stared into space, delivering a monologue that frequently had a paranoid ¯avor and conveyed the idea that he had been unjustly served by life. If I made any signi®cant intervention, the response was often similar to that of a startle reaction. He would say ``What!'' and would look around as if surprised to discover that there was another person in the room. In this way he resembled those in Stern's classic description of the borderline condition. ``Most patients will talk on uninterruptedly as though oblivious of the analyst, but interruption of the ¯ow of associations will bring about as a rule, anger or anxiety.''13 On one particular occasion, the session began in the usual way. After about 10 minutes, however, Burt began to work himself into a rage. He announced that following the session he would follow a woman, any woman he saw in the street. A few minutes later he enlarged upon this, threatening to follow her to her home. Finally, he demanded to know what I was going to do when he had raped the woman, when the case reached the courts and the newspapers, and when my name was mentioned. Indeed, he demanded, in a threatening manner, to know what I was going to do to stop him. Listening to this monologue of escalating vehemence, even violence, I became aware that it had been broken up by tiny pauses. On re¯ection, I also realized that, without being quite aware of it, I usually ®lled those miniature silences with some brief, nonverbal vocalization, such as a grunt or a murmur. I

Body feeling and disjunction

87

realized that on this occasion, I had not responded in this way. I then said that something had been going very wrong during the previous few minutes and speculated that it might have been related to my behavior during the pauses, that he might have felt that I was not listening. Burt responded by saying I was like his mother, who never listened. He went on to describe her behavior, his violence diminishing as he did so. She was constantly belittling him, comparing him adversely with his elder sister, the perfect child. In an attempt to be heard, he, as it were, turned up the volume, becoming a brash and noisy child. She retaliated by beating him ®ercely or, at least, attacking him verbally. He could remember her only as cold, brittle, rejecting, and as having so emasculated his father that he spent a great deal of time away from the house. Burt imagined that the family's emigration from the north of England to Australia during his adolescence was their attempt to hold their marriage together. The conversation progressed to where the patient was able to describe the fantasy associated with the as yet unknown woman in the street. He imagined standing in the garden outside the window as the woman undressed. His greatest wish was not particularly erotic in the ordinary sense. He wanted her to look up, see him, and gaze upon him with admiration. The woman's gaze of admiration was needed, it seemed, to restore the sense of existence which had been lost, attenuated or broken up due to the silences and their activation of an unconscious traumatic memory system. His perverse sexual activity was supposed to reconstitute, however brie¯y or maladaptively, a disintegrated sense of self.

Chapter 11

Stimulus entrapment

In the previous chapter we considered people whose developing sense of self was constantly interrupted by the effect of an environment in which they were repeatedly made to turn towards the outer world. Ceaselessly, a reality that came from outside was forced upon them. This state of affairs culminates in a habitual state of experiencing, which I call stimulus entrapment. It is a form of disability that is often quite subtle, since it is not observed by those who do not know the individual well. Sometimes, indeed, he or she seems a model person, active, busy, very competent in those situations, such as committee work, in which linear thinking is important. When, however, such a person enters treatment for a prevailing sense of deadness, the true picture emerges. The presenting picture is dominated by catalogues of events and of responses to stimuli. The patient talks endlessly of problems with family, with work, and of bodily sensations. In this chronicle, nothing comes from an interior world. In essence, the patient seems unable to imagine. Consciousness is adualistic. Re¯ective awareness of inner events is barely operative. Pierre Janet described the state of stimulus entrapment in his patients who, typically, had suffered developmental trauma. They told him the same despairing tales, day after day. Their conversations were relatively lacking in memories of the past or images of the future. Their consciousness was, as he put it, constricted. Janet conceived their habitual experience in terms of a hierarchy of consciousness, an idea to which he was likely to have been introduced by one of his most important mentors, TheÂodule Ribot.1 Ribot was heavily in¯uenced by the theories of the great English neurologist, Hughlings Jackson, who had also in¯uenced Sigmund Freud. Jackson was the ®rst medical scientist to use the term ``self'' and to propose a neural model for its basis. What he called ``self'' is the dualistic consciousness described in detail by William James. This kind of consciousness, so Jackson believed, emerges very late in evolutionary history and is probably unique to the human primate. Jackson's principal proposal is that the organization of our brain±mind system is decreed by evolutionary history. The most recent functions are the most fragile, most easily

Stimulus entrapment

89

overthrown by adverse environmental events. In this circumstance, the consciousness becomes more limited, less complex, and more automatic. It presumably resembles the states of consciousness characteristic of earlier periods of evolutionary history. Dualistic consciousness, on the other hand, is relatively large. We can, as it were, roam about in it and bring before the ``eyes of the mind'' episodes from our past. We can even wander into spaces which do not exist, which are imaginary, and are able to conjure up a future. When this state of mind is lost, there is a slippage down a notional hierarchy, what Janet called an ``abaissement du niveau mental,'' a lowering of the mental level, a state which is not only constricted but relatively disuni®ed. Jung was very impressed by this concept, referring to it more than 50 times in his writings. A principal aim of Jung's work was to overcome this constricted state of mind and to potentiate the emergence of a larger and more uni®ed form of consciousness. ``Individuation,'' he wrote, ``is thus an extension of the sphere of consciousness, an enriching of conscious psychological life.''2

The system of entrapment Robert Hobson describes the experience of being with someone in the state of stimulus entrapment: ``A cloud of boredom closes around me. I feel bad about it . . . Freda hardly moves. Her face shows little change of expression, and I detect no in¯ection in her droning voice. The monologue goes on; Freda talking about her symptoms ± as if they are `out here!' She is treating herself as if she were only a thing, and talking at me as if I were a thing, not talking with me as a person. We are trapped in a world of things''.3 People like Freda are truly trapped. They cannot relinquish the dependence upon things, events and stimuli, because if stimuli were to cease nothing remains but a painful emptiness. As long as they go on seeking sensations, they are protected from it. But, in contrast, since they constantly seek stimuli, there is no opportunity to develop an interior zone. Indeed, as soon as life becomes relatively peaceful, distractions are sought that break up this relative calm. In some extreme cases, in borderline patients, inexplicable crises develop when, for the ®rst time, tranquility appears in their lives. Turmoil erupts as if it were needed. The trap has reverberating consequences that compound the dif®culty of escaping from it. Since there is no end to the impingements of the world, there is no silence4 out of which can arise something that the person feels as his or her own. Yet an awareness of inner life allows others to connect with us. When they do so, they allow a play space to emerge in which may be generated experiences sensed as peculiarly personal. A Catch-22 is apparent. Since connectedness with others cannot occur, inner life cannot come into being. Since inner life cannot develop, neither can connectedness occur.

90

Part II: Disruption

The entrapment is enhanced by anxiety. Although a person in the situation of Freda does not usually appear to be anxious, the appearance belies the actuality. As the catalogue of symptoms and troubles goes on, the therapist becomes aware of bodily discomfort, of a faint tension, which indicates the diffuse low grade anxiety which permeates the relationship. Although the therapist often comes to feel that the patient does not experience him or her as being in the room, as if he were simply not there, the feeling is not accurate. The patient is so aware of the therapist that the smallest movement or change in respiration or in¯ection in voice is registered. The patient is in thrall to the imperative for attachment. Anxiety is very largely generated around this need, which the prevailing sense of disconnection has ampli®ed, so enhancing the disconnection.

Pain It has long been known that anxiety enhances the intensity of stimuli and exacerbates the experience of pain. The pathophysiology of this phenomenon is not understood, but clinical evidence suggests that, at a certain level of anxiety, a notional gating mechanism limiting the amount of sensory input, is breached.5 The consequence is an increased salience of stimuli. Salience enhances the attention directed towards stimuli, which further compounds the entrapment. It is part of ordinary experience that we enhance the intensity of a sensation by paying attention to it. For example, the physician listening to heart sounds, by extremes of attentional discipline, is able to hear what is normally not heard. An example of this capacity to magnify almost imperceptible stimuli is given by LeÂvi-Strauss.6 He discovered that before the era of navigational aids, sailors had developed extraordinary perceptual abilities. He found, through looking into old treatises on navigation, that the early mariners were able to see the planet Venus in full daylight, a feat that to the modern mind seems impossible. This kind of story provides a background to the growing body of evidence which suggests that attention has the effect of amplifying sensory input. In some cases, the effect of this ampli®cation may reach the level of pain. It seems clear that in a rough way, this magni®cation is re¯ected in the size of the electric potential wave evoked at the cerebral cortex by the stimulus. High intensity stimuli, including those that elicit pain, evoke large waveforms. The amplitude of the waveform, however, is not simply a function of stimulus intensity. It is altered by attention. It has been shown that the component of the waveform that arises about 200 milliseconds after the presentation of the stimulus can be increased by three times when the subject is asked to attend to the stimulus rather than ignore it.7 One might predict that an extreme attentional focus upon ordinary bodily sensation

Stimulus entrapment

91

may induce pain. This indeed seems to be the case. In one experiment, for example, subjects were connected to a sham scalp stimulator and were told that a headache could occur as a result of the electrical current they received. This information might, presumably, cause at least some of the subjects to concentrate on inconsequential sensation in the head region. Half the subjects reported pain following this sham stimulation.8 Pain is a prominent and somewhat puzzling feature of those suffering severe disruptions in the sense of personal being. It plays a large part in the presentation of the syndrome which was once called ``hysteria'' and upon which the fame of Pierre Janet, in his heyday, was based. It was at SalpeÃtrieÁre, in Paris, where this condition was ®rst studied in a scienti®c way. Paul Briquet catalogued and classi®ed all the symptoms of 430 patients at SalpeÃtrieÁre who had been given the diagnosis of hysteria. He found that the typical patient had a lifetime history which involved a large number of medical problems, particularly involving pain. He published his ®ndings in 1859. They became the basis of a current, and rather unsatisfactory diagnosis, namely ``somatization disorder.'' Janet and others added to this picture by enumerating various dissociative phenomena which are part of the syndrome. Janet also described what amounted to the arrest of personality development which was central to the disorder. As a consequence of the neglect of Janet and his ideas during much of the twentieth century, the syndrome of hysteria ceased to be understood. It became the most inaccurately, and dangerously, diagnosed condition in medical and psychiatric practice. As a consequence, in 1980, the term was removed from the psychiatric lexicon and the syndrome split into its three main parts, as if they were unrelated. These parts are somatization disorder, personality disorder, and dissociative phenomena (including conversions, or somatic dissociation). Somatization disorder is the name currently attached to a lifelong pattern of seeking medical help for multiple symptoms which are often inexplicable and which frequently involve pain. Explanations of the frequent complaints of pain suffered by these people include the notion that pain, or the body, becomes a kind of communicative system. This explanation of so-called somatizing behavior must be treated with some caution. The matter can be approached by a consideration of the communication of affect. The early affective experience of the infant presumably involves a diffuse conglomerate of sensations from skin, bowel, muscle, and other parts of the body. The later distinction of the psychic component of this early experience depends upon appropriate expressiveness of the caregivers to facial, bodily, and visual manifestations of particular affective states. At ®rst this responsiveness will be nonverbal, the parent's demeanor and facial expressiveness representing a particular affective state. In later development, the representational function is taken up by words. Where the social environ-

92

Part II: Disruption

ment fails to represent the psychic element of an emergent affective state, it remains bodily. Events continue to excite appropriate affects that involve bodily changes. Since there is no other representation available, the body is used to communicate the affective state. This form of communication is not metaphoric nor is the bodily symptom a symbol. Rather, what is communicated is a description of actual experience. Determinants of this phenomenon include the effect of culture. Language is an important determinant of which components of an affective response will be differentially perceived and communicated in a particular culture. Languages for the affects and emotions differ across cultures.9 In some societies there are many words that describe variations of a particular affective state. In other languages there may be very few such words. Sometimes the same word is used for different affects. In languages in which there are few words for psychic states, the bodily accompaniments of emotions are used to express them. This seems to be so in the development of our own language. ``Anxiety'' is an example. The Indo-Germanic root angh is the basis of a series of words that involve the experience of choking, constriction and precordial oppression. They include ``anger,'' ``anguish,'' ``angina,'' and ``anxiety.'' Although the ®rst two are relatively ancient words, anxiety was not used until the sixteenth century. The Oxford English Dictionary gives a de®nition of the term made in 1661: ``as a condition of agitation and depression, with a sensation of tightness and distress in the precordial region.'' In the medieval period, this state was presumably signalled by bodily means. Despite the evolution of a more sophisticated vocabulary, the tendency persists. For example, a retrospective study of 55 patients with panic disorder referred from primary care, found that 89 percent had presented with cardiac, gastrointestinal or neurological symptoms.10 A large number of the functional somatic complaints were found to be associated with anxiety and depressive symptoms in a community survey of 18,000 people.11 For a language of affects to develop beyond the bodily, metaphor is required.12 Most words denoting emotions were originally metaphors, which are no longer recognized as such. Joy, for example, is derived from a word meaning ``jewel.'' The development of this affective lexicon will, according to the thesis of Sapir and Whorf,13 have a feedback effect on an individual's perceptions, in¯uencing the structure of a personal reality. Where the psychic component of an affect is not named, it will be perceived less frequently and memorized with more dif®culty. Consequently, the experience is less likely to become part of a personal reality. Alternatively, the naming of physical aspects of the affective state will potentiate somatic experience. As Lipowski puts it, somatization is a ``tendency to experience [my emphasis] and communicate somatic distress in response to psychological stress.''14 Certain cultures, through the effect of language and other means, will cause

Stimulus entrapment

93

the attentional focus to be directed towards physical elements of an affective response, so enhancing this aspect of the total experience. The family provides a mini-culture in¯uencing the predominance or otherwise of a somatizing expression of affective states. It might be predicted that where parents tend to respond to bodily manifestations of distress in their children, the children will somatize. Furthermore, it might be expected that those parents will themselves be somatizers. The research data support these two predictions.15 The somatic expression of distress in childhood is often understood in terms of attachment theory. The child's need for nurture and appropriate caregiving is the most studied aspect of the developmental background of those who in later life are ``somatizers.'' A child may come to know expressions of sadness, fear, or loneliness or may excite no appropriate response from the caregivers. On the other hand, bodily distress may trigger a nurturing response. Alternatively, models of care-eliciting behavior16 may come from others in the child's family who have physical illnesses, or the behavior may be stimulated by responses to the child's own illnesses.17 A person who had a childhood background in which bodily states were used as ``idioms of distress'' may continue to do so in adult life. These explanations are useful but incomplete. There is something beyond them. The central nervous system of these people functions in a way which differs from other people. Their processing of stimuli has been altered, presumably by the effect of repeated environmental impacts.18 My colleagues and I studied patients suffering the disorder Janet described, and later, in another series of investigations, patients with somatization disorder. We found that these subjects were unable to screen out irrelevant stimuli in the way that people usually do.19 It was as if they could not ``turn off'' the environment. Second, the amplitudes of the electric potentials evoked in the brain by stimuli were larger than in controls, consistent with the possibility that these people experience stimulation in a way which is more intense than other people.20 It is possible that, in the manner of the subjects testing the sham scalp stimulator, what other people experience as fortuitous sensation or ordinary forgettable discomfort, these patients experience as pain. It is important, however, that this disturbance of sensory processing is functional and at least partially reversible. This was demonstrated by Dr Hany Samir. Samir was treating, very successfully, a woman, Vera, suffering borderline personality, but who also had marked dissociative disturbances and ``somatization,'' i.e., she spent a great deal of time talking about her headaches and other bodily troubles. Samir studied audiotapes of 20 sessions randomly chosen from a year's treatment. He compared the ®rst 5 minutes of the tapes with another period of 5 minutes, taken from 20 minutes into the session, in terms of reference to pain and bodily discomfort. He found that references made to stimuli emanating from the

94

Part II: Disruption

body in the ®rst 5 minutes were very signi®cantly greater in number than were made at mid-session. An explanation for this difference is that by mid-session the therapist has been able to regain contact with his patient, and that this changed form of relatedness led to an alteration in her state of consciousness. This speculative explanation leads to the hypothesis that the way out of the impasse of stimulus entrapment is through the therapeutic relationship.

The problem of ownership There is a class of sufferers from stimulus entrapment who seem, to others, to be unaf¯icted by a malady of any kind. In their orientation towards the social environment they have learnt expertly to respond to its expectations. They are skilled in their strategies of dealing with the world, of carrying out requisite tasks, and performing roles which exhibit resource and apparent independence. Yet they suffer a dull dissatisfaction, a realization that these tasks and roles de®ne them, and that beyond these activities, or behind them, there seems to be nothing. In order to discover what might lie behind this life of busy competence, it is not uncommon for people to seek therapy, or to take up writing or painting, or to enter therapy in order to be able to write. A curious outcome resulted from one such initiative. The patient was a middle-aged man who felt he was not quite alive. Although very successful, his ordinary experiences did not feel genuinely his own and lacked the quality of reality. Intuitively, he had come to the idea that an activity that in important respects was like a child's play, in this case writing, might be helpful. But it was not. What he produced did not feel as if it came from the core of him, as if he ``owned'' it. Indeed, he wondered if it were anything more than a series of quotations from other people's work. He felt that he was a plagiarist. The sense of ``ownership'' of the experiences that make up personal existence is crucial. Privacy and ownership are two of the central themes apparent in the evolution of self.21 The origins of a sense of ownership of experience are likely to be complex. They will include the emergence of the play space, in which the objects of play are those the child has chosen. They represent his or her own experience in the way the child wishes. In contrast, experience coming from the external world does not have the quality of being owned. This notion, that experience coming from outside is not felt to be part of the personal system, whereas that which comes from within is felt as one's own, was noted by Descartes. Descartes (1637±1641) tried to ®nd the fundamentals of reality through introspective explorations. His purposes were ostensibly philosophical, but they also seemed to involve a search for the basis of self. Having locked himself away from all sensation, he described the ideas that came to him. They were, broadly speaking, of two kinds:

Stimulus entrapment

95

Some coming from outside and yet others to have been made and invented by me. For the faculty which I have of conceiving what is called in general a thing, or a truth, or a thought, seems to me to derive from nowhere else than my own nature; but if I now hear a noise, if I see the sun, or if I feel heat, up to now I have judged that these sensations came from certain things existing outside me.22 There are consequences of a habitual mode of experiencing that which comes from ``certain things existing outside me.'' Where experience comes from one's ``own nature,'' to use the words of Descartes, they are felt as peculiarly personal. These inner states have about them a state of ``meness'' which ClapareÁde described in a classic paper written in 1911. He wrote: ``The propensity of states of consciousness to cluster round a me which persists and remains the same in the course of time, is a postulate of psychology, as space is a postulate of geometry.''23 These experiences are one's own. William James remarked that for most of us the elementary psychic fact is ``not thought or this thought or that thought, but my thought, every thought being owned.''24 For those caught in entrapment, however, whose experience comes from outside and so belongs to everyone, this sense of ownership of experience is lost. Not surprisingly, the case of the man who wondered if he were a plagiarist, is not an isolated one. His story is very like a well-known case of Melitta Schmideberg. The patient was a scientist who was unable to publish, since he had a compulsion to plagiarize, for which he sought treatment. Ernst Kris25 took over this case and took the trouble to discover the content of the plagiarism. The man said he had just completed a book and had taken, despite himself, ideas from other people. In fact, the man had done nothing more than conform to the conventions of scienti®c writing in acknowledging and referencing his sources. Kris then made the interpretation that the patient wanted to be a plagiarist in order not to be one. Lacan reviewed this case and seemed, to my mind, to arrive at the right answer. ``It's his having an idea of his own that never occurs to him.''26 Put another way, the patient had never sensed that his ideas were his own and did not come from someone else. Both these men, the scientist and the weekend writer, had been unable to develop an interior life that they felt as their own. A system of stimulus entrapment leads to a diminishment of a personal experience that is owned and unique, and to doubts about the authenticity of existence. Moreover, there is little con®dence in the veracity of personal experience. This relative lack of con®dence may extend to matters of simple and raw perception. This has been studied in an interesting experiment by Arnold Buss. Buss27 devised a ten-item questionnaire that re¯ected private selfconsciousness. The responses to this questionnaire given by normal people showed that there is a considerable variation in this parameter. Those

96

Part II: Disruption

whose evolution of an interior life was well developed were surer of their own perceptions and less likely to have the reality of others thrust upon them. For example, in one study, subjects drank a peppermint-¯avored liquid and rated the strength of the ¯avor. Then, a second drink was presented, and half the subjects were told that it was stronger than the ®rst liquid. Subjects high in private self-consciousness (Highs) gave almost the same intensity ratings to the second drink, whereas those low in private selfconsciousness (Lows) rated it as more intense. The rest of the subjects were told that the second drink was weaker. Again, the Highs hardly changed their rating at all, but the Lows rated the second drink as much weaker. Thus the Highs were not susceptible to suggestions about their taste reactions, but the Lows were. These ®ndings suggest that the development of an interior life brings with it a certain stability and continuity. Where, in contrast, innerness is lacking and the subject is stimulus dominated, personal reality is shifting, determined by others and, in this sense, discontinuous. Indeed, the lack of continuity of personal experience of those caught in stimulus entrapment is often remarkable. There is often no connection between sessions or even experiences in a particular session. This system of enslavement to external circumstances, in some individuals, extends beyond a lack of the sense of ownership of experience to an experience of falseness ± the subject of Chapter 17.

Chapter 12

Transference and trauma

The development of personal being is impeded in two main ways, passive and active. Passive impediments come from the failure of caregivers to provide the necessary ``facilitating environment'' of resonance and recognition. Active disruption is a consequence of traumatic impacts upon the experience of personal being. They are stored in memory, frequently of an unconscious kind. Such memories repeatedly irrupt into the larger consciousness of ordinary living, sometimes merely disturbing its surface and, at others, taking it over entirely. The effect, as Pierre Janet pointed out, is to hinder maturation. He wrote: Unable to integrate traumatic memories, they seem to have lost their capacity to assimilate new experiences as well. It is . . . as if their personality has de®nitively stopped at a certain point, and cannot enlarge any more by the addition and assimilation of new elements.1 He was proposing that traumatic memory causes a developmental arrest of a particular kind. The words ``cannot enlarge'' are important. He was implying that the developmental arrest leaves the individual with a narrow and constricted consciousness of the kind described in the previous chapter. Dealing with the intrusion of traumatic memory into the therapeutic conversation is a main focus in working with the patient towards a larger and more vital sense of personal being. These intrusions are often very slight, indicated, at their smallest, by a single syllable. For example, ``Marguerite,'' who had been constantly told she was ``hopeless,'' unable to do anything in a competent way, is coming to life as she talks with her therapist. Contrary to the reality imposed upon her, she realizes that she cares for her children very well. Their meals, for example, are ``top qu. . .'' She cannot ®nish the word. To contemplate the possibility of her being able to provide ``top quality'' food for her children is suf®cient to trigger the traumatic reality that tells her that this cannot be so. She changes her description to say, ``they don't get sweet rubbish.'' Traumatic memory produces effects which range in compass from the organization of a

98

Part II: Disruption

sentence to the organization of a whole life. This woman's entire manner of living was constructed about the traumatic reality of her hopelessness. This way of life included marriage to a man who reminded her each day of her uselessness and incompetence. At times the traumatic memory is triggered internally, as was the case when Marguerite tried to say ``top quality.'' Any time she began to feel good, to feel con®dence in an ability, or to make an expression which was creative, the internally triggered system of self-demolition would crush her.2 At other times, the system is set off by external events, slight and perhaps accidental behaviors on the part of others which, in some way, resemble the original trauma. In these circumstances, the other is experienced as the original traumatizer. The subject does not realize that he or she is under the sway of memory. When the unpleasant memory overtakes conscious existing, what is happening is experienced as occurring entirely in the here and now. A complex of mental life, which came from the past, has been ``transferred'' into the present, as if it originated there. The concept of transference is a central aspect of the traditional psychotherapeutic approach. The term is used in two main ways: ®rst as a revival of experiences from the past of which the patient is unaware; second, as the totality of the patient's feelings towards, perceptions of, responses to the ®gure of the therapist.3 I am using the term in the ®rst and restricted way, and am understanding the phenomenon to refer speci®cally to the manifestation of the activation of unconscious traumatic memory. To consider all the various shifting states which arise in a conversation to be part of the phenomenon of transference renders the conception useless, at least in my view. Experiences such as the idealization which is part of the maturational process, are qualitatively different from transference phenomena. The notion of unconscious traumatic memory can be understood in terms of a hierarchy of memory constructed in terms of the age at which a particular form of memory ®rst appears in an individual human life (see Table 12.1).4 For many years, memory was considered to be a single function. In clinical terms, memory function was de®ned by what a psychologist could measure. It is now apparent that memory has not a single form. There are multiple memory systems. Furthermore, psychological testing provides only a limited glimpse of the multiplicity and complexity of memory. A leading contributor to the new conception of memory is Endel Tulving. He reintroduced the Jamesian view of memory after its long period of banishment during the behaviorist-positivist hegemony. James had written of a form of remembering which concerns one's own personal world, in which episodes of the past are brought into consciousness again, to be viewed, as it were, ``in the mind's eye.'' This system of memories of personal events is distinguished from another memory system which accesses facts. These facts, the body of our knowledge of the world, are remembered as

Transference and trauma Table 12.1

99

Hierarchy of memory

Memory type Episodes Remote episodic or autobiographical Recent episodic Generic episodic Facts Semantic Movements Procedural Sensations Perceptual representation

Age of appearance

Degrees of re¯ectiveness

Declarative vs non-declarative

4 years

Re¯ective (autoneotic)

Declarative

2±3 years 2±3 years

Declarative Declarative

Last part of ®rst year

Non-re¯ective (noetic)

Declarative (in 2nd year)

Early

Non-re¯ective (anoetic)

Non-declarative

Birth

Non-re¯ective (anoetic)

Non-declarative

discrete data, unconnected to the episodes in which they were learnt. These episodes, in most cases, are no longer retrievable.5 Tulving called the ®rst kind of memory, which is dualistic, dependent upon re¯ective awareness, ``episodic.'' The adualistic memories of facts he labelled ``semantic.''5 He extended the latter system in an interesting and important way, to include not only our knowledge of the facts of the world but also those which concern ourselves.6 Each of us has a series of ideas about who we are, and, in particular, who we are in relation to others, but the episodes in which we learnt these attributes, or ``cognitions,'' in general, are no longer available to consciousness. It is these attributes of self and other which are central to the noxious characteristics of the unconscious traumatic memory system. The ``semantic'' system is ``declarative'' in that the facts we have learnt can be expressed in words. In this sense, the memory is conscious. However, there is an ``unconscious'' element in this remembering since the episodes in which the facts were learnt are no longer present in consciousness. There is a third system of memories which is ``non-declarative'' and for which consciousness is not required. Tulving gave to these three main groupings of memory types the names ``autoneotic,'' ``noetic,'' and ``anoetic,'' where ``noesis'' means mental activity. The ``anoetic'' memory systems which current research identi®es are the ``procedural,'' concerning a memory for motor repertoires, and ``perceptual representation,'' an extremely accurate, rigid, atomized system of recognition of sensory impressions. It is operative at birth. In the ordinary consciousness of day-to-day living all memory systems are active and coordinated with each other.

100

Part II: Disruption

An understanding of the formulation of unconscious traumatic memory depends upon Hughlings Jackson's principle of ``dissolution,'' which states that adverse impacts upon the brain±mind system cause mental functions to be lost in an order which is the reverse of evolution and also of their order of their appearance in human development.7 Memories of things which happened months or years ago, the capacity for ``remote episodic'' or ``autobiographical'' memory, emerge very late, around 4 years of age. It is, therefore, using Jacksonian theory as a guide, the most fragile, the ®rst memory system to be lost, whether the adverse impacts are ``physical,'' in the form, for example, of toxins or a blow on the head, or ``psychological,'' in which a ``vehement emotion,'' to use Janet's term, perhaps of shame or terror, disorganises cerebral function. The theory predicts that memories of traumatic events which cause re¯ective consciousness to be inoperative will be stored in a memory system some way down the hierarchy. It is also predicted that the extent of the descent is determined by the age of the subject and the severity of the trauma. However, such a prediction is not fully borne out by studies of severe trauma. George Vaillant and his colleagues studied the effect of front-line combat on about 100 World War II veterans who before the war had been judged well integrated, having, in terms of the jargon of the time, good ego strengths. The authors noted that ``in spite of heavy combat exposure, our study group experienced relatively few post-traumatic stress disorder (PTSD) symptoms.''8 These men were unusually resilient. An understanding of resilience and vulnerability in the face of adverse environmental events can be inferred from Jacksonian theory. Jackson had suggested that the higher order consciousness, which he called ``self,'' and which was the forerunner and perhaps the original model of James's description, is the consequence of a high level of coordination between the various systems of brain activity. This level of coordination underpins a form of consciousness which is relatively integrated and coherent. At a level somewhat lower down the hierarchy of mental life the coordination of brain systems is diminished, leading to a form of consciousness which is less integrated, or disaggregated. Such disaggregation to use a term of Janet and his American colleague, Morton Prince, leads, in their view, to vulnerability, a propensity to form unconscious traumatic memory systems.9 On the other hand, a highly developed system of selfhood affords resilience. A remarkable example of such resilience was provided by Brian Keenan. Keenan, an Irishman who was teaching at a Beirut university, was captured in 1985 and held hostage by fundamentalist militiamen. He was held for four and a half years, often in solitary con®nement, kept in darkness, beaten and tortured and in other ways humiliated. For three years he was chained to a wall at the ankles and wrists10 and living under the threat of execution. Yet he survived. A very important factor in building his resistance to mental disintegration was a discipline he imposed upon

Transference and trauma

101

himself. In essence, it depended upon a repeated and persistent activation of re¯ective or dualistic consciousness. In a moving account he described his rehearsal of remote episodic and autobiographical memory. He wandered, for example, in his mind's eye up and down the streets of Dublin. He exercised, however, the capacity for dualistic consciousness beyond memory to include imagination. He told himself stories. He tried to remember and piece together fragments of memories of old movies, which he watched in his head.11 He told himself old stories like that of Robinson Crusoe.12 These stories were vividly visualized, their intensity sometimes reaching near hallucinatory levels. He had consciously decided upon a strategy of self-preservation: ``I decided to become my own self±observer, caring little for what I said or did, letting madness take me where it would as long as I stood outside it and watched it. This is the strategy I employed for the rest of my time in captivity.''12 After an extended period in prison Keenan was joined by another captive, John McCarthy. Their companionship was helpful but after a time McCarthy intimated that he feared he was going mad. He said, ``My mind is breaking up.'' Keenan told him what to do: ``Listen to me John,'' I said ®rmly. ``Listen?'' he looked at me. ``Try to imagine something.'' He stared at me intently. ``I'll tell you what to do,'' I said. ``I get these moments as well, and I try to imagine a room, any kind of room, anywhere. I think of two things in that room and then try to build a story around it why those things are there. What happened in that room? Where did these things come from? Who lived in there? You've got to build a story in your head.''13 He was advocating the creation of an imaginative narrative, analogous to the story told in symbolic play in which is generated the ®rst elements of selfhood. Through such disciplines Keenan was able to maintain a coherence of personal being. An individual who has endured the typical rejecting, abusive and neglectful parental environment of a person af¯icted with the borderline condition is likely to be in a situation opposite to that which Keenan developed for himself. A person for whom the experience of selfhood has been impeded is made vulnerable to potentially traumatic events. In this case the high arousal associated with the event, for example, the terror or the shame or both, slices through what Freud called ``the stimulus barrier,'' which must depend upon higher order inhibitory mechanisms. The memory of the event in these circumstances may be recorded in the most primitive, or earliest, memory system, the perceptual representation. Here are two examples. In the ®rst case, a middle-aged woman noticed that, at times, particularly when she was anxious, it felt as if the skin on her forearms was rotating

102

Part II: Disruption

laterally. This related to an occasion when she had been raped. Two men had alternately assaulted her, one pinning her by the forearms while the other raped her. In the second case, a young woman, when she was alone, anxious, or awake in the middle of the night, sometimes felt something like a silken cord wavering obliquely across her face. Eventually it was discovered that this sensation originated from a motorcar accident. She had been driving, travelling with a companion, when she suddenly realized the accident was about to occur. In a momentary state of terror, she anticipated her imminent death. However, she was not badly injured. As she lay by the roadside afterwards, blood from a scalp wound trickled obliquely across her face. In these cases, atomized or fragmentary sensory impressions, like literal imprints or bits of traumatic experience, are recorded as ``bodily memories.'' Although Janet had described such phenomena, they were not recognized in psychiatric practice for much of the twentieth century. Traumatic events are not always unconsciously recorded. In the ®rst of these cases, the trauma was remembered and could be directly connected with the skin sensation. In the second case, the connection emerged only very slowly. Lenore Terr has pointed out that a single traumatic event is likely to be remembered.14 Repeated or cumulative traumata are those which are more generally recorded in pre-re¯ective memory. There is a growing acceptance that the consequences of accumulated memories of traumatic events, often apparently minor, and going on day after day, are a principal concern of the psychotherapist. In my view these memories are most often stored in the semantic system. However, it should always be remembered that traumatic memory is frequently layered, earlier and less accessible traumata underpinning those which are nearer to consciousness. The conception of transference as put forward here differs from a more traditional view, which sees the experience as a re¯ection of repressed drives of sexuality and aggression that give rise to various unacceptable wishes and impulses. In this conception, the origin of transference is largely intrinsic, whereas, in the trauma-based conception, it is extrinsic. Wishes and impulses, of course, are part of the traumatic complex but they must be considered as part of this totality, which depends upon the representation in memory of episodes in the person's history in which another individual, usually a caregiver, has acted or failed to act, so as to disrupt traumatically that person's sense of self. Seen in this way, the representation concerns two persons, traumatizer and traumatized, linked in the form of relatedness which characterized the trauma. Activation of the traumatic memory leads to a playing out again of this relationship so that, in the usual case, the subject feels himself or herself in some way diminished and devalued, and in the presence of the individual who has in¯icted such an injury. Even if this is not overtly described, the other in the current relationship sometimes begins to have experiences induced by an ``expectational ®eld'' (see Chapter

Transference and trauma

103

14) emanating from the traumatic representation. The therapist who becomes aware of such experiences is now able to sense something of the character of the original traumatizer. Glen Gabbard has pointed out that dealing with these experiences unites several approaches to therapy.15 Dealing with transference phenomena is a central issue in psychotherapy. The traditional view, however, is now increasingly seen to be unsatisfactory. The potentially malignant effects of the therapist persistently pointing out what he or she believes to be in the patient's ``unconscious,'' even when this con¯icts with the patient's own sense of things, are discussed in Chapters 16 and 22. Although in¯uence of the traditional view has waned, residual effects remain. One of the most important is a belief that transference interpretation is the main means of effecting cure. This belief seems to have an implicit basis in a particular view of mental life in which consciousness is single, a unitary phenomenon. The consciousness of the patient, involving various ``distortions,'' requires recti®cation. The approach put forward in this book is based on a different view of consciousness. Consciousness is seen as multiple, made up of numerous and shifting forms. Traumatic consciousness is one of these forms. It is of a negative, even noxious and constricted kind. This largely ``noetic'' consciousness is governed by laws different from those which underpin the movements of the larger ``autonoetic'' consciousness which we are calling self and which has certain characteristics of play. Therapy is directed towards fostering this latter kind of ``higher order'' consciousness but traumatic memory blocks its emergence. Transference is an impediment. Its effect must be removed or mitigated in order that play, in a metaphoric sense, can begin. Such mitigation is complex, dependent upon a transformation of the adualistic traumatic material into a form which comes to resemble the dualistic consciousness ®rst shown in embryonic form by the child engaged in symbolic play. In this way, to use Janet's term, the trauma is ``liquidated'' (see Chapter 22).

Chapter 13

Reversals

There is an important but not widely discussed aspect of the representation of traumata in memory. It is the phenomenon of reversal, which is manifest in sudden and often puzzling switches in transferential experience and behavior. The changes in who-one-is in traumatic representation might be ®guratively conceived as occurring, at any moment, in three dimensions. First, there is a range of people, occurring in the present, who are good, bad, likeable, incompetent, and so on, who, as it were, are confronting and linking to a range of experiences of the other. Who-one-is, here, occurs along a horizontal plane. A second category of experiences is vertical, ¯uctuating along a chronological axis. The individual's states range between those of a young person and those of someone who is more nearly mature. The third dimension is also in the horizontal plane, orthogonal to the ®rst. It involves a back-and-forth change in which the subject becomes the other. This chapter concerns this last axis. The traumatic representation, which includes a particular form of relatedness made up of traumatizer and traumatized, is reactivated from time to time, as we have seen, leading to an experiencing of the original relatedness in a current situation. In the usual circumstances, the individual is, as it were, occupied by that pole of the relatedness in which he or she has in some way been harmed or diminished. However, the traumatic representation, being hedged about by anxiety and unintegrated into the larger consciousness of self, is, in a metaphoric way, unstable. It can oscillate so that, in a polar switch, the subject is ``inhabited'' by the original other. This instability, with its consequent oscillations, seems to be particularly associated with more severe disturbances of personality development such as the borderline condition. Freud was the ®rst, as far as I am aware, to describe this oscillation which he called ``reversal into the opposite.''1 He termed the relationship ``sado-masochistic.'' In a paper in 1924, he pointed out that this term did not necessarily imply sexuality.2 Furthermore, he suggested that the socalled masochistic pole, that of the victim, might be primary. It could, however, alternate, so that the individual might take over the role of the

Reversals

105

abuser or attacker. Here are two examples of reversal, the ®rst more salient than the second. The ®rst case is of a woman of 19 who has a history of multiple suicide attempts. She is talking with a trainee psychiatrist who has recently become her therapist and is asking him about the suitability of multiple sexual liaisons. The question has arisen because several men have told her they wished to live with her. Within a few sentences of listening to her, however, the therapist ®nds himself accused of advocating a life of sexual license. The patient reprimands him for this moral stance. The therapist is bewildered because, as far as he knows, he has done nothing of the kind. What is particularly baf¯ing for him is that there has been a very rapid shift in roles. At one moment the girl is treating him like a parent, asking for advice about the complexities of relationships of late adolescent life. A few moments later she becomes the parent, lecturing him about morality. A second and a more subtle reversal comes from a patient who does not have a borderline personality, although she could be described as having a disorder of self. She is sophisticated and intelligent and is telling the therapist about a book she has been reading. A few sentences later, without apparent reason, the therapist ®nds that she is being lectured to by the patient on the subject of Freudian theory, of which the patient has a very comprehensive grasp. Once again the therapist is perplexed by a reversal of roles, which, in this case, ®nds the patient switching from something like a child±pupil role to that of parent±teacher. What has happened in these two cases? Might it be that the transient reversals shown in these two examples had a somewhat similar basis? Were they responses to being misunderstood that precipitated a disruption of the sense of self? This, then, is the hypothesis: reversals are a consequence of a severe disruption of the sense of self. This disruption occurs when there is a disjunction or disconnection with the other who is sensed as necessary to the subject's going-on-being. Where the other is not available, or physically not there, then the threat to self emerges. How does this idea help us to understand the two vignettes? In the ®rst case the girl was frightened by the possibilities that confronted her. Although she seemed con®dent, in fact, she was scared, not knowing how to cope with the men around her. The therapist, however, responded to her in a manner that he considered to be non-judgmental. There was nothing particularly wrong with this response except that he did not pick up her anxiety, and so, for her, there was feeling of being misunderstood. A disconnection or disjunction occurred of which the therapist was unaware. In the second case, the therapist did not realize that the book about which the patient spoke had an intense personal signi®cance for the patient. Although the therapist tried to respond in a way that was empathic, the response was not perceived in this way. Once again the patient was not understood, and a disconnection or disjunction occurred, of a very subtle

106

Part II: Disruption

kind. In both these cases, then, the reversal might be caused by a break in the sense of connectedness between self and other such that it was experienced as a threat to that individual's sense of existence. A reversal, then, is the consequence of a pathological situation in which anxiety of a fundamental kind is aroused, in which something akin to annihilation or disintegration is momentarily experienced. Anna Freud drew attention to the phenomenon of reversals in her essay ``Identi®cation with the Aggressor.'' She suggested that behavior that seemed to mimic the other was a form of defence against an anxiety that had been precipitated not long before. At the beginning of the essay, she gave an example of a boy who made faces in class. These were so gross that at times the whole class would burst out laughing. When the child was examined in conjunction with the teacher, the psychologist Aichorn saw: The boy's grimaces were simply a caricature of the angry expression of the teacher and that, perhaps, when he had to face a scolding by the latter, he tried to mask his anxiety by involuntarily imitating him. The boy identi®ed himself with the teacher's anger and copied his expression as he spoke, though the imitation was not recognised. Through his grimaces he was assimilating himself to, or identifying himself with the dreaded external object.3 As Anna Freud put it: ``A child introjects some characteristic of an anxiety object and so assimilates an anxiety experience which he has just undergone.'' How do these ideas of defense relate to the phenomenon I am describing? If we consider the ®rst example of the girl besieged by several men, we ®nd that a reversal is indeed due to anxiety. There are, however, two levels to the anxiety. The ®rst is the anxiety about not knowing how to manage her relationships. Underneath this is a second and more fundamental anxiety, which arises from the failure of the therapist to understand her feelings. This anxiety, which arises through the disjunction and which poses momentarily and in a limited way a threat to the sense of existence, is fundamental. This latter and more primitive kind of anxiety seems to be the necessary trigger to a reversal. Following this postulate, one would suppose that the boy who made faces was not merely afraid of scolding. Underlying this fear, presumably, was a more basic and powerful form of terror associated with a disintegration of self. We next consider whether, in fact, a reversal is a defense. I am saying that a reversal is a consequence of a situation in which there is a loss of connection with the other, who is felt as necessary to going-on-being. When the other fails, the state of self of the child, or the patient, is threatened and diminished. How can the consequence, in which the subject takes on a salient aspect of the original other, be conceived as a defense?

Reversals

107

I do not believe that defense is the essential nature of the phenomenon. It might be said the behavior is a defense in that the reversal is a response to anxiety. It is not, however, the kind of defense proposed by Anna Freud. She conceived the child's angry appearance as a defense against an ``external object.''4 It was meant to frighten the aggressor. However, I would speculate that the basis of this boy's behavior was different. Most children are afraid of a scolding, but they do not make bizarre faces. It seems not unreasonable to suppose that when the reversal occurred, the little boy was so afraid of the teacher that all sense of self had been obliterated. The story of this boy suggests the possibility that a reversal is the consequence of an obliteration of the experience of going-on-being, leading to the behavior of the other at the point of the disjunction becoming the behavior of the subject. The child in Anna Freud's example behaved in a way that resembled echopraxia, a state in which the individual seems forced to mimic the behavior of the other in an almost mirror-like way. For example, the subject raises his left hand when the person standing in front of him raises his right hand. This behavior is sometimes observed during a schizophrenic illness. Its origins are not properly understood but it seems possible that at certain stages of this illness the individual is af¯icted with a terrible and terrifying emptiness in which inner reality has gone. All that is left of a personal reality consists of that which is seen or otherwise sensed. The behavior and expressions of people suffering from schizophrenia suggest that they may be affected by lesser degrees of this state. For example, the psychiatrist asks: ``How are you feeling?'' licking his lips as he does. ``My mouth is dry,'' is the reply. It is as if there is no inner reality. The void is ®lled by the image before him. He has become the man who confronts him. In ordinary normal development such behavior is only shown in the ®rst few weeks of life when, for example, babies might protrude their tongues in an echoic way in response to adults whose faces are close to theirs and who stick out their tongues.5 The traumatic situation may resemble the essential features of these two anecdotes, taken from schizophrenic experience and the behavior of early life. In both cases it is assumed that there is an absence of inner life. A traumatic reality may be similar. Consciousness is of a primitive, ®ght or ¯ight kind. There are no imaginings, no wanderings through memories of one's past. The only awareness is of the feelings, perhaps of terror and personal demolition, of the bodily responses of tightening gut and beating heart, and most salient of all, the destructive ®gure who confronts one. In this condition in which inner life is obliterated and very little remains of inner life, the emptiness is occupied by the ®gure of the other. This may be all that there is of personal reality. Who-one-is has become the other. This idea is useful in comprehending experiences such as the following:

108

Part II: Disruption

A woman, frightened about her anger towards her small son, enters therapy. There is a background of physical abuse by her father. During one session she is able to describe her strange experience when she was about to strike her son. She said: ``I saw my dad and me in place of me and John [her son]. Him yelling and screaming and threatening me. Getting ready to hit me. Fear, like a knot, in that situation. I was feeling it as a little girl. It was the same feeling I'd had through my whole life, which is the trigger for a worrying situation.'' She went on to say: ``I didn't want to be like that. The awful thing, I was repeating a memory that was totally abhorrent to me and I didn't want to be like. I had no control. I always said I would never be like him and here it was happening beyond my control. It was as if it were subconscious, like I was being controlled by something out of my power. It was like being demonized. Like having someone in your body making you speak and making you act, even though you're ®ghting it the whole time. Like your body's not your own. You don't have control of your body or your speech.''

This description supports the notion that a reversal ®rst occurs in a situation of high anxiety, even terror. Accounts such as these are helpful in trying to understand the phenomenon of the victim of abuse later becoming a perpetrator. Such behavior is not explicable in terms of, say, learning theory. The theoretical position put forward here leads to the prediction that the reversal is produced by the more extreme form of abuse, in which little remains of the sense of self. This idea conforms with the observations of some authorities in this area. Steele, for example, notes: Although there is no absolute correlation between the type of maltreatment occurring in infancy and the type of maltreatment expressed in later life by the adult parent, there seems to be a tendency toward direct literal repetition. Victims of more severe physical punishment tend to repeat the severe spankings and whippings with belts which they have undergone.6 Literal repetition, rather than a digested or transmuted form of internalization, is a principal characteristic of the phenomenon of reversal.

Value and devaluation The experience of value is at the heart of self. Attacks upon this fundamental and largely unformulated feeling are, in my view, among the most potent traumata in¯icted upon the developing individual. We might expect, then, that reversals may very often involve devaluation, perhaps of a severely contemptuous kind. Devaluation which is not ®xed but which

Reversals

109

comes and goes, sometimes to an extreme degree, is often seen as characteristic of the borderline condition. An example of the appearance of devaluation: A woman of 35 is being seen for the ®rst time. She has been referred because recently she has had dif®culty in sleeping recently and has been drinking heavily. Her appearance conforms to the stereotype of the actress. She is noticeably bejeweled, expensively dressed and carefully made up. Her manner is both patronizing and charming. She suggests that nothing is really wrong. It is simply that her sleep has been poor since breaking up with her ®anceÂ. Perhaps some medication can ®x it? The therapist responds in the manner of the physician, telling her that any therapeutic suggestion must be based on a thorough knowledge of the details of her life. Since he does not respond to the central element of her story ± the dif®culty in soothing herself ± nor to the anxiety she is experiencing in the present, a disjunction occurs. She suddenly becomes angry, arrogant and contemptuous, belittling of the therapist.

When we think about it, this disjunction involves more than misunderstanding. She is being treated as a ``patient,'' a lesser person. She is being put down. The feeling that this is so presumably triggers an unconscious memory system to do with disparagement. A reversal occurs in which she takes on the role of the original other. The therapist, in this case, meets a person who seems to be patronizing. He too, apparently unaware of it and perhaps in¯uenced by his own unrecognized anxiety, also becomes patronizing. We might suppose that, even at a ®rst meeting, he has become caught up in an expectational ®eld, to be discussed in the following chapter. The reversal which is a consequence of devaluation is not always obvious but emerges through exploration. The following is an example: The patient Judy is 35. Her background includes repeated sexual abuse by her father with which, apparently, her mother colluded. The mother was an unstable woman who was neglectful of her daughter and whose responses to her were unpredictable. The patient has been admitted to a psychiatric hospital more than 30 times with manifestations of borderline personality, including quasipsychotic phenomena, suicide attempts, and self-mutilation. She has responded to a change in session time by mutilating herself. At the beginning of the following session, the therapist notices that there is something different about the patient and remarks upon it. There is no initial response, but after about 10 minutes she says: ``The only thing I can sort of think when I arrived, I had been pondering on what was different about it . . . the only thing I can think of [pause] y'know, I felt such utter contempt towards you.''

110

Part II: Disruption

She then went on to talk about anger and how she wanted to hurt her husband when he hurt her. This, however, was an ordinary anger, different from the extraordinary anger she had felt for her therapist and which, although this was not made explicit, was expressed during her self-mutilation. The therapist replied by saying: ``I was wondering if it seemed I was contemptuous of you, that I was sort of dismissing you and your feelings,'' [i.e. through changing the session time]. The patient replied: ``Yeah, well it sort of felt like I'd been given the bum's rush.'' The therapist said: ``I wondered if you'd had that feeling with your mum, that she was contemptuous of you.'' The patient replied: ``Very much, mm. Irrespective of what I thought or felt or what I would have liked to have been, if she'd already decided on something, it didn't matter, I didn't enter into the conversation.''

We might suppose that, originally, the child's integrity of self was threatened by parental contempt. It seems that when the therapist changed the session time, it rekindled the hurt Judy experienced as a child. It signi®ed that she was of no value. She sensed contempt. A reversal occurred in which she too was contemptuous.

Introjects How do these ideas relate to previous conceptualizations? In particular, is a reversal an introjection, the word Anna Freud had used? Since introjection is frequently seen to be a product of anxiety, notably in Kleinian theory, it resembles a reversal. One of the problems, however, about the word introjection is that it is used to describe not only a pathological situation based on anxiety, but also a normal one. For example, Melanie Klein in her famous 1955 paper ``On Identi®cation'' wrote that ``identi®cation as a sequel to introjection is part of normal development.''7 This collapsing of pathology and normality into one concept seems unsuitable. There is a case for retaining the use of the term introjection, or introject, but using it in a speci®c and con®ned way. I suggest that an introject is the end product of a reversal that has become relatively ®xed. Since it is hedged about with anxiety, it cannot be integrated within the self-representation. The introject is ``undigested.'' Introjection might be seen as an incomplete process. The object does not become part of the self but remains within, separate, sometimes experienced as an alien.8 The normal process of identi®cation is different. It is anxiety-free and is fostered by an atmosphere in which the individual feels understood. Its ®rst phase is simple copying. For example, a little boy of 2 swaggers around with his hands in his pockets, looking like his father. This is different from a reversal, which is almost echopraxic at times, for example, in the case of

Reversals

111

the little boy who made faces. There is little distinction between self and other. In contrast, the 2-year-old who is swaggering around like his father shows this distinction. He is not his father. He is like him. It is as if he were his father. His behavior has about it a duality described by Stern, who writes: To perform delayed imitations, infants must have two versions of the same reality available: the representation of the original act, as performed by the model, and their own actual execution of the act. Furthermore, they must be able to go back and forth between these two versions of reality and make adjustments of one or the other to accomplish a good imitation.9 Identi®cation progresses, we suppose, from a ®rst stage in which the experience of the other is taken in as an aliment, a kind of perceptual food. Gradually, through the processes of assimilation and accommodation, the object representation is taken into the self-representation completely. Sandler and Rosenblatt10 use the metaphor of ``shape'' for this process. At the completion of the taking in of the object representation, the selfrepresentation changes shape. The form of the original other can no longer be found. This is the opposite of the reversal in which the sense of the other remains as an alien and unintegrated element of psychic life sometimes called, by the patient, the ``it.'' A description of such an ``introject'' is given by a woman who suffered a severe borderline condition: The patient was about 30. She had survived a childhood characterized by terrifying physical abuse from her father. Her way of trying to maintain something of herself during these beatings was, as she afterwards wrote, to ``retreat within myself where they could not get me.'' She would never cry. ``There was only me to comfort myself and to try and stay strong.'' Afterwards she would remain alone in her bedroom. ``I would sit up in bed and then I would get very angry as well and I would hit my head on the metal bedhead. I liked this and started to relieve my feelings this way. I was in my early teens when I started cutting myself.'' Despite these traumata, she managed to function socially. She was able to work and she married in her twenties. She had two children. Not surprisingly, she had fears of harming them and had, in fact, done so. She entered therapy after a series of serious suicide attempts. Her history of self-mutilation and shoplifting then emerged. Both activities were associated with a ``high.'' Her marriage was distant and asexual. Although quite a small woman she gave the impression of being a man masquerading as a female. Her clothing was nondescript. She usually wore

112

Part II: Disruption

jeans. She dangled a handbag as if it were a totally unfamiliar object. It soon became evident that she identi®ed with male violence. She trained with heavy weights and learned martial arts. At nights she sometimes wandered in parks in the hope of being accosted by a man so that she could retaliate by beating him up. Therapy was extremely dif®cult. Her tension would sometimes rise alarmingly during sessions so that on occasion she would leap from her chair and smash her head on the wall or windowsill, once requiring suturing. She was frequently silent. However, she was able to explain in writing, something of her experience. It seemed that there was an ``otherside'' inside her, which she called an ``it'' and which felt alien to her. At times, it took control. She wrote: ``I feel the otherside always preoccupying my thoughts when I'm in therapy. I lose control of how I want the session to go. It seems it is deliberately ruining it for me, as if I don't deserve for it to go well and for me to improve. I think it feels it won't be in control anymore. I am worried as to what will happen next if it feels threatened anymore.''

Summary A reversal is the term applied to a ¯eeting change of self state in which the individual becomes the other. It is induced, in the ®rst place, by intense anxiety, which obliterates inner reality. In the therapeutic situation, it is particularly likely to come about through a break in the connectedness between self and the other who is experienced as necessary to existence. This break is experienced as massive compared with that produced by an optimal frustration11 in which the individual's sense of personal existence remains. When the break is optimal, a duality emerges, made up of an awareness of an inner life that contrasts with a response to it that does not ®t and that is experienced as external. The reversal, in contrast, is adualistic. In the therapeutic situation, a reversal is most likely to occur in those individuals whose sense of self is somewhat precarious, that is in borderline personalities. An attenuated sense of self produces a vulnerability that may lead to a series of rapidly changing and often perplexing reversals during a single session. The reversal may become relatively ®xed. In this case, it might be called an introject. Since it is surrounded by anxiety, it cannot be integrated into the self-representation and remains relatively sequestered. Its adualistic basis fosters its resistance to change. Without re¯ection upon it, the system cannot change. The concept of reversal may be useful in the understanding of perpetrators of abuse, who have themselves been victims. These pathological identi®cations are contrasted with those that are normal, anxiety-free, and that arise in a state of connectedness with another. The word internalization might be used to refer to this process in order to

Reversals

113

distinguish it from introjection. The way towards healthy identi®cation begins with the individual having within him or her the dual experience of both self and other. It is supposed that something like an oscillation goes on between these two poles, leading to an eventual integration of the experience of the other into that of self so that its original form is no longer apparent.

Chapter 14

The expectational field

A woman is to meet a man who is unknown to her. Her heart is beating fast as she sits, trying to read. Soon someone comes to take her to his room. He rises to greet her. She would remember afterwards that he was smiling, his hand outstretched. As she sits down in the chair she says: ``I hope I can answer your questions.'' The background to their meeting is an illness she has suffered for the last three years. For the ®rst nine months she was investigated by neurologists who ®nally realized that she was suffering an anxiety state which included panic attacks. She has been treated subsequently by behavioral techniques, with no success. She is now in hospital for more intensive treatment. During her stay she has been asked to meet an eminent visiting psychotherapist.1 At ®rst sight, the context explains her curious opening remark. Yet nobody else the therapist has met on his visit to the hospital has opened the conversation in this way. Her spontaneously expressed hope is likely to have a personal signi®cance. She is about 40, slight and pretty, with dark hair, dressed in matching yellow trousers and blouse. She sits in her chair stif¯y, knees close together, in the posture of a ``good girl.'' It seems she has an expectation that she will be questioned and also an anxiety that, in some way, she will be judged. Will her answers meet his approval? He pauses after her remark, saying something to the effect that they might come to that later, but that he has not come to ask questions. He wants to have a conversation with her in which she can say what she wants to say. After explaining to her the time limits, the aim of their conversation and so forth, he tells her that he has heard nothing about her.2 She ¯ares up, momentarily. ``I wouldn't think you would.'' She describes a succession of hospital personnel, none of whom seem to know anything about her. He then explains, after noting that this was upsetting, that it is his practice to see people without prior knowledge, fresh, as it were, so that he has no preconceptions. Once again, her remark seems, at ®rst sight, unremarkable. The impersonality of the hospital system is a common experience. But her brief, and quickly mitigated, ¯ash of anger suggests that this too has a personal signi®cance. What this might be is suggested some moments later

The expectational ®eld

115

when he asks what she wants most from him and from the hospital. She replies that she just wants an ``answer'', she wants them to ``understand.'' Like the two previous responses this seems run of the mill, something anybody might say. However, when one considers it, the response is strange. Why does she not ask for relief of her symptoms? The medically oriented listener hears only an implication that she wants a diagnosis. A different kind of listener suspects something deeper. This is con®rmed some minutes later. He asks her to tell him about her illness. He listens, responding with interest, as she describes rather vague symptoms, which include a fear of falling. This is accompanied by ``uneasiness'' and a feeling of being ``unsafe.'' On the other hand, she feels ``safe'' now, sitting on this chair. A hypothesis, the ®rst seeds of which had been sown by her opening remarks, has now formed in his mind. The fundamental experience of security and safety is provided for the child by the sense of connection with caregivers. When this is lost, ``uneasiness'' arises. This anxiety might reach an intensity in which existence itself is felt to be threatened. The child often conceives death as equivalent to separation from parents.3 And death might be represented as falling down. Separation anxiety, he thinks, might be the basis of her panic attacks. He asks if her symptoms are any different when she is with other people? It is as if she senses that she has been understood and that at the same time, does not wish to be. She replies in some detail, telling him that she is worse when others are around. He is not thrown off. In a gentle and wondering voice, with a rising in¯ection, he says, ``But what if you're with someone you're close to?'' The story now becomes clear. She con®rms his supposition. When she is with her mother during an attack, she clings to her. She goes on to say that her mother is someone who ``understands.'' She volunteers that to be understood is to be ``safe.'' However, her husband does not ``understand'' and as a consequence, she feels ``unsafe.'' Moreover, ``He doesn't understand because he doesn't want to understand.'' The therapist has reached the denouement. In less than 20 minutes he has discovered the basis of her illness, and has unravelled a mystery for which three years of medical investigation has failed to ®nd a solution. She now goes on to tell him about the change in her family constellation which occurred three years ago and which, it is now clear, triggered the onset of her crippling anxiety state. At this point something remarkable occurs. He loses interest. As she talks, more freely now, he realizes he cannot focus on what is being said, his mind is drifting. He will not be able to respond appropriately to what she is saying because he has not heard. What has happened? At this point it is reasonable to suppose that her illness is related to a developmentally induced vulnerability to separation anxiety that has been triggered by the emotional distancing in¯icted upon her by her husband. The

116

Part II: Disruption

vulnerability is likely to be a consequence of the environment of her childhood, in which the caregivers' responses did not show an understanding of her emotional and more deeply felt personal reality. Those around her did not behave so as to ``know'' her and to make her feel connected with them. Since this was what she desperately needed and wished for, she attempted always to make this connection, trying to seek approval, trying to act according to what she guessed were the other's expectations. Orienting towards others became habitual. She is prepared, in the manner of Winnicott's compliant false self (see Chapter 17) to give up her own reality in favor of what she believes is required. At this meeting, her own experiences are concerns lesser than gaining his approval through the way she answers his questions. Nevertheless, despite her expectations of not being known, or understood, she blocks him at the point where he begins to explore his understanding of her. She has two powerful expectations. The ®rst is that she will not be understood. The second is that to make oneself known to another is to risk a feeling of harm which comes from responses which will, in some way, fail to recognize and give value to what has been revealed. Therefore, one must avoid being understood. These expectations create a subliminal but powerful ®eld of in¯uence which affects him as she begins to talk, at greater length than in the previous 20 minutes, about the central dif®culties of her life. The expectational ®eld has had its effect on her medical attendants. They have presumably merely asked questions for three years. The circumstances of her life, crucial to understanding her illness, have not been revealed until this point, since nobody spoke to her in a way which attempted such an understanding. Indeed, the hospital staff experience her as rather cut off. They know little of her and dislike her. She is called a ``somatizer,'' someone whose only topic of conversation is her bodily state. As he tries to shake off the in¯uence of the expectational ®eld, the therapist realizes that he has become the parent, who, she has come to believe, although this is never formulated in a conscious way, will never ``understand.''

Subliminal perception An explanation of what I am calling the expectational ®eld depends upon evidence that our brain registers and responds to stimuli of which we are not consciously aware. Lea Williams, working at Westmead Hospital, performed a series of fascinating experiments which provide some of this evidence. In one study,4 she ¯ashed photos of the face of an individual on a screen while subjects' brain activity was being recorded as they watched. At the same time, a recording of skin conductance was being made. The photos portrayed either a neutral expression or an expression of fear (50 percent each). Twenty two subjects were studied. Professor Williams

The expectational ®eld

117

separated out their responses to the fearful face from those to the neutral face. She then made a second separation in terms of the skin conductance recordings. Those who showed a rise in skin conductance when the fearful face appeared were compared with those who showed no such change. Increased skin conductance indicates activity of that part of the brain to do with emotional life, the limbic system. This arousal is transmitted to the body via the sympathetic nervous system. The grouped recordings in the two situations showed quite different patterns of brain activity. When sympathetic activity was evident, the main area of brain arousal was in the amygdala, the part of the limbic system particularly associated with the experience of fear. There was also concomitant activity in the dorsal pre-frontal region, adjacent to the anterior cingulate. The activated area has been linked to amygdaloid regulation. This general picture resembles that induced by traumatic memory. There was no activation in the orbito-frontal cortex which Damasio has associated with the experience of selfhood.5 On the other hand, when there was no indication of arousal, a different network of brain activity was evident. It involved the hippocampus and the lateral pre-frontal cortex which has also been associated with the experience of selfhood. However, the amygdaloid region did not light up. In this study, functional MRI was used to display the regions of brain activated by the stimuli faces when they could be perceived consciously. She has repeated this study for fear and neutral expressions presented so brie¯y as to prevent conscious detection, i.e., for less than 20 milliseconds. In this case only the right amygdala was activated and it was engaged via a direct pathway via the brainstem (rather than via the sensory cortex). This is the pathway thought to be engaged by ``blind sight'' patients; ``blind sight'' being the capacity of an individual who has been blinded by damage to the occipital lobes, which are necessary to vision, to correctly point to an object when asked to guess its location. ``Blind sight'' is an example of unconscious perception. The system of ``conscious'' perception, in contrast, depends upon the engagement of neocortical areas. In a second sequence of studies,6 Professor Williams used measures of the electrical activity induced by a stimulus ± the so-called event-related potential. On this occasion, the faces were ¯ashed on to a screen for 170 milliseconds or more, so that they could be seen, and also ¯ashed for much briefer periods, 10 and 30 milliseconds to prevent detection and discrimination. These short exposures did not allow the face to be seen (10 milliseconds) or the emotion discriminated (30 milliseconds). Nevertheless, both visible and invisible presentations evoked electrical activity in the brain. In the case of the responses that were ``unconscious,'' there was an enhancement of the early response, which has been linked to the amygdala. In contrast, the pattern of wave-like electrical activity was relatively undeveloped late in the wave. These later elements of this event-related potential

118

Part II: Disruption

are associated with ``higher,'' or cortical dependent function. The greater amygdaloid responses to unconsciously perceived stimuli is consistent with other studies using different experimental designs.7 A somewhat similar study of ``unconscious'' perception from a London laboratory suggested that activity of the more ``primitive'' parts of the brain associated with automatic and emotional processing is different depending on whether the face is perceived consciously or unconsciously. In this experiment, the face was an angry one, its effect being made more unpleasant by a conditioned link to it of white noise. When the face was visible, the left amygdala was activated, but when the face was only subliminally perceptible the right amygdala was activated. Consciousness had, it seemed, inhibited the response of the right amygdala.8 A third study from Lea Williams concerned the way in which a person scans the face of another person in order to ``read'' what is expressed by that face.9 The experiments depended upon a machine that allows the movements and ®xations of gaze to be charted with great accuracy, as subjects look at a face on a television screen. In one experiment, people looked at a man or woman with a neutral expression. Typically, the subject's eyes made a triangular scan-path, from one eye to the other, down to the mouth and back again. The individual was then shown with a smiling face. The typical scan-path now became more complex. In addition to the triangular path, the subject's gaze ®xated on the wrinkles at the corners of the eyes, which give an indication of the genuineness of the smile. This happened so quickly and so automatically that the subject could not have been aware that he or she was making such a check. However, if the wrinkles had not been there, the individual may have had the feeling, vague and not easily formulated, that this smile was a mere formality, or a posture, not conveying the pleasure of a true smile. We must suppose that this scanning behavior involves that brain system for perceiving and remembering stimuli which cannot be consciously perceived. It depends upon the same structures that are implicated in ``blind sight'' (i.e., superior colliculus of the brain stem and pulvinar).10 This system is separate from but operates in parallel with another system which deals with stimuli of which the subject is aware. How do these ®ndings relate to the strange situation of the doctor losing interest just when he comes to understand an intractable and mysterious illness? A likely scenario is as follows. The woman who is about to meet the visiting psychiatrist is anxious. This state activates a system of unconscious traumatic memory, which is associated with anxiety. Although she is not aware of it, she is in the grip of a memory as she begins the conversation. This unconscious memory system, or ``complex,'' now directs her physiology, including tone of voice, posture, gaze, feeling in the body and so forth. The brain state will resemble that of the subjects who responded to the fearful faces as if they too had experienced a ¯icker of fear.

The expectational ®eld

119

The ``complex'' includes not only a generalized memory of a series of similar traumatic events and their associated emotions but also the form of relatedness in which the trauma took place. The rekindling of the memory ®nds the individual living out this form of relatedness, giving to herself the attributes which the trauma produced. She now feels herself as, for example, ugly, useless, worthless, isolated, helpless, or a mixture of these and other devaluing epithets. At the same time, he or she feels herself to be in the presence of someone who is, for example, critical or controlling or neglectful, locating an experience that came from the past as occurring in the present. In this state, her physiology and her demeanor are in¯uenced by the expectations which derive from the form of relatedness which had underpinned the trauma. Minute indications of these expectations in voice, gaze and other nonverbal cues are picked up by the therapist in the same way that the experimental subjects registered the wrinkles at the corner of the eyes in the smiling face, without knowing that they were doing so. Slowly he is drawn into the ®eld of in¯uence created by these expectations. Soon, in a very minor way, he is playing out the part of the original other. He is unable to listen.

Unconscious expectation or projective identification The experience of the ``expectational ®eld'' was ®rst identi®ed by Melanie Klein. Its essence is the therapist's feeling that he or she is under subtle pressure to behave or respond in a particular way. Klein considered that this feeling was the result of a ``projection'' from the patient's personal system. As Segal explained the Kleinian view: ``Parts of the self and internal objects are split off and projected into the external object, which then becomes possessed by, controlled and identi®ed with the projected parts.''11 Klein's original formulations, put forward more than half a century ago, have exerted wide in¯uence. To cover the extensive literature which has developed around this subject is beyond the scope of this book. However, it is necessary, ®rst, to acknowledge the importance of Klein's observation, which has been followed by similar observations from her followers, and second, to make clear that my explanation of the phenomenon differs, in important respects, from that of the Kleinian. The ®rst difference concerns defence. The concept of ``projective identi®cation'' depends upon the notion that an element of a form of relatedness, embedded in memory, is frightening or in other ways unacceptable. As a consequence, it is jettisoned and placed, as it were, in the psychic system of the other, which it comes to in¯uence. The original psychoanalytic system was built around defence, the most important form of which was repression. Freud wrote that ``the theory of repression is the cornerstone on which the whole structure of psychoanalysis rests.''12 The emergence of ego-

120

Part II: Disruption

psychology led to a further emphasis upon the concept of defence. This traditional background was presumably a signi®cant determinant of the original ideas about the basis of what I am calling the ``expectational ®eld.'' In my view the concept of defence does not ®t what is observed and goes beyond the data. It seems better to understand the therapist's experience as an effect of the patient's unconscious construction, at that moment, of his or her way of existing in relation to the other. A second difference between the traditional understanding of the phenomenon I have been describing and my own concerns intentionality. Since the experience of the therapist, if it is recognized, gives an indication of the unconscious form of relatedness which underpins the patient's experience at that time, it is sometimes supposed that the effect upon the therapist is a form of implicit communication, which, for some reason, the patient is unwilling to make explicit. This leads the therapist to attempt to express what is assumed to be an underlying message. Once again, and again in my view, the notion of intentionality is a mistake and often leads to puzzling and disconnecting interpretations. The effect upon the therapist comes from a system which is unconscious, automatic, and repetitive. We cannot properly call this effect a communication unless we also call, for example, the smell of a particular ¯ower a communication, which in a way it is, since it gives a signal to an insect, bird, or other creature. Rather than conceiving the experience of the expectational ®eld as an intentional communication, it is better to say that one has come across something which is helpful in developing a speculative framework for understanding a habitual form of traumatic relatedness, represented in an unconscious memory system. This leads to a way of responding to the experience. Here is an example. The patient is a young woman who has been an in-patient for eighteen months. The symptoms include depression and suicidal ideation. A young therapist is seeing her for the ®rst time and knows only that her three previous therapists felt persecuted by her, and that she has been a university student. The therapist is also aware that the nursing staff are very pleased he is taking over her treatment and is likely to have conveyed this to the patient. He is somewhat surprised that she does not reply to his opening remarks. She sits with her head hanging, not looking up, quite mute. He begins to frame speculations which, to him, seem relevant. They concern, for example, her feelings and thoughts about losing a therapist and having him replaced. Tears are now silently falling. However, she remains speechless. Whatever he says fails to gain any response so that he too now retreats for a moment into silence. The continuous falling tears now exert a hold on the therapist's

The expectational ®eld

121

attention. They assume a salience such that they seem to splash on the hard ¯oor. He begins to feel angry, sensing he is under attack. He wonders if she, also, feels his silence is a kind of attack, and asks her exactly this. She explodes: ``Don't treat me like the last one.'' He is mysti®ed. Nevertheless, he realizes that he is beginning to be caught, in a slight way, in the sense of persecution experienced by the previous therapists. What he has just said presumably replicated their behavior. There is little to be gained from pursuing this line of approach. Something else must be done. He distances himself from the immediate impact of the encounter, putting himself into a different frame of mind in which he allows himself to enter a more associative state. He begins to try to imagine who he is in this encounter. Who is this person who causes simultaneously this girl's misery, her silence, and her anger? Using his own experience at that moment as a starting point, his drift of thought leads to an image. He begins to sense himself as someone old, stern and forbidding. Someone who might be experienced as oppressive, frightening and even cruel. Could it be that her strange tense silence is due to the feeling, not quite formulated, that she is in the presence of a person who, in some way, is in¯icting silence upon her? This is what he asks, speaking in a way which seems not to be questioning but rather, framing speculations. In a wondering way, he begins to try to depict who she feels him to be. Suddenly she starts to talk, and words pour out as if something had been released.

In this case, the expectational ®eld has produced a sense of unconscious perceptions which the therapist, using a state of mind which might be called reverie, brings together as an image. This image has not been ``placed'' in his mind in order for the patient to be rid of it. Rather, he himself has created it from the multitude of observable and subliminal signs emanating from the patient's expressions in her body and face. The image is not a replica of the past but is co-produced, emerging from a ®eld which includes both the therapist and the patient. The image is not a fact, magically inserted into the therapist's consciousness, but arises by means of exploration and of helping to portray a form of relatedness which is ``subconscious'' or only dimly sensed. Using this approach, the therapist in the opening vignette tells the woman to whom he was no longer able to listen, after this realization and after re-establishing contact, that he thinks that she feared, before she met him, he would not ``understand.''

On becoming a host to the field Although we do not yet have evidence like that produced by Lea Williams, it is not unreasonable to suppose that the expectational ®eld with which we

122

Part II: Disruption

are most concerned is that arising from unconscious traumatic memory. Anxiety-free expectations that do not involve the same kind of activation of the areas of the brain to do with emotional processing are likely to be much less powerful in their production of subliminal signals. The unconscious traumatic memory system potentiates the repeated development, throughout the individual's life, of the form of relatedness in which the experience of trauma arose. The medical system takes part in these repetitions. Examples include medical systems' responses to patients suffering anorexia nervosa and those who are called ``borderline.'' It is a common clinical observation that those who suffer anorexia nervosa have, in the typical case, a familial background characterized by a high degree of control, the parent or parents acting in a way which reduces the developing individual's sense of personal agency. The young anorexic patient has learnt to expect control from the social environment. When she enters treatment this expectation is frequently ful®lled. The standard treatment unit for those with anorexia nervosa is built around a regime of fairly rigid schedules, rules and regulations. In one well-known unit of the recent past, the patients were kept in glass-doored cubicles in order to make sure these various regulations were properly carried out. This system of control is reinforced by the anxiety of the patient. If the manifestations of control are not evident, she insists that the treatment is obviously unable to offer her bene®t. In the case of the patient who is called borderline, the medical response is starkly different. These patients have generally endured a childhood in which they were abused, rejected and neglected. When they present to psychiatric facilities, they are very often abused, rejected and neglected. It is not unusual to hear stories of nurses, who are otherwise kindly and caring, ask a patient who has been admitted after attempting suicide, why he or she did not do it properly. Again, it is not uncommon to have this same patient discharged, i.e., rejected, soon after resuscitation. They are most frequently neglected in terms of psychiatric care, being considered ``untreatable,'' or else not eligible for psychiatric care since personality disorder is, for administrative purposes, ``not a mental illness.'' Responses such as these are not universal. They are only exhibited by a certain proportion of mental health professionals. What is their basis? As far as I know, there are no studies that help us to make a scienti®c reply to this question. However, it seems possible that people who treat others in the ways described consider their responses are ``normal.'' The nurse talking to the suicidal patient might think that she is being forthright and genuine. Such a view could be formed in a family in which frankness becomes a license for emotional abuse. The hypothesis arises that the nurse herself had been emotionally abused. This possibility leads to the idea that in order for the original trauma to be re-enacted, the expectational ®eld requires a ``host.'' Its perpetuation does not depend upon a single psychic

The expectational ®eld

123

system alone. It is the job of the therapist to become aware of the way in which he or she might have become such a ``host.'' The way in which one comes across the sense that one is caught in the ®eld depends upon a certain attentional discipline in which the usual ``screening'' of extraneous or generally irrelevant stimuli and inner events is relaxed, and, at the same time, the therapist monitors those experiences to which he or she has been now made open. The screening system is essential to ordinary coping. A huge amount of sensory input, which is not relevant to the task at hand, is inhibited at points on the sensory pathways before it reaches consciousness. As we speak to someone we are not aware, for example, of the noises in the street, or the touch of our clothes upon skin. In the same way, feelings, images, scraps of phrases, ideas, memories, and so forth, which this conversation may have stirred, remain latent, able to enter consciousness if required, but otherwise screened out. If the therapist is able to become aware of some of these forms of mental life, now held in a metaphoric ``antechamber of consciousness''13 and, as it were, to play around with them, he or she may gain a better understanding of the ``expectational ®eld'' he or she is in, and of the nature of his or her role as the other. One may become aware of feelings, say of sadness, regret, or boredom, which are out of kilter with the patient's overt expression. For example, her chattering in a bright voice, which is pitched too high, reminds one of a woman one knows who has lived alone for years. It is a desperate voice, spoken as if to an empty room. Had this person also lived, for an important part of her life, as if there were nobody there, as if there would be no answering voice? In addition to feelings and memories, words may come to mind, such as something one is about to say. For example, a question is formed but not said: ``Did you think of doing it any other way?'' Pondering these words, one becomes aware of a critical tone. The therapist is about to speak in the voice of the original other. These examples suggest that it is useful to allow oneself to become a ``host'' to the in¯uence of the ``expectational ®eld'' in order to learn something of its nature. An awareness of this in¯uence is enhanced by the therapist entering a complex form of consciousness in which he or she listens to the ``minute particulars'' of the conversation, and metaphorically listens to inner states, while, at the same time, monitoring and mulling around, in an undirected way, what has been heard. One adopts the attentional stance described by Freud, who, in a famous passage, suggested that the therapist ``surrender himself to his own unconscious mental activity, in a state of evenly suspended attention, to avoid so far as possible, re¯ection and the construction of conscious expectations, not to try to ®x anything that he hears particularly in his memory, and by these means to catch the drift of the patient's unconscious with his own unconscious.''14 There will be times when the therapist's awareness of the in¯uence of the expectational ®eld is diminished or lost. This might be an effect of anxiety,

124

Part II: Disruption

which impairs re¯ective function. Equally important is the situation hypothesized for the abusive nurse. The therapist does not notice the in¯uence because his/her background has taught him/her that what is going in the therapeutic relationship is ``normal.'' For example, the therapist's failure to respond to a patient who has never been adequately responded to may seem to him or her to be correct procedure, a display of ``analytic neutrality.'' Alternatively, the lack of responsiveness might arise out of a therapist's background in which distant and remote parents led to the child having no expectation of resonance from the other. ``Participation'' was the term Jung used to describe this latter situation, in which the therapeutic dyad share the same unconscious traumatic memories. He wrote: The emotions of patients are always slightly contagious, and they are very contagious when the contents which the patient projects into the analyst are identical with the analyst's own unconscious contents. Then they both fall into the same dark hole of unconsciousness, and get into the condition of participation.15 In another passage he calls the same process contamination: Contamination through mutual unconsciousness happens as a rule when the analyst has a similar lack of adaption to that of the patient. He has an open wound, somewhere he has an open door which he does not control, and there a patient will get in, and then the analyst will be contaminated.16

Reverberations This chapter has focussed on the expectational ®eld as it affects the therapist, an experience which, as Glen Gabbard has pointed out, is central to therapeutic process.17 However, it is obvious the ®eld must operate in both directions. Not only is the therapist being unconsciously in¯uenced by a series of slight and, in some cases, subliminal signals, so also is the patient. Details of the therapist's posture, gaze, tone of voice, even respiration, are recorded and processed. A sophisticated therapist may use this processing in a bene®cial way, potentiating a change in the patient's state without, or in addition to, the use of words. On the other hand, the therapist's anxiety, particularly of an unrecognized kind, is likely to compound that of the patient, in the manner of contagion, exacerbating a mutual unease and sense of disconnection. At times, a therapist's own traumatic memories might be aroused and enter into the creation of the inter-subjective experience shared by the partners of the therapeutic conversation. Jung's observations concern one

The expectational ®eld

125

consequence of such a creation. The notion of the bi-directional expectational ®eld, of the mutual involvement of each other's past and present in the creation of a shared ®eld of experience, leads to a conception of the therapeutic conversation as more than a series of responses. Rather, the interplay of two psychic systems creates a complex patterning, which is shifting from moment to moment.

Chapter 15

Restoration

A traumatic disruption of the sense of self causes the subject, now in a state of anxiety, to try to rectify it. Sometimes the restoration consists of a form of behavior which, to an observer, is entirely adaptive and not apparently a traumatic product. At the other extreme, there are restorative behaviors which this same observer would consider clearly maladaptive. An example is self-mutilation: Judy, after a considerable trust has developed in her therapist, describes how, for her, cutting herself has a restorative effect. When she was 6 or 7, she found that the only time she would get a hug from her mother was when she hurt herself accidentally. She then started to cut herself to gain this solace. It soon began to fail as her mother realized what was happening and reverted to her system of neglect. Nevertheless, the child found that cutting herself was still soothing. There remained within the act of cutting something of the soothing effect of her mother's care. The patient described it: ``I remember I used to feel much better inside. I didn't feel so empty, so lonely somehow.'' In this way, the self-mutilation was an integrating act.

In this case, the sense of restoration comes with the feeling associated with maternal care. Such an explanation is not generally available early in therapy since, in the usual case, the behavior is enacted in a state of dissociation. The patient does not recall the incident in terms of its associations, as Judy was eventually able to remember it. The shift into the state in which the restoration occurs is instantaneous and automatic, without re¯ection. In this constricted state of mind, the individual is impervious to ordinary reason and external in¯uence. The impetus towards the restorative act is typically unstoppable. Perverse sexual activity is one example of the behaviors involved. Restoration of the sense of self is very often directed towards regaining some sense of contact with the attachment ®gure, very often but not always, the mother. These restorations may be evident at a micro-level, in the therapeutic conversation. An example is provided by Moira:

Restoration

127

Moira was a woman in her thirties, who presented with an intractable lowgrade depression. Although very successful in her career, which involved the ordering of supplies and maintenance at a large hospital, she was dissatis®ed with her life which, was without intimate relationships. She was intelligent and engaging with an attractive laugh, and the therapeutic conversation seemed to move relatively easily. However, its form was frequently that of high-level stimulus entrapment. Sometimes, when beginning to talk of something which provoked intense anxiety, her voice was tense, low, shaking in a barely perceptibly way. Then it would suddenly shift, almost in mid-sentence, to another voice, which was ®rm, matter of fact, and con®dent. This was the voice of a sensible woman, who could cope with the world about her. This was a manifestation of her restorative system. She had had a dif®cult early life which involved poverty and living in isolated areas of the Australian outback. Her father was a hard, remote man and an unsuccessful geologist; her siblings were frequently sick; her mother was depressed. She became a selfobject for her mother, i.e., she had the task of shoring up her mother's failing sense of self. Moira was able to restore her mother's mood by being sensible, competent and dealing with the chores by which her mother felt overwhelmed. In behaving in this way she also restored something of her own sense of self, threatened by the emotional distance from her mother. This system of restoration became habitual. Her whole existence began to be organized about it. Whereas others admired her for her ef®ciency and competence, she sensed that the role in which she felt caught was underpinned by a void. She raged against the absence in her life of something more vital.

The restorative system does not always so directly involve some memory of the feeling of connection with an attachment ®gure. It works, indirectly, through associations to that ®gure. An example comes from Kohut's Mr W. Mr W lived in a state of stimulus entrapment. This included ampli®cation of the intensity of stimuli. He ``overreacted'' to strong sensory stimuli (in particular, he reacted with great irritability and anger to noises, smell and bright lights).1 He showed an ``inability of his mental apparatus to handle the stimuli intruding from the surroundings and to cope with external problems of average complexity.''2 During periods of disconnection from his therapist, particularly early in therapy, he ``®lled the sessions with more or less anxious descriptions of various physical sensations.''3 The therapist was very frequently bored by Mr W's ``droning on endlessly about seemingly irrelevant details.''4 In one such dull session, which had hanging over it the threat of imminent ``interruption of the analysis,''4 Mr W's reading off of the events and stimuli of his environment had come down to listing

128

Part II: Disruption

the contents of his pockets ± the exact number of coins; a piece of crumpled note paper; a ball of woolly fuzz; etc. It is relevant, at this point, to note that the major trauma in Mr W's life had occurred when he was three and a half, when his parents were forced to leave him on a farm, for one year, with unfamiliar people. He did not see his father at all during this period, and his mother only on a few occasions. It is very likely that memory of this traumatic period was active during this session because a break in Mr W's relationship with his therapist was imminent. Mr W's therapist, who was being supervised by Kohut, noted that there was a ``quiet calmness''5 accompanying the patient's inventory of the contents of his pocket. Kohut considered that this feeling might be signi®cant. As a consequence, when Mr W repeated his behavior, the therapist remarked on the affect. This brought forth the following experience: A number of childhood memories began to emerge concerning the time when he was ®rst on the farm, when no one had paid attention to him, and when he was often alone while everyone was working in the ®elds. It was at such times, when his unsupported childhood self began to feel frighteningly strange to him and began to crumble, that he had in fact surrounded himself with his possessions ± sitting on the ¯oor, looking at them, checking that they were there: his toys and his clothes. And he had had at that time a particular drawer that contained his things, a drawer he thought about sometimes at night when he could not fall asleep, in order to reassure himself. His preoccupation with the contents of this drawer might well have been the precursor of his preoccupation with the contents of his trouser pocket.6 The little boy used the things that reminded him of ``home,'' the place that held within it the feeling of parental care, as a means of holding himself together, of shoring himself up, as Kohut might have put it. This restorative behavior was carried through into later life.

Beyond repetition The woman who cut herself, the man preoccupied by stimuli, and the woman who could cope, were all, in their own ways, caught in a system of restoration of personal being, which, although it reduced anxiety, was an impediment to the feeling of being alive. Is it possible to go beyond this system, to transform it, so that the stereotyped response is not endlessly repeated? The following excerpt from a session gives a hint that such a possibility exists. The patient, Max, who had been referred for treatment of frightening ®ts of violence, had been in therapy for about a year. There has been considerable progress and fears were no longer held for the safety of his family. Nevertheless, the therapist has suggested that it may be desirable

Restoration

129

to maintain the frequency of sessions. The patient seemed reluctant. The session begins with the patient's complaints about the heavy rain he had had to travel through on the way to the session. Therapist: How did you feel about coming today? Patient: I don't really know how I felt [pause]. Sort of funny really, my trail bike has been sitting there. It's been a real mix-up with the parts that I need for it. I told you about the bike shop? The patient's response is odd, a non sequitur. What has happened? The therapist has understood Max's dreary account of his journey as a further expression of reluctance. His question is an attempt to explore this possibility. Max, however, has understood the question in a different way. An unconscious memory system has been triggered. A shift of consciousness into that resembling the traumatic state is indicated by changes in affect, for example, deadness, tension, anger; by linear thinking; by external orientation, for example, toward events rather than feelings or memories, and in extreme circumstances, to the mere stimuli of the present. In addition to changes in form and phonology, the content of the subject's conversation is now likely to re¯ect something of traumatic system, although the individual is unaware that this is what he or she is describing. A story might be told which, although it concerns events outside the room, contains the elements of what has just happened in the therapeutic conversation. It tells what the patient feels has just been in¯icted upon him or her. A second kind of content manifests the restoration system. Although the therapist does not know it at this stage, the bicycle parts have a peculiar signi®cance for Max. In his relatively deprived and neglected early life, lived in the semi-slums at the outer suburban reaches of a big city, Max had only experienced a sense of care when with his grandfather, whose main hobby and preoccupation involved motor cycle engines. When he was with the old man, as he tinkered with the cycle parts, the boy felt the warmth and security that was otherwise lacking in his life. Once again, the memory of the feeling associated with the attachment ®gure is conjured up as a means of restoring a failing sense of self. As Max talks on about the cycle parts something new emerges, a different element of the story. This new element concerns pressure. It seems that it's a hassle to get to the Yamaha shop. Max says: ``See, that's something I've been putting off. Although it's at my own convenience, I still put it off because a simple thing like that makes me feel pressured.'' The therapist listens to these words with the principle in mind that what the patient says about a relationship in the world ``out there'' may be sketching the outlines of the relationship in the room, going on in the present. It is not that the

130

Part II: Disruption

patient is communicating in a kind of code. Rather, since, at an unconscious level, he is in thrall to the memory of a trauma, he begins to tell stories which remind him of, or which are consistent with, that experience. The mood of a situation in the present potentiates the memory retrieval of other situations in the past to which this mood belongs.7 The therapist attempts a ``transference interpretation,'' connecting the sense of pressure with the patient's having to come to the session. He cannot ®nish. Max talks over him. The therapist does not persist. Freud said of the transference phenomenon that ``a whole series of psychological experiences are revived, not as belonging to the past, but as applying to the person of the physician at the present moment.''8 It is important that what is being lived in the present, without a past in it, is ``a whole series of psychological experiences,'' the total traumatic complex, which has at its heart not just the experience of the other but also the experience of the subject. Every form of consciousness, including the traumatic, is underpinned by a particular form of relatedness. A second matter of importance concerns the triggering of unconscious traumatic system. Transference is not simply a habitual way of experiencing others which is intrinsic and unrelated to current circumstances, as it was sometimes thought to be by therapists from an earlier time. As Morton Gill puts it: ``The emphasis shifts from looking upon the transference as determined solely by the patient in essential disregard of the current therapeutic situation to understanding how, at the very least, the transference has been stimulated by or is a response to the therapist.''9 This view changes transference from being a single-person phenomenon to one in which the interaction between two people is involved. Furthermore, it is not simply the past that appears in this interaction but also the present. This is apparent in the illustrative session with Max. The patient's experience comes not only from the past but also the present. The therapist, in fact, put pressure on the patient by apparently focussing, in his query that opened the session, on the patient's presumed reluctance. His behavior replicates, in a very minor way, the behavior of the original traumatizer. This soon becomes evident. The talk of hassles goes on. The therapist says: ``So you end up feeling scared off by all the hassles.'' Max replies with: ``Yeah, no such thing as simple parts service anymore.'' The therapist now offers a contribution which is more sophisticated and developed than his previous attempt at ``transference interpretation.'' He says: ``I guess that makes you feel pretty vulnerable, being in that situation.'' In this case, he tries to represent a feeling. He addresses the other pole of the traumatic form of relatedness, i.e., the subject's feeling of himself in relation to the other. Although this has not yet been con®rmed, it is likely that the traumatic experience of the other is of ``pressure,'' of being controlled or dominated. The subject in the presence of this ®gure feels diminished, perhaps weak and helpless, even frightened. The therapist's guess is

Restoration

131

an empathic one. ``Vulnerable'' may not quite encompass the experience but it apparently strikes a chord for Max. A connection is made. This is indicated by ``what happens next.''10 The conversation now has positive elements. Max talks of his wife for whom ``nothing is a hassle.'' Soon, he reveals that ``it was sort of pressuring me coming,'' i.e., to therapy. The therapist's attempt to represent the feeling that is imposed upon his patient by the other who hassles and pressures him is more successful than the previous somewhat formulaic linking with another relationship. Max, we can suppose, felt that he had been, at least partly, understood. His therapist was, in a way, ``with'' him. He is now in a form of relatedness different to the uneasy state of disconnectedness in which the session began. This changed form of relatedness allows a larger kind of consciousness to emerge, which is more positively toned, and in which he is freer to move and to make associations. As they explore the ``pressure,'' the therapist remarks, ``It was almost getting to the point where I was telling you to come, like your father might. . .'' Max replies, ``Ah, in a way I felt a bit pressured like when I knew you didn't want to cut down the sessions.'' Then, spontaneously, he goes on to describe the pushiness of his father. The therapist's aim is not ``insight'' in the sense of telling the patient something he does not know. Rather, it is to provide a ``scaffolding'' of understanding as a means of helping to represent the totality of an experience in both its present and past aspects, so that, rather than lying below the horizon of consciousness, it is displayed before the ``eyes of the mind.'' This is part, but only a part, of a process of integration. They play around with the father's pushiness. Patient: So, do you get what I mean? Therapist: Yeah, sounds a bit like you end up being ignored. Patient: Um, well, yeah. You ask for something, he'll agree to help more or less only in the way that he thinks you should be helped, not in what you're actually asking. You don't want what he tells you should want. So from that he can get very pushy. Therapist: Was that the way you thought I was being? Patient: In a way yeah . . . it's a similarity. I can't quite pinpoint it. Therapist: Mm, hmmm. Patient: If you said like ``Yeah, I agree, it should be what you want, but I really think you should come twice a week regardless,'' well that's the sort of pushiness, that would be the similarity . . . Therapist: Yeah. Patient: Getting off the track, I really enjoyed it though . . . I quite like it sometimes. At this point something remarkable happens. The patient's words seem to have no connection with the conversation. ``Getting off the track'' comes

132

Part II: Disruption

out of the blue and represents the ending of the sense of disconnection. In terms of metaphor, the patient has, for a moment, entered the play space. This change in the mode of being with the other has been triggered, or facilitated, by the therapist's continuing efforts to establish the requisite enabling atmosphere. The switch, however, of the patient's experiential mode is too fast for the therapist to track. He does not notice it. Nevertheless, this failure does not cause the patient to leave an imaginative zone entirely. He begins ``re¯ecting back,'' in his words, on his early adult life, ®nding in it positive aspects he had not seen before. He re¯ects also upon experiences, such as travel, that he's missed out on. The word regret comes up, mirroring the tone of his voice. After about 7 minutes, the therapist makes a response that tries to put into words the sense of regret. This triggers a reply, which makes clear what is meant by ``getting off the track.'' Max has now entered a state of dualistic consciousness. He is able to re¯ect upon his past and personal reality. Time has entered his awareness as shown by the word ``regret.'' Unlike the affect associated with trauma, which has no time in it, but is more nearly instantaneous, like being hit, regret involves memory, and thinking of something lost with distress or longing. We are not told how this comes about but our theory would predict that it is due to the implicit acknowledgement and recognition of Max's personal reality. The therapist seems covertly to be intimating that he had, in fact, been pushy. The therapist ``stays with'' the regret, to use Hobsonian language. He tries to put into words the sense of reply. This allows Max to make clear what is meant by ``getting off the track.'' Patient:

And the more I think about trying to ®nd what it is I want to do. . . I'd like to get on my bike and just drift for a couple of months. Just give my notice and hop on my bike, go south or west, for a couple of months, live in a caravan. Therapist: Yeah. Patient: I think it'd be great to go and just do that, just drift around for a while. It'd be pretty lonely I suppose, `cause it's not like I'm known in the west. I'd just like to go somewhere different, just drift, enjoy my bike. Once again, he kicks into a different mode of experiencing. In this new state of dualistic consciousness, in which imagination appears, he conjures up a sense of ¯ow, a drift through relatively empty, pure space. It is tempting to suppose that the wandering is a metaphor for play and that the continent is the play space. The emergence of the spontaneous material is too sudden for the therapist, who fails to resonate with it. Nevertheless, Max is not completely thrown off course. He returns to re¯ecting upon his early adult life. His excursions into these memories are extensive, taking up much of the

Restoration

133

remainder of the session. The therapist tries to follow him, and slowly the story becomes more personal. The man begins to express a feeling of some fundamental lack, of having been deprived of ordinary experiences that other people have and that leaves him with a feeling of being handicapped, perhaps irredeemably. All he knows about is engines. With this awareness of lack and deprivation comes another awareness, of a need to ®nd a way by which to generate those core experiences that are basic to an ordinary sense of existence. This sense of need seems to be related to the fantasy of wandering with his bike through the interior of the continent.11

A personal myth I do not know what happened to Max, but it would be nice to think that had an outcome like that of the hero of Robert Persig's novel Zen and the Art of Motorcycle Maintenance,12 in which a preoccupation with the minutiae of motorcycle mechanics is transformed from manuals, catalogues and protocols into something large and creative, a way of being in the world. The story of Max suggests a way in which the repetitive restoration system might be transmuted. When he is able to establish, however brie¯y, a form of relatedness in which there is sensed ``fellow feeling,'' his conversation changes to re¯ect a larger kind of consciousness, in which there are movements resembling the dynamic forms of play. For a moment, he seems to enter the zone of what might be called the generative secret which differs from the pathogenic secret. He begins to speak of something peculiarly personal which concerns some imaginative idea about ®nding himself. Such moments, as they spontaneously present themselves, offer an opportunity to become the ``third thing,'' like the toys ``between'' the caregiver and the child, which can be played with, in a state of ``fellow feeling,'' as part of the need to ®nd and express a growing narrative of self, symbolically told. The bike and the images of the inland continent are unrealized metaphors, or proto-symbols, which have the potential to evolve beyond their raw expression. In a particular kind of conversation, they might be imaginatively and empathically elaborated in the joint creation of a personal myth, one among the multitude of tales which, like Persig's story, make up the monomyth of the hero.

Chapter 16

Impasse Paradoxical restoration

At times the therapeutic conversation reaches an impasse. It has a repetitive quality, and is without imagination or spontaneity. A deadlock is reached in which it seems impossible to move forward. The causes of impasse are various and not all are yet understood. Those which can be identi®ed include the systems of accommodation and avoidance (discussed in Chapters 17, 18); the effect of the expectational ®eld in replicating aspects of the original traumatic system in either or both the therapeutic situation and the individual's social environment; the absence of re¯ective selfawareness on the part of the therapist.1 Another kind of impasse is the subject of this chapter. Although it may not be the whole answer, it seems likely that the system of attachment has an important part to play in this form of impasse. Attachment has been so widely studied and written about since Bowlby put forward a persuasive case for its signi®cance in human development and life, more than 30 years ago, that it would be super¯uous, in this volume, to embark on the details of this subject.2 However, it needs to be emphasized that this form of pair-bonding, which is characteristic of mammals, is driven by anxiety. The expressions of this anxiety in humans are very like those in other primates. Both mother and child display anxiety on separation from each other. Bowlby considered that the evolutionary purpose of the behavior was protection from predators. In humans, separation anxiety ®rst appears at 6 to 7 months; it reaches a peak of about 18 months, that is, at about the time the means towards a new form of pair-bonding, intimacy, are beginning to form; it then diminishes to tolerable levels at about age 4, when the new pair-bonding is ®rst played out.3 When Freud came to review his understanding of the genesis of morbid anxiety he found his earlier theory of repression unsatisfactory. Whereas once he had believed that repression of unacceptable and intolerable drives was the primal basis of pathological anxiety, he no longer considered this idea plausible. Repression, he now believed, was a consequence of anxiety and not the other way around. This being so, what was the origin of

Impasse

135

primal anxiety? His thinking was both empirical and developmental. He remarked: Only a few of the manifestations of anxiety in children are comprehensible to us, and we must con®ne our attention to them. They occur, for instance, when a child is alone or in the dark, or when it ®nds itself with an unknown person instead of the one to whom it is used ± such as its mother. These three instances can be reduced to a single condition ± namely, that of missing someone who is loved and longed-for. But here, we have a key, I think, to an understanding of anxiety.4 Freud was suggesting that the most fundamental form of anxiety in ordinary human life is produced by separation from caregivers, i.e., attachment ®gures. A very important implication arises from Freud's suggestion. Since separation from attachment ®gures is the fundamental basis of anxiety, then a fundamental basis for anxiety reduction must be reunion with the attachment ®gure. This ®nds those who have been traumatized by the attachment ®gure in a paradoxical situation. When the traumatically induced anxiety is provoked, the subject makes efforts to regain contact with the attachment ®gure, since such contact will reduce, at least for the moment, the intensity of the anxiety. Learning theory now suggests a vicious circle. Since a powerful form of reinforcement and conditioning is anxiety reduction, the more the trauma is evoked, the greater the dependence becomes. Seen in this way, the repetition of the traumatic relationship is a perverse form of self-restoration. This hypothetical system of pathological attachment may be helpful in understanding the behavior of those who, having been abused in early life, and who might be expected to avoid those circumstances where such a trauma may be repeated, ®nd themselves in relationships in which, once again, they are abused. A possible model of this behavior is provided by what has come to be called the Stockholm Syndrome.

The Stockholm Syndrome The Stockholm Syndrome is an extreme form of paradoxical restoration. The term originated from an incident which occurred in Stockholm in 1973. An escaped convict, ®ring a submachine gun, entered a bank and took four of the staff hostage. They were held in a small vault for nearly six days. On release, the captives' responses were strange and they themselves could not explain them. They defended the person who had held them in terror. This paradoxical outcome has also been found in many situations of a similar nature. The essential features of it are as follows:

136

1 2 3 4 5 6 7

Part II: Disruption

The subject's existence is under threat. The subject cannot escape. The captor is seen as the only person who can preserve the subject. The captor offers the subject intermittent acts of kindness and care. The subject acts so as to please, placate, and appease the captor. This involves vigilant scanning of the captors' expressions in order to gauge his expectations. These may involve an espousement and even a taking on, of his view of reality.

This outcome has sometimes been explained in terms of Anna Freud's concept of what she called the defence of ``identi®cation with the aggressor.'' However, this conception does not encompass the complexity of the phenomenon, the basis of which con®rms more nearly to some models of brainwashing developed in eastern Europe during the Stalinist years. A more plausible explanatory hypothesis for the behavior of the Stockholm captives includes the drive for attachment.

The persecutory spiral The people held captive in the Stockholm were literally in a form of prison, living under a real and constant threat to their ongoing existence. The person who has been abused and who sees the abuser not only as a ®gure who inspires fear and hatred but also as the only means of reducing a threat to existence, is also in a kind of cage. Although the prison is not actual and the threat not ``real'', but of the kind Freud envisaged when he tried to understand the child who is left alone, the sense of enthralment is powerful. In non-salient form, the system is not uncommon. The traumatic impacts may not seem to an observer to be abusive since, in my view, they most frequently involve not physical harm, or terror, but devaluation. Constantly, the frail person is subjected to a system of disparagement, which may be subtle but which has the repeated effect of demolishing a fragile sense of self. The individual begins to lose those features of selfhood such as a sense of personal agency and con®dence, which would be necessary to escape. As the inner reality fades, the person begins to doubt the veracity of his or her experiences. What is true and certain comes from the other. As despair, and even derealization begins to mount, the importance of the other, upon whom existence seems to depend, grows. This scenario must be understood as a two person-situation. The traumatizer is, characteristically, also in the grip of an anxiety system. Once again, it is not unlikely to be based on fears of separation. An example is provided by a marital pair in which the husband aged 30, appears to be ``normal'' while his wife of 20, who suffers anxiety symptoms, is ``ill.'' It soon emerges, however, that his separation fears are profound and that he

Impasse

137

constantly needs to remind his wife that she is weak, damaged, and resourceless, because in this state she will never leave him. In 1977, Robert Hobson and I described an iatrogenic form of this intractable system. In the space of a single paper we were able to discuss only one form of therapeutic anxiety, that which comes with a threat to the therapist's omnipotence. This is our description: Frequently, however, his omnipotence is unobtrusive, and he is unaware of it. Nevertheless, his implicit role is to be the bearer of an esoteric system of knowledge which he conveys to the patient, uses to change him and, in other ways, `passes down'. When the patient fails to improve, is silent, presents impenetrable defences, the therapist may feel a sense of impotence which he is loathe to consider. His anxiety, which he may also fail to recognise, is roused by the threat to his role. His response is to enhance omnipotence, and the various behaviours that go with it. The therapist's denial of the two-person situation, together with his opacity and rigidity, is increased. Furthermore, he emphasises the patient's `sickness' and his defects. The patient, in turn, experiences growing helplessness and bewilderment and unreality may become profound. The sense of helplessness and persecution, now felt by both partners, may mount to dangerous levels. It is sometimes resolved by ending the therapeutic relationship. Typically, this can only be done by the patient, since it is inconsistent with the therapist's view of himself. The patient, however, is often unable to leave, for his experience of himself at this point is child-like in relation to a parent ®gure who knows him to be weak, bad and resourceless. At the same time, he has come to believe that this ®gure is omniscient, and the only one who can redeem him. He is therefore trapped. Suicide may be the consequence.5 Such an outcome was potentiated by the intellectual climate of the time in which our paper was written. Therapeutic orthodoxy was dominated by the idea that ``insight'' through interpretation is the ``supreme agent of therapeutic principles.''6 Rigid and relentless interpretive behavior, often overriding the patient's protests, in the manner of the so-called ``steadfast interpretation,'' was performed in an atmosphere which was characteristically one of disconnection, created by the therapist's posture of a ``blank screen,'' adopted in order to maintain ``analytic neutrality.'' Current outcome research shows that such behavior leads to poor therapeutic outcome and is likely to be part of the explanation for the ``deterioration effect,'' which was discovered by Bergin in the early days of psychotherapy outcome research.7 A large body of research ®ndings now suggests that good outcome is predicted by the quality of the therapeutic relationships,8 supporting a recent shift of emphasis in the psychotherapies to a ``relational'' perspective.9

138

Part II: Disruption

Despite this changed perspective lesser forms of the persecutory spiral are still found. The patient takes in, in undigested form, a reality which is not his or her own in the manner of the ``false self,'' to which we shall come in a later chapter. In brief, in a state of rising anxiety, the patient will sacri®ce his or her own reality in favour of the therapist's in order to maintain the fragile bond between them. The danger of such a state arising in psychoanalysis was remarked upon by the British psychiatrist William Sargant in his book The Battle for the Mind, using as his authority Ernest Jones's biography of Freud.10

Attachment to the traumatic experience I now come to a widespread and insidious form of paradoxical restoration. It is subtle, covert and frequently undiscerned, yet it is an important cause of therapeutic impasse. In the system of paradoxical restoration, the individual is afraid to lose and to become free of the traumatic experience because within it is also embedded the positive feeling associated with the attachment ®gure. This may lead to a dependence upon the current attachment ®gure, the person in the present who repeats the role of the traumatic other in the past. This is the situation described so far. However, not only may the experience of the other be repeated in order to reduce anxiety, but also the experience of oneself. The individual may play out those attributions which arose during the original traumata. The taking on these features of oneself-in-relation-to-the-other, say of helplessness, despair, or uselessness, however demeaning or unpleasant they may be, have within them some solace, some means of soothing, analogous to the experience of Judy who cut herself and who found within the act of harm came some feeling of maternal care. As she said, she ``didn't feel so empty, so lonely somehow.'' To overthrow the feelings, the attributes and the responses which the unconscious traumatic memory system decrees, when the traumatizer is also the caregiver, is to jettison, at the same time, the ®gure upon whom one's sense of being depends. Since those same feelings, attributes and responses are those that have caused the patient's diminishment, and for which he or she sought treatment, no cure can come about, since the risk is too great. The person who is the subject of the traumatic experience cannot change because, to become a different kind of person, and a different subject, is as to lose the original other and to face an anxiety which, in some cases, is a feeling akin to the sense of annihilation. The operation of this system is illustrated by the story of Eva, a young woman in her early twenties who had become catastrophically depressed following her boyfriend leaving her. She was admitted to hospital but responded poorly and slowly to a range of medications, including lithium. As a consequence of her failure to recover she was referred for psychotherapy. She was an only child who grew up on a small farm in the

Impasse

139

southern part of Australia. It was a tense and isolated domestic atmosphere in which both parents, but most particularly her mother, who was the dominant partner, would in¯ict silences upon her, refusing to speak to her. This could go on for many days, af¯icting her with the threat of abandonment. Sometimes she did not know what she had done wrong. During this time she would retreat to her room. Despite her dif®cult home life, she did well at school. She was clever, quite popular, and a good athlete. She quali®ed to study law at university, which allowed her to escape from the suffocating home environment. It was during this period that her breakdown occurred. Her sessions with the therapist would begin in a characteristic way. She would walk into the room as if the therapist were not there; sigh in a way which conveyed both exhaustion and despair; seem barely able to speak, uttering single words or incomplete sentences, interspersed with rather painful ``ums'' and ``ahs.'' The voice was as if strangled. Despite the dif®culty, therapy got under way. However, at the therapist's ®rst vacation Eva took an overdose and was readmitted to hospital. This incident, together with the loss which precipitated her illness, showed that abandonment, or the fear of it, was for her a potent pathogen. During the period after this hospitalization, Eva did not relapse into severe depression and could tolerate breaks in therapy. Nevertheless, she seemed unable to progress. The sessions routinely began in the same way ± the despair, the sighs, the constricted communication. Her conversation betrayed little of an inner life. Although she spoke of ``personal'' matters such as the vicissitudes of her relationships, there was little evidence of a private world of wishes and imaginings and so forth. It was not clear whether this was because she had limited access to such experience or because it was shielded from the world. That it might be the latter was suggested by evidence of her interests, which included Renaissance history and biographies of women. There was evidence in her conversation of a past of devaluation. Although her therapeutic sessions seemed to indicate little change, she was beginning to ®nd success in her professional life. She had graduated in law and now belonged to an international law ®rm. She had a specialized responsibility in that section of the of®ce dealing with, and structuring, company takeovers. Whenever she described an aspect of her competence in her work, she did so in an offhand way. Whenever the therapist responded with remarks which gave value to her achievements, she either dismissed them or played down her part in a particular success. Moreover, whenever she related, as she occasionally did, some incident from her past in which there was positivity and pleasure, she immediately mocked and disparaged it as if an internally triggered system of self-demolition was automatically released. It now seemed possible to understand the question provided by her repetitive behavior which was most evident at the start of the session. Why

140

Part II: Disruption

was an articulate lawyer barely able to speak, able to utter only broken fragments of speech interspersed with sighs? An answer depends upon anxiety. A session characteristically begins with this state underlying. It seems possible that by unconsciously becoming the person who was constantly belittled and diminished, made to feel helpless, almost speechless and miserable, she found that, at the same time, in a perverse and paradoxical way, her anxiety was diminished. How, in the face of this damage had Eva not only survived but also succeeded, at least in one compartment of her life? There seemed to be more than one answer to this question. First, there was her relationship with her therapist, who had consistently maintained a stance in which the system of devaluation was not repeated, which it might easily have been, in subtle and unobtrusive ways, unknown to the therapist, by the effect of the expectational ®eld. He did not indulge in forms of interpretive behavior that the patient might experience as devaluation. Beyond the relationship was a second source of strengthening, or means of keeping going. She had another system of restoration which was not the experiential equivalent of a cage and which had the potential of a ``generative secret.'' In order to escape the parental attacks of derogation and accusatory silence she had, as a child, escaped to her room. Once there, she could still sense the presence of her parents. They were still ``there'' as it were, just outside her room, but within it she could create her own means of solace. One was reading, another was the creation of the room itself. When she had left her parents house, subsequent rooms had a similar, heightened personal signi®cance, like Winnicot's zone of transitional experience. She furnished them with carefully chosen colonial pieces, reminiscent of, but more beautiful than, the old homestead. The possibility that the ``room'' was restorative was given support by a story from her childhood. Her old pony, of whom she was very fond, had to be ``put down.'' Nobody comforted her. She withdrew to her room, as if comfort, of some kind, was to be found there. Now, as a woman in her twenties, she often spoke of wanting to spend, particularly at times of stress, hours alone ``in my room.'' She lived, therefore, a curious dichotomy in which she feared abandonment but sought solitude.

The risk This chapter has concerned people in a situation similar to those described by Janet. He wrote: ``The essential point in the foregoing cases is, I think, this particular event. All the patients seem to have had the evolution of their lives checked; they are `attached' upon an obstacle which they cannot get beyond.''11 How is it possible to get beyond this obstacle? An answer, or at least an important part of an answer, depends upon the individual's form of relatedness.

Impasse

141

Eva's enduring form of relatedness could be called non-intimate attachment. In addition, her attachments frequently involved a repetition of the traumatic past. During her therapy she had formed a relationship with a somewhat older man who was married and lived in another state. In this relationship she suffered replays of the traumatic experiences which had marred her early life. The threat of abandonment was ever present and, although he was charming and told her he loved her, he was frequently devaluing. He was disrespectful in changing or cancelling plans for meetings; in forgetting important occasions; and in keeping her waiting for inordinate periods. His voice, she said, was sometimes harsh and domineering. This too seemed to have an echo in Eva's past. She also, sometimes, spoke in a voice with a similar quality, although at ®rst she was not aware of it. When she came to recognize it, she realized she used it when the need arose to become assertive, usually at work. The person she experienced herself as on these occasions was without positive feelings. This person was unlike the rest of her personality, alien, in the manner of a reversal. It was, as she said, ``split off.'' Her lover, it seemed, ®tted the template of her past. In order to become free of the shackles of this repetitive pathological attachment, it is necessary to discover the capacity for another form of relatedness, which depends upon the experience of inner states that may be shared with another. For some people these inner states barely seem to exist, but in the case of Eva, the situation was different. Eva had within her a form of hidden life, of which her room where she read was a metaphor. This life was stunted and impoverished by its lack of resonance from the world of others. It possessed, however, the potential for ampli®cation, to become the germinal centre of something larger, nourished and grown in the space between two people. This system of hidden ideas, feelings, imaginings and so forth is a ``generative secret.'' The generative capacity is latent but impeded by hiddenness. In small excursions, Eva began to reveal something of this secret and highly valued world, sharing, for example, treasured childhood memories and some generalities of the themes which underlay her reading. After each somewhat hesitant revelation, she appeared, as it were, to cover her tracks. The traumatic system of devaluation was immediately triggered, and she spoke dismissively of what had just been revealed. Nevertheless, a start had been made. It had depended upon the therapist's moving against a transferential effect of disconnection and alienation. Soon after these brief emergences, Eva overthrew her unsatisfactory egocentric lover. Small cracks appeared in her habitual sighing and despairing at the start of the therapeutic conversation, in which her words seemed to be sti¯ed and strangled by a negative force within her. This characteristic opening was now sometimes broken into by laughter, as if she would now ``view'' her behavior and see, in a wry way, some humor in it.

142

Part II: Disruption

Eva, at the time of writing, had reached a point where a choice confronted her. She had to decide whether to take a major risk, whether to make a leap into an experiential state which had previously been hedged about by prohibitive anxiety. As the traumatic story begins to be told, and the individual starts to depict that state, with its past and its emotional underpinnings, the individual now comes to realize, together with the therapist, that his or her existence is con¯icted. It involves two realities which cannot be reconciled. One is the traumatic reality. In this reality, the subject is a particular person in relation to the traumatizing other. It is an imposed reality, sti¯ed and diminished, yet it offers, within its atmosphere of anxiety, a perverse and uncertain safety. The other reality is emergent. It concerns the feeling of going-on-being which is more truly the subject's own, and in which there is sensed aliveness and the capacity to act. One young man came to this realization quite suddenly. One winter night, staring into dark water as he waited for a ferry, an awareness came upon him that he faced a choice. He could see the two realities. To stay within the familiar would mean he could never change. He could remain as if stunted and emotionally impoverished for the rest of his life. But to choose the reality which was growing within him was to take a risk, and it scared him. Nevertheless, he knew the risk had to be taken. As he spoke about it afterwards, all the details of the scene were remembered with unusual clarity. The planks of the jetty where he stood, the ripple of the water, the shimmering lights, his aloneness, and the space of the night, were described with vivid intensity. It was a moment of great importance in this man's life. Such an epiphany is uncommon. Nevertheless, working towards a portrayal of the two realities is a therapeutic aim.12 When they are becoming clearer, ``displayed'' in the play space between the partners of the therapeutic conversation, a second ``insight'' needs to be achieved. The notion that a choice must be made. The therapist might make what my colleague Michael Garbutt has called ``an appeal to irrealis.'' ``What if . . .'' the therapist might ask, ``you take a step towards an unknown reality? What if . . . you were to experience yourself as, and to act like, the person who you are beginning to feel is the real me?'' This appeal can only be made when the state of the relatedness has changed, and the elements of intimacy, or ``aloneness±togetherness,'' are beginning to appear. What follows the depiction of two con¯icting models of reality may be similar, in basic principles, to the process undergone by Niels Bohr as he struggled with the contradictory proposals of wave and particle in the evolution of quantum theory (Chapter 8).

Chapter 17

False self

The recording of traumata in memory is a larger matter than the simple registration of events of personal diminishment or devastation. The complex of traumatic material includes not only subsystems of restoration but also those designed to prevent the re-experiencing of the original injury. Two of the most important of these modes of defense involve ``accommodation'' and ``avoidance.'' Their manifestations in conversation and in forms of relatedness contribute to a larger view of transference than that which arises solely from the memory of the trauma itself. Examples of accommodative and avoidant behaviors are apparent in the illustrative vignette which opens Chapter 14. The repetitive use of a strategy of accommodation leads to a personality structure which was originally described as a false self. Avoidance results in a different skewing of personality development in which personal hiddenness is a major feature. These two modes of habitual relating are discussed in this and the following chapters. Most people caught up in the false self system do not seem false to others. This is one of its mysterious aspects. It is the people themselves who complain that their existence is fake, whereas those around them may see a lively and engaging but in no way fraudulent person. This state of affairs is illustrated by my ®rst meeting with a young woman who was referred because her depression seemed intractable and had not responded to long courses of antidepressant medication. Apart from this, I knew only that she was a successful engineer. The ®rst impression was surprising. She smiled and walked into the room with a step that was ®rm and decisive. Her dress was simple and stylish. She looked well. In following meetings she emerged as extremely likeable ± quick, amusing, and charming. However, she experienced herself as unauthentic, saying such things as: ``I copy people. I'm just an act, like being a fake person. I don't know what's really me.'' Or, ``I take on other people's mannerisms on the telephone, so that others know who I'm speaking to. I'm worried about having no shape or

144

Part II: Disruption

form unless other people provide it. It's not legitimate for me to have opinions. My personality is a facetious parodying of other people. I only exist in a negative way, reacting to other people.'' Indeed, it was true that her attractive demeanor belied an underlying despair that broke through at times, as if it had little connection with the person who contained it. Quite unexpectedly at our ®rst meeting, she began to cry in a way she could not explain. She could not be certain if she was crying through sadness and if this were so, from whence it came. She simply described an overwhelming sense of hopelessness, which came in almost formless waves. It was without images and there were no suitable words to attach to it. This description was then interrupted by a brighter, ®rmer voice, which said, ``It's getting on my nerves. I get fed up with this.'' Then followed, ``I'm wondering why you should want to hear about this. Nobody likes to hear this kind of thing.'' She went on to say, ``It means I'm not likeable. I don't like people seeing me like this.'' This woman's conversation had two voices. One voice spoke of her misery; the other told her, in effect, to stop speaking in this way, that it was ``getting on her nerves.'' The second voice sounded like a parent, in the manner of a reversal. The two voices suggested the possibility that as a child any expression of misery or distress would not have been tolerated. She would have been unlikable. The sanction against this was presumably some withdrawal on the part of parents, a withdrawal frightening enough for the child to feel that it was safer not to experience those emotions, to somehow act over the top of them, and, if possible, ignore them. In this way she gave up her own experience in favor of what was acceptable and what came from outside. She described a very dif®cult background ± father with a chronic illness, a vain and self-centered mother who was also probably depressed. The patient, however, was a brave and determined child. She learned not to complain of discomfort or even to experience it. For example, she suffered a hairline fracture of a bone in her forearm, but this was not discovered for days or weeks until a teacher noticed that something was wrong. Looking back, she could remember little pain. Other elements of her account suggested that she also learned not to recognize hunger or tiredness since a tired or hungry child might be bothersome of a parent.

Her story reminded one of a particular kind of delightful child whom Winnicott1 encountered from time to time. ``The point about her is a vivacity which immediately contributes something to one's mood, so that one feels lighter. One is not surprised to learn that she is a dancer or to ®nd that she draws and paints and writes poetry.'' What is important about her demeanor is that it is designed to enliven. It has the function of helping the

False self

145

mother through lifting her mood: ``The mother's need for help in respect of the deadness and blackness of her inner world ®nds a response in the child's liveliness and colour.''2 Of course, it is not always the case that such a child, although enmeshed in her mother's moods, grows to be false. She may not obliterate her own experience in order only to show what the mother needs. Her capacity for enlivenment may come from something that is genuinely hers and that she may later contribute to larger groups, perhaps as a singer or an artist. Her life has been shaped rather than sti¯ed. However, the young engineer was not so fortunate, for sti¯ement and deadness were what she habitually felt. Her sense of the ownership and even the value of her experience and actions was diminished. For example, she felt she had messed everything up at work and considered whether to give it up. Yet she had just been awarded a prize by her institute. It meant very little to her. She went on to say that she could not tell what was important; she could not assess her own standards and was unaware of how well she was performing. This related to her inability to tell whether, at times she was happy or unhappy. In a subtle way her existence was relatively discontinuous. She could not make links between her moods and events in her life. For example, when it was pointed out that a wave of misery seemed to follow a terrible argument with her sister, her reply was matter of fact. She accepted that there was a chronological relationship between the two events, but she was not at all sure that the link was causative. Winnicott3 more than anybody else, drew attention to the system that underlies this woman's experience. Although, as he pointed out, he did not introduce the idea, he is seen as the principal theorist and proponent of the false self concept. He helps us to understand the patient's sense of the inauthenticity of personal experience, which, on the face of it, is not entirely logical. As the engineer remarked, ``How can I say that I think what I feel isn't real? It is what I feel, it's all that there is, so it must be real.'' Winnicott solves this puzzle by ®nding that what is real resides in the body. The argument necessarily begins with the experiences of early life. The earliest and most fundamental experiences are bodily. There are presumably no affects that are separate from visceral, muscular, and dermal sensations. Psyche and soma are not distinguished. The core of self is bodily. The baby's feelings are spelled out, as it were, in bodily expression. The ordinary mother who behaves naturally reads them and responds. In this way she becomes something like an extension of the baby's own system. In this sense she is an illusion, as we have seen. She allows the baby to relate to her as an illusion. The illusion includes the child's belief that his or her wish, expressed in bodily movement or in other bodily ways, has brought about the response. Winnicott referred to this as normal omnipotence. He wrote of the baby's body expression as the gesture and of the way in which it maintains the illusion: ``Periodically, the infant's gesture

146

Part II: Disruption

gives expression to a spontaneous impulse; the source of the gesture is the True Self, the gesture indicates the existence of a potential true self.''4 When the mother responds to the gesture in a way that meets the affect it conveys, then ``the true self has a spontaneity and this has been joined up with the world's events. The infant can now begin to enjoy the illusion of omnipotent creating and controlling.''5 Put another way, the mother's response gives a shape, makes recognizable, what is going on in the baby's body. In this way, bodily states are joined up with emotions. Under these circumstances, the baby's emotional expression includes all the vitality of its bodily accompaniments. In favorable circumstances of the mother continuing to be ``good-enough,'' the ``skin becomes the boundary between the me and the not me. In other words, psyche has come to live in the soma.''6 As time goes on, ``the live body, with its limits, and with an inside and an outside, is felt by the individual to form the core for the imaginative self.''7 The circumstances, however, may not be favorable. Two contrasting experiences of the mother are the forerunners or early prototypes of the two playrooms. Where the mother responds in a way that connects with the infant's subjective state, she is an illusion; where her response is not dictated by an immersion in the experiences of her baby, but is determined by her own concerns, she is real, the actual mother. When the response of the mother is of the latter kind, the baby is alerted and orients toward her. He or she is now aware of her, rather than him or herself, showing an early form of other-directedness. There is consciousness now only of her gesture, which in this way is substituted in the baby's awareness for his or her own. A periodic awareness of response that comes from outside is necessary to maturation. Usually, the discrepant response does not break up those experiences that are early analogues of the ®eld of play and in which the continuity of being is sensed. However, extreme maternal failure to adapt to the baby's experience impinges on the baby like repeated loud noise. The embryonic self is, for these moments, obliterated. The infant can do nothing but react to stimuli that are alien. ``In the extreme, there is very little experience of impulses except as reactions, and the ME is not established.''8 If such a situation persists, there arises a need for impingements, since something must ®ll the gap where once was the continuity of being. ``Environmental impingement is a feature and must continue, else chaos reigns, since the individual cannot develop a personal pattern.''9 We enter now the zone of stimulus entrapment. Rather than a false self, what is being evolved to this point is a nonself. Through a hypertrophy of a dialogue with the real, ``the individual then develops as an extension of the shell rather than the core, and as an extension of the impinging environment.''9 The next stage, the development of falsity, is a consequence of dependence. The child senses that existence depends upon a continuing bond with the parents. The child will do anything to maintain the bond, even to the

False self

147

extent of sacri®cing his or her reality. In addition to responding unempathically, the mother may in various subtle ways demand particular responses from her child. For an anxious child, very slight changes in the mother, a frown, a turning away, may signify that the bond is about to be broken. The child not only reacts to stimuli but also complies with demands. A sense of falseness arises through a dislocation from bodily experience. All normally developing children respond at times to implicit demands and behave in a way that complies with the wishes of others. This is an aspect of learning to live with others and of growing to become part of a social group. What is important, however, in the development of a false self is that the demand concerns emotional behavior. The child, for example, must appear to be happy. In giving this appearance, he or she is not giving expression to a feeling that encompasses the whole self, including the body. The life and vigor of the bodily accompaniments of an emotion are not experienced. What is expressed has, for the individual, something lacking in it. It has no sensorimotor aliveness. The woodenness and lack of vitality, which are the result of having to grow up under such domination, may be apparent to others, but frequently it is the individual who feels that he or she is not ``real,'' since a person's reality is based on body experiences. The words of emotional expression come from what the individual reads in the other's face rather than the assessments of his or her own physiology. The individual who has grown up in this situation ceaselessly scans the social environment in order to judge the expectations of others. One ®nds one's face being endlessly searched and small nuances of expression responded to. The false self personality arising from continuing pathological accommodation and compliance to what is believed to be the expectation of the other is very common. The subtlety of its guises often leads to failure of its recognition. This is a danger in the therapeutic situation. A therapy which seems to be moving smoothly and easily may, in fact, be going nowhere. A non-therapy is being practised. A greater and related danger is the creation of an iatrogenic false self. The likelihood of this occurrence is enhanced by a therapeutic style in which a precarious personal reality is repeatedly overthrown by the therapist's ``interpretations.'' This may occur in those with a fragile sense of self when these ``interpretations'' are directed unremittingly to the patient's ``unconscious.'' The patient's report of unawareness of the feelings attributed to him is dismissed as a resistance. He may then sense a growing unreality ± an alienation from his own thought. That which he thought he knew is uncertain, and what seemed substantial a ®gment. He may enter a state of increasing bewilderment, despair and helplessness with which is associated a sense of ``unreality.''10 This is the matrix of the persecutory spiral, which was brie¯y described in Chapter 16. As his or her own reality fades, the patient now takes on, in undigested form, a reality that is not his

148

Part II: Disruption

or her own. The assumption of this alien reality may extend to copying the therapist's mannerisms of speech and gesture. This dispiriting picture is the end point of a therapy, the falseness of which is unrealized by either partner. In summary, the kind of false self discussed in this chapter is based upon compliance to the reality of the other. It is fueled by the belief that existence depends upon maintaining a bond with attachment ®gures. The result is not a mask. The function of the compliant false self is not to hide inner states, but to show those emotional expressions that will excite a suitable response from the other. The individual might describe him or herself as a chameleon. The consequence of this behavior is that areas of personal experience remain neglected, never having been responded to. They stay sequestered and underdeveloped. No words attach to them. Often, they are sensed as formless, connecting with nothing. Other experiences that are expressible, involving words, images, and feelings, cannot be revealed since they threaten the link with the other. They form a system that cannot be elaborated since true interchange with the environment has ceased. Nevertheless, they may be sensed as a core self ± a limited self that cannot be enlivened or grow but remains static and repetitive. The individual's experience is now divided into two zones, the private and the public, which do not connect. There is no intermediate zone. The realization of this gulf between one's own thoughts and feelings and the world of others, and also the fear that it may be unbridgeable, is desolating. The sense of loneliness is profound. Therapy is directed towards allowing this secret zone of experience to emerge. As Winnicott put it: Even in the most extreme case of compliance and the establishment of a false personality, hidden away somewhere there exists a secret life that is satisfactory because of its being creative and original to that human being. Its unsatisfactoriness must be measured in terms of its being hidden, its lack of enrichment through experience.11 This hidden life I am calling the generative secret.

Chapter 18

The mask

There is a second kind of false self system that is more truly mask-like than that of compliance. In this case the individual feels that his or her existence depends not so much upon others, but upon the core experiences that must not be lost, damaged, or contaminated.1 Winnicott came across this notion in a personal way. At the beginning of a paper on communication he wrote: Starting from no ®xed place I soon came, while preparing this paper for a foreign society, to staking a claim, to my surprise, to the right not to communicate. This was a protest from the core of me to the frightening fantasy of being in®nitely exploited. In another language this would be the fantasy of being eaten or swallowed up. In the language of this paper, it is the fantasy of being found.2 His response is perhaps different only in degree to that of the woman described in Chapter 1, who found the day dif®cult to get through because all interpersonal encounters seemed to involve something being demanded of her. Something of her precarious innerness had to be shown to others. It was as if Winnicott had been asked by the San Francisco Psychoanalytic Society to reveal his secret life. Pondering his response, he went on to remark: Ignoring for the moment still earlier and shattering experiences of failure of the environment-mother, I would say that the traumatic experiences that lead to the organisation of primitive defenses belong to the threat to the isolated core, the threat of it being found, altered, and communicated with. The defense consists in a further hiding of the secret self, even in the extreme to its projection and to its endless dissemination. Rape, and being eaten by cannibals, these are mere bagatelles as compared with the violation of the self's core, the alteration of the self's central elements by communication seeping through the defenses. For me this would be the sin against the self.3

150

Part II: Disruption

As we have seen, the ideas, feelings and memories that form this central core of existence are experienced as if they were substantial, so that any sense of damage to them is felt in an almost bodily way. A therapist who intrudes upon them or who invalidates or contaminates them takes on a persecutory aspect.4 Winnicott spells out the dilemma that arises from his intuitions and that has been described earlier in this book. The individual needs intimacy but fears the damage that may result from exposure of what is innermost and generally kept secret. The developing individual needs to have something of his or her life remain secret. Intrusion into this area precipitates the defense of a mask-like false self. Kohut5 described the dif®culties experienced by the children of psychoanalysts. Although ``good'' parents, the psychoanalysts were too understanding. They assumed too much knowledge of their child's interior states. The response was a walling off of private life so that it became relatively inaccessible. An emotional distancing was set up. Rather than compliance, a kind of stubbornness becomes a feature of this personality. The mask is truly to ward off intrusion, which may be felt in the bodily and physical sphere, as well as in the physical. An example was provided by a 30-year-old accountant who lived with a woman with whom he refused to have sexual relations. It seemed that this was related to a fear of intrusion of others into his inner space. The places where he lived became metaphors of the inner world. For example, the patient insisted on the privacy of his study, and he would become enraged if he discovered that his books had been moved around. He tried to keep her out in many ways, so that when his companion talked to him, he would continue another train of thought in his head as if to exclude her from his own experience. If she asked him to do some chores, he would fail to carry out her wishes, since it seemed as if he was being ordered around, and in this way, being made her own. Some, at least, of the origins of his fear were to be found in the behavior of his mother who, in many ways, was gentle and well meaning but who was also very immature. She intruded upon him in many ways. For example, when he was young, she reversed their roles. Rather that allowing her child to chatter and play while she encouraged him both with her presence and responsiveness, she usurped his position. It was she whose chatter fastened on the passing events of the world around her in an incontinent way: ``Look at that . . . come and see this,'' and so on. It was she who found the beetle and the strangely colored leaf. Moreover, the child was never allowed out of her sight. Super®cially, the appearance was of a good mother, concerned and preoccupied with her child. The effect, however, was of gross intrusion upon the child's developing sense of self. His responses included attempts to establish his own autonomy so that she found him dif®cult. At times, he would have rage attacks. Her disregard of boundaries continued into his twenties so that, as if they were husband and wife, she would urinate in front of him or embrace him like a lover.

The mask

151

This kind of story illustrates the effect of intrusion into the private core of self. As a matter of survival the individual begins to adopt a posture that keeps others away from this area of experiencing. Intrusion, however, is a minor trauma compared with those responses that diminish the value of that which is most inner, most intimate, and often concerned with the tender emotions. When the developing person reveals something of this core and it is mocked or in other ways denigrated, the blow is followed by hatred. The malevolent transformation6 now comes into being. The individual is unlikely to allow such damage to occur again. He distances himself from others so that what is inner cannot be known. Although conducting day-to-day conversation and operating among others, this person has become an isolate, in whom lingers a lasting sense of hidden rage and desire for revenge. The strategies adopted to maintain the integrity of the inner core are many. Distancing, silence, and withdrawal are characteristic. Rather than compliance, as previously remarked, non-compliance is a feature of the intruded upon individual. An incident, described in more detail elsewhere1 illustrates this attitude. A boy whose secret was the biography of a murdered queen spent his free time gathering information about her and visiting the places she had lived. On one occasion he cut passages from library books that referred to her. This caused him to be charged with an offense against public property. In court, he obstinately refused to utter one word of defense or explanation. He simply stared out a window as the magistrate questioned him. The matter was his own personal and sacred mystery, not to be sullied by the legal process. The core, as this incident suggests, often consists of a series of images relating not only to who-one-is, but also the mother or mother±child dyad, who are symbolically represented. These central images are highly charged with positive emotional tone. Although the false self system that protects an inner core is distinct from that designed to maintain the bond with others, the two systems often combine. In his well-known essay Winnicott touches upon a third kind of false self. He called it the caretaker self. This element of the personality is competent and sensible and, as it were, brings the patient along for treatment. Winnicott describes the situation in the following way: In analysis of a False Personality the fact must be recognized that the analyst can only talk to the False Self of the patient about the patient's True Self. It is as if a nurse brings a child, and at ®rst the analyst discusses the child's problem, and the child is not directly contacted. Analysis does not start until the nurse has left the child with the analyst and the child has become able to remain alone with the analyst and has started to play.7

152

Part II: Disruption

Winnicott did not elaborate upon this scenario, which he uses as his main example of the false self in his classic essay on the subject. Although it has similarities to the systems of compliance and hiddenness, it differs from them. It corresponds more closely to the phenomenon of reversal, but is not identical with it. Whereas the reversal depends, in extreme cases, upon a replication of the other, the phenomenon of the caretaker self involves taking on necessary functions and attitudes of the caregiver who has failed.8 Finally, Winnicott suggested that there is a ``normal'' false self system, manifest as ordinary politeness. Is this the case? I do not think so. There can never be an exact equivalence between self, as interior life, and identity or who-one-is-for-others. One has to do largely with thoughts, feelings, images, whereas the other has to do with behavior. The translation from one to the other cannot produce a replica. Nevertheless, where the inner zone of thought and feeling is linked and coordinated with the outer one of behavior, then falseness is not experienced. Where, however, the social manner is based on the desire for acceptance by a particular group, so that behavior loses touch with inner experience, a false self emerges, which consists of a fashionable facade. It is a variant of the system of compliance. In conclusion, three kinds of false self have been described.9 Each exists in relatively pure form, but the elements of compliance, hiddenness, and compensation are often mingled. A lack of true interchange between inner experience and the outer world is common to them, so that the area of real and bodily living has become shrunken. The sense of the reality of experience and its connection with the body's aliveness, is lost. The result is a persisting feeling of deadness, boredom, and dissatisfaction. The pathway towards recovery of ``aliveness,'' which is increasingly seen as a major therapeutic goal,10 may sometimes be found not in the words of the therapeutic conversation but by means of the bodily feelings which underlie it and which are the foundations upon which a personal reality is based. An example of the value of the therapist's tracking and responding to bodily experience is given in the following extract: Robin was a 30-year-old woman who had grown up under extremely adverse circumstances, the consequence of which was the development of a false self system. All three forms of this system are operative, as we discover. This session occurred relatively early in the therapy. It took place in a busy general hospital. Because of an emergency call, the therapist, a young female psychiatrist, was 30 minutes late. The patient began in a pleasant and conversational tone. A lot of catching up to do, have you? Yes ± keeping me late. Mm. [Laughs in a sisterly and sympathetic way] You sound a bit winded.

The mask

153

[Given her patient's history of deprivation, the therapist knows that the patient will fear separation, even of the smallest degree, and as a consequence the non-arrival of her therapist will have made the patient anxious. Anxiety, however, is nowhere betrayed in these opening remarks. This suggests that Robin has learned that the expression of negative emotion is not tolerated by those around her. Not only is genuine expression unacceptable, it seems that she has to look after those whose role it is to look after her. She may feel the therapist is uncomfortable or even guilty over her late arrival. She responds to her therapist in a way designed to make her feel better.] [pause] I'd like to discuss what we discussed on Monday. Mm. I can't remember what we did discuss. [She then laughs in an infectiously engaging way.] What were we discussing on Monday? [The patient cannot remember what is unpleasant since it is unacceptable. She has learned to repress what the mother will not tolerate. She allows herself to experience only what is permissible. As a consequence she asks what went on during the Monday session. The therapist is encouraged to determine, even create, the patient's experience. In this way the relationship with the mother is recapitulated. The patient enmeshed in a false self system is always trying to discover what the therapist wants.] Lots of things. Something's on your mind that related to Monday? [The therapist avoids the pitfall of selecting the patient's experience. Instead she relates the patient's need to raise Monday's events to the patient's present state.] Being accused of wasting money [by her husband]. That really cut in. Mainly that that's bothering me. Feel really hostile. That is what you'd like to discuss? [The feeling that is remembered from Monday is hostility. This relates to being misunderstood, albeit in a gross and derogatory way. It seems possible that this again relates to the present.] Well, I don't often feel that angry. He started on me on Friday and didn't let up, constant pick pick picking over the weekend. Sometimes I just

154

Part II: Disruption

wish I had a place where I could go and not have anybody hassle me or even talk to me. Sometimes I can go 3 or 4 days without talking. To have your privacy. [The therapist follows what is offered.] Yes. Privacy is very hard to ®nd in our house. You can't get privacy. No. Even in the bath when you want to relax, the kids want something. People seem intrusive ± sort of barge in. [A new theme has arisen. It concerns the need for a sense of personal space in which one's own experience can, as it were, live and grow. Her desire for private experience, however, is constantly frustrated by her mother who is intrusive and dominating. Even now, although the patient is in her thirties, her mother is in constant contact with her. She is often in the patient's home, sometimes using the latter's bedroom to change her clothes. The bedroom is a place where the patient tries to express something of herself so that the mother's intrusion into this area is like a violation of intrapsychic space. In the bedroom is a poster of a rock star who dresses bizarrely, often in a way that suggests an ambiguity of sexual identity. This poster expresses aspects of Robin's identity, in particular, her gender identity. Even this fantasy is not allowed to remain as her own. Her mother cuts out newspaper articles about the rock singer and sends them to her daughter.] It's taken for granted you're always there. They're always wanting me to do things, but whenever I want something done, nobody's ever got the time. So it seems unfair. [The therapist's remarks seem simple, and in one sense they are. She is behaving naturally, rather like a mother, who without thinking about it, ®ts in with her child's experience. She responds to the momentary changes in the patient's mood, in this case the sense of unfairness of others that is found in the tone of expression rather than Robin's actual words.] I think it's unfair. Why should I always be there for somebody, but when I want somebody, nobody's there?

The mask

155

[This statement relates not only to the fact that throughout her life others have used her for their own needs, and that she never complained or spoke out, but also, presumably, to the therapist's failure to be ``there'' at the expected time. The therapist has the opportunity of pointing this out. Put another way, she might offer a transference interpretation. Instead, she chooses something different.] And that's why you can't sit still? [Body movements are likely to re¯ect genuine emotion and, in the case of someone who has spent a lifetime concealing her true feelings, to be closer to the heart of the personal than what is conveyed by words alone. Although the form of the therapist's expression may be questioned, the effect of her intervention cannot. It very quickly leads to the patient's underlying emotional state.] [laughs] Yeah. I have to be on the move all the time. [pause] Whenever I get really depressed, I get this really tight wound up feeling, that's why I keep moving [laughs loudly]. Tight in your whole body, your stomach? [The therapist tries to elaborate the experience, starting with its most primitive components ± the bodily.] Yeah [laughs rather nervously]. I get a real pressure feeling at the back of the head. If I don't do something ± jump up and down, scream or something ± it feels as if the back of my head's going to blow off. This is when you feel depressed? [The therapist's remark closely follows the text. The patient has already said that depression accompanies her body's tightness and feeling wound up. The therapist's assumption is that the expression of the emotion itself would have not been permissible during Robin's development and that only the somatic and concrete elements of the experience were acceptable. Reintroducing the word depression is an attempt to elaborate the feeling state.] This is when I feel self-destructive [laughs loudly].

156

Part II: Disruption

[The laugh, because it is quite engaging, is not obviously defensive. Yet that is what it is. Robin's fear of expressing depression is such that she does not admit to the state itself ± only to those acts that might accompany it.] Self-destructive? What ± overdoses or cutting your wrists? Oh, I've only overdosed a couple of times. Sometimes when you think of o/d-ing, they can stomach pump you, but slashing your wrists is so ®nal, isn't it? How long does it take blood to pump out of your body? About 6 minutes? Then you think of the kids ± so there's this constant thing of the walls closing in all the time. [This is a dif®cult connection. There seems to be a link between feelings of selfdestruction (or depression) and a constriction of personal space as if one might be the result of the other.] Is that happening at the moment? [The therapist again concentrates on immediate lived experience ± what is happening now rather than at other times in other places. Once again her intervention connects.] I feel very [laughs] closed in here. While I'm in here I can't look you in the eye. I'm always watching the walls [laughs very loudly]. As I said, the door handle's right there, so . . . as long as the door's not locked [laughs]. [It is as if to look someone in the eye is to invite another to see into her inner world. This kind of intrusion is what she tries to avoid.] I wonder if the tightness and tension have something to do with us starting 30 minutes late. Oh no, no. I have had this ± it started building up since last Friday. Right. [The therapist has obviously been waiting to introduce the subject of her lateness, since Robin's response to it will have been providing an important undercurrent of feeling during this dialogue. Perhaps the patient's rejection of her therapist's supposition is accurate. It is possible that the therapist has not directly taken from what was happening at the moment and has reverted to theory. It is, however, equally possible that Robin ®nds it dif®cult to accept

The mask

157

negative feelings directed towards the therapist, and so rejects her speculation.] As if something's bound to happen. [A sense of threat, a feeling that some disaster is about to occur, is characteristic of the anxiety that arises during separation. Although Robin has overtly rejected her therapist's attempt to approach the matter of her lateness, she now seems to be talking about it covertly.] That's what you feel? Something's going to go wrong, or you're going to do something, or . . . Oh, something might go wrong. I don't really know how it's going to come out. I just ride with it and that. I don't know. I've tried to explain it to people. They sort of go ``huh'' [contemptuously] ± everybody gets tense ± fair enough, everybody probably does get tense. Rushing from up there down here thinking I mustn't be late ± things like that. There's levels of depression. [Here everything comes out in a rush and somewhat incoherently. She seems to be saying that those around her fail to understand her feelings and, indeed, do not wish to understand them. She implies that the therapist is part of this social universe. But at the very moment when she begins to express such a thought, she obliterates it. ``Rushing from up there down here thinking I mustn't be late'' represents a condensation of two opposite tendencies. The ®rst is to connect the therapist with those who contemptuously dismiss her feelings of tension. The second, and much more powerful tendency is to empathize with the therapist and to understand her hectic life and her anxiety. The impulse to take up the caretaker role, to look after the therapist, overwhelms her own experience.] What level now? [There are many things in the previous passage that the therapist could follow. She has to make a choice. Since she is aware that Robin has adopted a mask of jolliness that hides her depression from others, and in this way perpetuates her sense of futility and worthlessness, the therapist picks out the depressive theme and at the same time tries to keep it in the present.] I've been putting on a front for so long. It sometimes takes a while for me to realize that I'm alone there and something might happen.

158

Part II: Disruption

[Robin acknowledges the mask. She also acknowledges that there were feelings relating to the therapist's lateness, but this is expressed obliquely ± ``I'm alone there'' presumably refers to the waiting room. Third, and importantly, she seems to be saying that because of the mask she is no longer able to discern what her feelings really are or at least it ``takes a while'' for her to realize. This may explain Robin's initial rejection of the connection between tension and waiting.]

By discussing an immediate experience and what seems most ``personal'' in what has been offered her, the therapist has enabled the patient to enter and share a reality which is more truly her own.

Part III

Ampli®cation and integration

Chapter 19

A drive to play

For those whose development of personal being, or self, has been impeded, the experience of life is diminished. The ¯ow of interior states, the Jamesian stream of consciousness, is barely sensed. There is a feeling of nothing happening inside, of stasis, and of deadness. At times it seems there is nothing there at all save a painful or even terrifying emptiness. This is related to an inability to be alone, amounting at times to an addiction to certain people, experiences and even to stimuli. Reality comes from outside, consisting merely of the rattle of world. The constricted space of personal existence is relatively broken up, consisting of shifting states in some of which arise destructive and self-destructive impulses. All this goes in against a background of dysphoria, dissatisfaction and a feeling of low personal value. At the heart of these disturbances lies the sense that there is no ``real me.'' These experiences are common and sometimes they are mild and involve minimal incapacitation. In severe degree, as we have seen, a constellation of these features makes up what has come to be called borderline personality disorder. Its main identifying criteria can be inferred from the model of the origins and disruptions of self-described so far. The way the various characteristics of the disorder can be understood is outlined in the notes.1 We now come to the question of treatment. Essentially, this depends upon overcoming what Janet saw as a developmental arrest. Seen in this way, the therapeutic purpose is to begin again the developmental processes that were disrupted in childhood. In 1935, Jung, who had worked with Janet, told a group of British psychotherapists that ``analysis is a process of quickened maturation.''2 Beginning again, however, is no easy task. It is not re-mothering as is sometimes imagined, since the signals upon which the ordinary, devoted, and ``good-enough'' mother depends are no longer present, or are used in a distorted way. The means of connection have been lost. Nevertheless, principles of development derived from observations of children are used in approaching those with disorders of self. In essence, the aim of the therapist is to create conditions in which a mental activity emerges that is analogous to that underlying the play of the 3-year-old

162

Part III: Ampli®cation and integration

child. The ``metaphor of play'' provides not only a means of understanding something of the vicissitudes of personal being but also a framework which guides the healing process in those with disorders of self.

A drive to play Paul Ornstein3 has written of ``a thwarted need to grow'' in those people suffering disorders of self. He was implying that we have within us something like a drive towards the discovery of those circumstances which allow this experience to emerge and ¯ourish. This implication leads to a larger view of human motivation that that originally proposed in psychoanalytic theory. Freud's early ideas about the psychic function were built on biological foundations, which included evolutionary theory. His own theory was organized around phylogenetically given drives of sexuality and aggression. This system remained largely unaltered for many years. However, with the emergence of ethology and the in¯uence of Bowlby, a drive, ``need,'' or propensity for attachment came to be recognized. Indeed, the ethological model suggested that a considerable number of other genetically given tendencies to action could be shown in the higher primates. They included play. At present, no suitable taxonomy of play exists. The activity is various, composed of multiple categories. Brueghel's 1560 painting of Children's Games, for example, shows 250 children playing at least 75 games.4 Play occurs in animals. The notion that it is instinctive is supported by McLean,5 who suggests that play in animals has a biological basis, depending upon the cingulate gyrus and its subcortical connections. At least two kinds of play can be observed in primates. One is social play and the other might be called rehearsal play. At times, they intermingle. Goodall described the social play of chimpanzees: They like to play with each other, chasing round and round a treetrunk: leaping, one after the other, through the tree-tops; dangling, each from one hand, whilst they spar and hit at each other; playfully biting or hitting or tickling each other as they wrestle on the ground.6 Less commonly, she observed a second kind of play: ``the infant chimpanzee who tries, again and again, to bend a branch under him for a nest or who attempts to catch a termite with a minute and totally inadequate piece of grass.''6 Such observations led Groos7 to suggest, in The Play of Animals, that the function of play in animals is to prepare the developing organism for adult activities. He extrapolated from animal studies to the human and concluded, in The Play of Man,8 that play in children involved the rehearsal

A drive to play

163

and practice of tasks which would be necessary in maturity. Groos's observations, however, did not include a type of play which appears to be unique to man and which Piaget9 made the centrepiece of his study of play, i.e., ``symbolic'' play. This particular ludic activity is not mimetic as is the play to which Groos referred. Rather it represents something which does not exist in the word of actuality. The child who says that a leaf is a boat and then shows its destruction by a monster, which is a rock, is exhibiting a symbolizing capacity which is an essential feature of human expression. In symbolic play the child is often telling a story. This is not true merely for middle-class children of the west. Lois Barclay Murphy was astonished to discover, in a study in India, that children in this very different culture played in the same way as did American children. In play, children project the ``basic time±space patterns of their lives.''10 This seems to have been the case for many thousands of years. Artifacts from the earliest civilizations include miniature representations of people and animals, presumably used as toys. It is dif®cult not to conclude that the capacity to play is part of our genetic endowment, just as a potential for language creation is biologically given. Unlike, say, the ability to walk, this capacity depends upon the responsiveness of the environment. Murphy found that children from deprived, poverty-ridden backgrounds were often unable to play with materials in a way that revealed a theme. Although these children could indulge in a sensory play with sand, water, clay and ®ngerpaints ± and to wash a baby doll or make a sand pie, they did not project sequences of experience and behavior. This kind of play depends upon caregivers responding so as to facilitate it. The ``thwarted need to grow'' can be seen as an impediment in the drive to play. Therapy is a means of enabling a play-like mental activity to begin again. Therapy, ideally, establishes a play space in which can be generated an experience of selfhood which Jane Goodall believes may be unique to the human primate. It depends upon the exchange of that which is most ``inward,'' the meaning of ``intimate.'' Intimacy is an interplay between people who know the experience of self. The play, in this case, is with symbols which we use in our ordinary conversations without noticing what we are doing. Such interplay is necessary to the maintenance and growth of self (see Chapter 23). Symbols are distinguished from signs ± Jung de®ned a sign as ``an analogue or abbreviated expression of a known thing'' while a symbol is ``the best possible description or formulation of a relatively unknown fact, which is nonetheless known to exist or postulated as existing.''11 A sign belongs to a collective reality whereas a symbol may not. Jung considered that the ``play instinct'' is the source of symbols.12 Although the matter remains controversial, it seems that a capacity for the use of symbols by primates other than the human is only minimally apparent. Despite strenuous attempts to teach primates to communicate in

164

Part III: Ampli®cation and integration

a human manner, this language cannot progress beyond a language of signs. A level of two-word sentences has been achieved.13 In the wild, primates emit a range of vocalizations which scientists interpret as signals.14 There is no convincing evidence of the ``generative'' linguistic capacity of a human, who is able to construct a sentence he or she has never heard and have it understood by another individual who has also never heard it. Although a symbolizing capacity is not evident in primate language, there is anecdotal evidence of some minimal capacity for the use of objects symbolically. Kohler,15 for example, described the behavior of an adult chimpanzee, Tschego, who had a stone she treated as a treasure, much as a child has a transitional object. Morris16 was able to teach chimpanzees to paint. Some animals were able to produce work up to the level of the preschool child. Moreover, the animals found the activity pleasurable just as children enjoy play. The most pro®cient painter, Congo, became more upset by being disturbed at his paintings than having sex, eating, grooming or sleeping interrupted. An attempt to replicate the Morris experiment had less than impressive results.17 Hughlings Jackson's theory, which predicts that those ®ndings in human life which emerged late in evolutionary history are lost ®rst in adverse circumstances, suggests that the symbolic function is fragile, its development relatively at risk. This supposition is supported by observations of those with severe disorders of self. Their conversation is hypo-symbolic. They live in a world of signs, a zone of collective reality. The aim of therapy is to foster entry into an additional mode of reality, the symbolic, which is one's own in the way that dreams are unique to the individual.

The drive to play in adulthood The idea that those who suffer a disorder of self must be helped to move from a state of being unable to play to another state in which they can is not to be understood in a literal sense. Play, in this context, does not refer to play therapy nor to playful behavior in the therapeutic session. Play is a metaphor for a particular kind of mental activity which manifests verbally. The drive to discover it, in adulthood, is often evident in a search for the circumstances in which such a form of mental life might grow. Here is an example: With a strange intensity and absorption, a man in his thirties tells his therapist about an Indian guru he has heard about. The guru has, it appears, supernatural powers and as a consequence has amassed great wealth. Nevertheless, he has, in the view of the patient, been neither exploitative nor manipulative. He has done ``good things'' with his money. It is clear that the image of the guru is idealized. Moreover, it is connected with the therapist who is seen as an expert

A drive to play

165

on theology, about which the patient asks questions. However, he seems to expect no answer. When the therapist responds, a different kind of monologue is triggered. The atmosphere of idealization vanishes. It concerns the mass of people who are aggressive and jealous, who bump him on the bus, who allow him no space of his own and for whose arrogance he feels contempt. These digressions are brief, and the patient soon returns to the main theme. This changes to a description of an essential lack. It concerns his education. Since he left school early, he feels that he is irretrievably de®cient and that nothing can redeem what he has not been given. Interestingly, he thinks about overcoming it, not by entering night school or applying for mature age education, but by writing. He has made numerous enquiries about courses of instruction which might somehow allow him to know how and what to write. As the session ends, the man makes the point of his preoccupations clear. He asks the therapist how he can ®nd for himself a life with meaning.

This man's meandering talk concerning the guru and the possibility of writing is not mere chatter. His absorption in what he says shows its importance. He senses within himself a fundamental lack and he has an illde®ned intuition of what he needs to do in order to overcome it. This brief account illustrates not only a manifestation of what might be called a drive to play but also of the individual's sense that realization of this drive is repeatedly blocked. In this session, a monologue is delivered in an atmosphere which seems to be that of ``fellow feeling''. However, every time the therapist speaks she breaks the developing ``atmosphere.'' Her remarks are factual, too concerned with the guru and not enough concerned with the skein of feelings, wishes and imaginings which underlie the patient's words. The therapist now becomes an impediment to the individual's drive towards health. The sense of impediment evokes momentary anger, perceptible in the content but not the tone of the conversation. The therapist becomes, brie¯y, one of those who, metaphorically, bump into the patient, allowing him no space to grow. In another language, transference has arisen. Transference, seen in this way, is a manifestation of a breaking up of, or an obstruction to, the mental activity which underlies both symbolic play and self. The therapist is experienced as rather like the original other who in¯icted upon the individual those traumata which interfered with the emergence of self. The identi®cation and management of these important moments in the session is touched upon in Chapter 22.

Therapeutic play: An illustration Play is complex, having characteristics beyond those touched upon in an earlier chapter. Many of these characteristics were described by James

166

Part III: Ampli®cation and integration

Mark Baldwin in his pioneering three-volume work Thoughts and Things in which he set out, in some detail, the way in which symbolic play contributes to the development of self. His study is an intriguing one, anticipating many of the ideas of Winnicott. Piaget makes frequent reference to Baldwin's work. Baldwin pointed out that play depends upon a doubleness of mind and the creation of experience in which the ``real'' and ``unreal'', the ``serious'' and the ``non-serious'' coexist. This dualism is concentrated on the object with which the child chooses to play. Baldwin called it the ``semblant object.'' It is ``given the semblance of a sort of reality although the coef®cients of that sort of reality are lacking.''18 One of these realities can be called inner and the other outer. In the use of the toy, or other play object, inner and outer are brought together. ``The play object becomes not the inner or fancy object as such, nor yet the outer present object, as such, but both at once, what we are calling the semblant object, itself the terminus of a sort of interest which later on develops into that called `syntelic' or `contemplative'.''19 The ``semblant object'' shows, in small form, the larger atmosphere of the scene of play which also goes on in a place in which is neither inner nor outer but both. Baldwin wrote: The real world, actually there, remains through the entire development, a sort of background of reference. The inner make-believe situation is developed against the background. Consciousness, even while busy with the play objects, casts sly glances behind the scenes, making sure that its ®rm footing of reality is not entirely lost. There is a sort of oscillation between the real and the semblant object taking place in the psychic sphere, giving an emphasized sense of ``inner±outer'' contrast which persists in the further genetic progressions.20 In this game, the child is using imagination while at the same time knowing the construction is imaginative.20 This doubleness represents a signi®cant developmental shift, a ``subtle movement of consciousness,''20 similar to the movement towards which therapy is aimed. Fostering what Hobson called ``the healing power of imagination''21 is an important aspect of the therapeutic conversation, particularly in its developed form. Although this play-like state of mind is now ``mental'' rather an observable activity, it still goes on in a place. The signi®cance of the place in which it occurs must not be neglected considering the therapeutic process. It is important to the task of psychotherapy in a way that hospital authorities, among others, frequently fail to recognize. A most important characteristic of the setting is reliability. The child must have con®dence in a fairly predictable environment. It is only through such con®dence that play can begin. Those with disorders of self are often extremely sensitive to small changes in the environment and are disturbed

A drive to play

167

by them. The signi®cance of this predictable environment has been noted earlier. It is as if this space becomes a precursor of inner space. However, those who work in busy hospitals often have to use different rooms from week to week, unsettling their patients. Reliability in terms of space is often neglected in discussions of the therapeutic setting, whereas the therapist's temporal reliability is, rightly, emphasized. Because a history of impingement is the basis of the patient's disorder and because he or she is now unduly sensitive to intruding stimuli, it is important to reduce the salience of the environment. The place must be quiet, free of noises from the corridor, from telephones, and the sounds of conversation in neighboring rooms. This seems so obvious as to be banal. Yet hospital psychiatric services are rarely set up with these provisions in mind. The decoration of the room should re¯ect something of the therapist, who is expected to be ordinarily human, and not the opaque, neutral individual of classical times. He or she lives like other people and has around him or her things that are personal. Nevertheless, his or her life should not obtrude. The therapist, after all, is attempting to become a facilitating background, to become impersonal in the same way that an artist is impersonal. That is, his or her own personality is not imposed upon what is being created. The actual setting up of the therapeutic space was important in the outcome of the following illustrative case.22 The patient was a woman in her forties, who for three years had been depressed following the death of her mother. Various forms of pharmacotherapy had been unhelpful. She was the ®rst-born child of parents living in dif®cult circumstances. The next sibling, a boy, was born when the child was 18 months old. This infant contracted encephalitis and was severely disabled. The mother became totally absorbed in the rehabilitation of her son. Her daughter was employed as her helper and ally, always deferring to the needs of her brother. Her own needs were neglected. The patient remembered her mother as sitting for two or three days on end, without speaking. In retrospect, it seemed that the mother was depressed. The patient's dependence upon her was never relinquished. For the rest of her life, the patient made contact with her mother every day. This persisted even during the patient's marriage, which eventually failed. In thinking about her childhood, the patient felt that the parental focus upon her brother, and the sense of stress and anxiety which pervaded the household as a result of her brother's illness, had inhibited her opportunities for play. Soon after entering therapy the patient began to paint, as if somehow aware that this may be part of the process of change. This intuition may have been compounded by reading Jung. The paintings were, initially, a series of very

168

Part III: Ampli®cation and integration

beautiful mandalas. During this activity, her progress, although steady, was not remarkable. She was chronically dysphoric. Her characteristic mood state was of emptiness and wanting to die. Life was without pleasure or any kind of happiness. The patient, however, retained her impetus towards growth. She asked, spontaneously, that she try painting, or something similar, during the session. On the ®rst occasion, she found it very dif®cult. The presence of the therapist seemed to act as a prohibition. She told the therapist afterwards: ``It was hard because you were in the room and yet I didn't want you out of the room.'' She went on: ``I became aware of how much on guard I am. As a child I remembered, `Let me do it but don't look at me, don't see me,' and not really knowing whether I'm allowed to do it wasn't enough. It's got to come from in here.'' Two sessions later, however, she had a very different experience. During the session she started to ®ngerpaint. The following session she described the remarkable effect this had upon her. ``I felt like a light bulb had gone on ± as though I could see ± and feeling lighter inside ± instead of darkness inside.'' The experience was reminiscent of the description of ``®t,'' in which there is an almost chemical sense of enlivenment. She said: `` I felt like a drug addict that can't get it's supply of drugs and then it can, or it was like someone had injected me.'' The elation associated with this session lasted for days. Such persistence of happiness was unexpected. She said, with a giggle: ``It wasn't exactly like I was on guard but I didn't expect it to stay.'' The experience brought with it other changes. This was illustrated in a Tai-chi class the day following the session. The instructor made a mistake and ``for the ®rst time I was able to carry on without him.'' It seemed that the painting session allowed her to have some sense of an inner life with the consequence of which was an enhancement of the continuity of being. This session was a turning point in therapy. Rather than existing as a series of reactions to others, caught in endless busy-ness and an apparently unbreakable system of stimulus entrapment, she brie¯y experienced something which was her own and which, at the time, was valued by another. Painting ceased to be a feature in therapy. Nevertheless, from time to time the patient would ®ngerpaint, talking as she did so. She painted nothing speci®c, merely blending colours, but the activity had a soothing effect. She had become relatively spontaneous and there were enduring periods of positive affect. She was no longer clinically depressed. Some months later the signi®cance of her painting became clearer. The patient entered the therapist's room and noticed children's building blocks. She wanted to play with them. The therapist then remembered an occasion, much

A drive to play

169

earlier in therapy, when the patient had come into the room when the blocks had not been tidied and placed in their box. Panic showed on the patient's face and she asked the therapist to remove the blocks. The possibility now emerged that the patient's depressed mother had been unable to tolerate mess and muddle.23 If the child did create a mess there would be panic through a threatened loss of the attachment bond to her mother. This possibility was consistent with other pieces of information. The patient is unable to tolerate the untidiness of her granddaughter. When this occurs, the patient feels as if she is unable to breathe, and is forced to tidy up. She also remembered that at kindergarten she wanted to play but was unable to. At the end of each day, it was she who would pick up the toys and put them away. However, she adamantly stated: ``I never played with them.'' In retrospect it seemed that this individual intuitively understood a major deprivation of her childhood. In her case, the child's need, or drive, to play had been thwarted. However, it is important to note that she could not bring this state into being simply by a matter of will. Although we might say that her initial series of mandalas was a manifestation of a drive to play, it did not work. It did not lead to the emergence of self. It was not based on a sense of inner freedom.24 The development of an experience like ``fellow feeling'' provided the necessary environment of con®dence in which growth could occur. In addition to this experience, something else was needed to activate the movements of an inner life. The patient initiated this herself, demonstrating an impetus towards health. Her drawing and painting allowed her to make ``real'' her inner feelings and also an emergent sense of self. The therapist observed that this development was associated with the patient's increasing sense of personal freedom. The therapist also noticed that the patient made clearer selfstatements after painting sessions than after sessions which were simply verbal. It was as if the painting, as an analogue of symbolic play, broke through some impediment to a more complete awareness.

Chapter 20

Coupling, amplification and representation

An impetus or drive towards health, and towards a larger and more satisfying experience of personal existence, cannot, in the usual case, be realized on its own. The origins of self are social. Unlike primitive functions, the regulation of heartbeat, for example, which develop inevitably according to genetically given programs, the development of higher functions is ``incomplete,'' to use Hughlings Jackson's word. The program is insuf®cient in itself. An environmental provision is required for proper maturation. Important elements of the necessary social environment are touched upon in this and the following chapters. Although they may have developed mature systems of adaption, those who have been damaged by the circumstances of their early lives have not, in many cases, reached a level of maturation of self equivalent to the level of symbolic play. An earlier stage of maturation must ®rst be activated. Therapy often begins with a form of relatedness which seems to be analogous to a de®cient and unful®lled proto-conversation. The typical form of mother±infant interaction cannot be used as a direct guide to establishing, in adult life, the maturational pathway which failed or was stunted many years before. As remarked in an earlier chapter, the situation is now complicated by the fact that the signals and cues for responsiveness which parents read in their children's faces, bodies and vocalizations are no longer there. For example, distortions and disguises may hide more ``personal'' underlying states. This was so in the case of Robin (see Chapter 18) whose pleasant demeanor, attractive laugh and comforting facËade concealed the frightened, sad and angry person who could not present herself. Relatively ®xed forms of relatedness arising from the failures and impacts of the social, particularly the parental, environment hinder the potential for setting up a dynamic to-and-fro style of relatedness and conversation shown by the mother and her child engaged in the protoconversation. A paramount impediment or confusion is created by affect. The mother responds in different ways to the two main categories of affect, i.e., positive and negative. If the baby is distressed, the mother does something about it.

Coupling, ampli®cation and representation

171

If the baby is crying through hunger, it is fed; if the child is frightened, he or she is comforted. The task of the mother, on these occasions, is to understand her child and to respond according to her understanding. The mother's behavior when the baby's emotional state is positive differs from what she does when the baby is, for example, frightened or unhappy. When the baby's affect is positive, the mother often participates and contributes to it. Her behavior is unlike her response when the baby is distressed. She does not, for example, join in with his crying (although she may frown and even moan a little bit). However, when the baby's affect is positive, the mother's response is, characteristically, one of participation in this mood state. When the infant is content, for example, during feeding, the mother is content; when the child is interested, she too shows interest; when the child is happy, the mother often behaves like the child, escalating the happiness. However, the distinction between emotional states is often blurred or hidden in the therapeutic situation, so that the natural response is not elicited. Pleasure is muted since its revelation might lead to devaluation; distress is masked for fear of losing connection to the other. A background dysphoria, a state of dull monotony, or deadness, is neither positivity nor immediate distress. The therapeutic response demands skills and discipline, since the natural response alone is insuf®cient or, at times, inappropriate. The parental response to the child's positive emotional states is often called mirroring (e.g., the example from Mahler in Chapter 9). However, the word is not suitable (see also Chapter 4) since it implies mimicry, and an echoic responsiveness on the part of the other. This is not the way the mother behaves. Although her behavior resembles that of her child, it is not precisely imitative. If it were, it would have the effect of teasing or taunting. Similarly, the use of the word mirroring in the therapeutic situation might be misleading. Simple re¯ecting back, if repeated, goes nowhere. The subject is caught in a cage of mirrors. Sometimes the re¯ections are worse than ineffective. In responding merely to what is presented, the therapist may be perpetuating a system of compliance. Rather than a facËade, what must be appreciated is often shown as if in disguise, since positive emotions or creative expressions had been met in the past with responses that seemed crushing. Because of this, the individual mentions something that is intensely charged with personal meaning, nonchalantly, matter of factly, or as if in passing. For example, a man mentioned that he was taking up painting. His ®rst picture was of the house where he had grown up. He mentioned the subject so casually that the therapist failed to respond to it. The man dropped out of treatment a few weeks later. The responsiveness of the parent during the proto-conversation is complex. Despite its apparent simplicity the actual behaviors of the two partners are dif®cult to capture in a research system of codi®cation. Nevertheless, important elements of the parent's responsiveness can be seen as consisting

172

Part III: Ampli®cation and integration

of coupling, ampli®cation and representation, which are intertwined and often exhibited at the same time. These behaviors are also those which are important in setting off the necessary movement down a maturational pathway which those with disorders of self had not traversed in their early history. Each of these behaviors needs explaining. We start with infancy. Coupling describes the mother's (or other caregiver's) response to the baby's positive emotional state which initiates the proto-conversation. The baby's positive state is, at ®rst, usually displayed at a low, even minimal, level of intensity, say, an indication of interest. The mother joins in with this state in some way. She shows an attunement to the baby's immediate personal experience at that moment. In linking up to and participating in this experience she may act in a way which resembles the baby's emotional and cognitive state. In other words, she might become something of a ``double.'' The word coupling implies not only the doubling function, but also the joining up and joining in. The proto-conversation involves a reciprocal positivity. The vocalizations, facial expressions and body movements of the two partners ®t in with each other in a ¯uid and complex ``dance'' (see Chapter 9). This leads to an escalation of the emotion and its expression. There is an ampli®cation of the original affect going on. The mother is adding something to the baby's experience. Her ampli®cation is particularly affective but, as the child gets older, it is likely to include cognitive elements. Ampli®cation, however, typically involves another component. The introduction of the experience of value. This is shown in the mother's face. Her pleasure, her warmth, even her adoration shows her delight in her child which the baby senses as a delight in self. The child sense of personal value comes not only with what is perceived but also the feeling of ``®t'', the joining up with the other who, although the child would not yet conceive it in this way, has ``understood.'' Ampli®cation becomes more extensive as the child grows older and begins to play. During play, the parent, sibling, or other caregiver contributes in a way that is consistent with the play going on and that fosters it. He or she shares appropriate delight and admiration, uttering exclamations such as ``Wow, look at that.'' He or she helps the play along by adding to the picturing of the experience, making remarks such as ``that's a high one'' or ``he must be cross.'' The third component of the caregiver's responsiveness in the protoconversation is representation. The earliest representations are made by the responsive caregiver's face and voice, which re¯ect the baby's emotional state. The expression on the mother's face is equivalent to a word. Her response is analogous to naming the formless experience that inhabits the baby. She gives it a reality. At ®rst, the naming or representing of the baby's experience goes on face to face. There is no other reality than that which is instinctive and bodily.

Coupling, ampli®cation and representation

173

Soon, however, there is a movement of attention toward what the baby is doing and expressing in action. Instead of the original dyad, the engagement now has three components ± the third is the baby's activity, which is directed toward the environment. In this new, tripartite situation, the caregiver's naming or representing continues. This is illustrated by a visual cliff experiment,1 mentioned in Chapter 5. At some point, as the child moved out across the glass, he or she became aware of the increasing space below. The child glanced up at his or her mother in order to discover the meaning of this strange situation in which he or she was poised, apparently precariously, over a void. The mother's expression gave shape to the child's reality. The child's looking toward her for this kind of response is known as social referencing. We might suppose that at the moment when the baby glanced toward the mother's face, his or her feelings were amorphous and mixed, including both apprehension and curiosity. In this particular experiment, the mothers were asked to respond in one of two ways, to show either pleasure or apprehension. In ordinary life, the mother's response will be determined, at least in part by her own personality and experience. If a situation similar to the visual cliff arose in day-to-day living, some mothers would signal anxiety and others would encourage daring. There is, however, a third possibility. The mother makes no response at all. What will be the effect? First, we presume, the child will wait, however brie¯y, for the mother to play her part in the child's experience. She is required, as it were, to complete it. If she continues to show no response, the experience has about it a feeling of being un®nished. Moreover, the child is now of two minds. Is this situation dangerous or merely interesting? What is its meaning? What reality is he or she in? This experiment suggests that when the other fails to make adequate responses to the experiences of the child, the child will be left with a diminished sense of the reality and meaning of his or her existence. This de®cit is sometimes the central presenting feature in those who have suffered a disruption in the evolution of self. One man, for example, described a lifelong feeling of unreality. This depersonalization was described in a number of ways. He felt he was living in a movie, or in a dream, or like a Martian. Even his own thoughts were strange and puzzling to him. He felt disconnected from others, often ®nding it dif®cult to follow conversations. There was, however, one situation in which he felt ``solid,'' to use his own word. His sexual life, for a moment, made him feel real. It was as if his private world of wishes and fantasies found an answer in their enactment in the outer world. In this way, his action functioned as a self-representation. The puzzling disconnectedness and alienation of this man was described by another patient, a professional woman, whose predicament resembled his. In a limited way, the woman understood that reality depends, as she said, upon the description that has been put to it. The therapist came to feel

174

Part III: Ampli®cation and integration

that he was required to ®ll the gap, to make this representation. However, he did not do so. His rationale was that the only reality that was worthwhile was her own, not his. A more likely reason will be suggested on reading Chapter 14. They were stuck. She remained in a state ``like dreaming.'' This woman's accounts of her current experience, had a surreal quality, an eerie fragility of meaning, originating from earlier experience in which the social environment provided no representing responses necessary to the building of a ``solid'' personal reality. Most children, however, have people around them who respond in a way that shows an understanding of the child's immediate and personal experience. They do so selectively. The child's developing reality is not a constant potential. It is not objectively there, to be acquired passively. Its emergence depends upon another. There is no single correct response, no true reality. Who is to say that the experience of the baby in staring down through a glass ¯oor into a space is frightening or merely interesting? There is a range of responses from which to choose. The choice is in¯uenced by the personality and experience of the other. The selectivity of the parent's response is evident very early in the child's life. Very soon after birth, parents begin to give attributes to their children that often come from their own personal world and that reveal fantasies of what they hope the baby will become. The fantasies may be based on their own unful®lled wishes. For example, in one of our studies, a dancing teacher with almond-shape eyes searched her child's face when she ®rst saw her and found the same eyes. Two days later she said ``My husband keeps saying she's going to be a little ballerina. I said only if she wants to be. I mean obviously she'll come to class with me.''2 This mother is especially likely to value those aspects of the child's behavior that are consistent with her imaginative wish about who her child will become. This fantasy becomes the framework into which a life moves, constantly being shaped. This is normal. Normality is breached when the selectivity of the other acknowledges something that is not part of, or perhaps not affectively central to, the experience of the developing child. What is essential in adequate representation is the portrayal of what one already knows. This is beautifully described by Virginia Woolf writing of Sir John Paston, a landowner, living in medieval England: Sometimes, instead of riding off on his horse to inspect his crops or bargain with his tenants, Sir John would sit, in broad daylight, reading. There, on the hard chair in the comfortless room with the wind lifting the carpet and the smoke stinging his eyes, he would sit reading Chaucer, wasting his time, dreaming ± or what strange intoxication was it he drew from books? Life was rough, cheerless, and disappointing. A whole year of days would pass fruitlessly in dreary business, like dashes of rain on the windowpane. There was no reason in it as there

Coupling, ampli®cation and representation

175

had been for his father; no imperative need to establish a family and acquire an important position for children who were not born. . . . But Lydgate's poem or Chaucer's, like a mirror in which ®gures move brightly, silently and compactly, showed him the very skies, ®elds and people who he knew, but rounded and complete. Instead of waiting listlessly for news from London or piecing out from his mother's gossip some country tragedy of love and jealousy, here, in a few pages the whole story was laid before him.3 These words express the effect of language that offers no explanation of mental states, but does more than merely clarify them. Rather, an inner world is illuminated and shaped. Chaucer shows Sir John the world he knows, but more brightly, rounded and complete. The portrayal of one's experience, which gives it reality and shape, does not always come from the faces and words of another. Sooner or later the child begins to do it for him or herself. Although the child of 1, 2 and 3 is constantly engaged in social referencing and in seeking appropriate responses of caregivers, there comes a time, as we have seen, when the child seems totally absorbed in play, apparently oblivious of others. At this time, his or her peculiar language has no communicative purpose. I suggest that at least one of its functions, and perhaps a principal function, is to help, together with material objects, to represent the child's embryonically inner but as yet merely personal universe. Put another way, the child is moving toward the doubling of self, taking on for him or herself, at least for a moment, the representing function of the other. These three elements of responsiveness shown by the caregiver often occur together. In this circumstance, the response might be called resonance.

Coupling We now come to the clinical situation. Resonance is often neither possible nor appropriate at the beginning of the therapeutic endeavor. Anxiety is a frequent impediment. The pathway to selfhood is relatively anxiety free. Both the proto-conversation and symbolic play are halted when anxiety is aroused. The opening of the therapeutic conversation must be conducted with an awareness that such an underlying state is likely to be present. It should, where possible, be dealt with. This may not necessarily involve a verbal approach. The non-verbal cues and signals given off by a calm therapist are also effective. In starting off the developmental trajectory which was thwarted earlier in life, the therapist is hampered. That which has been biologically given to him or her, the particular talent of mankind, of being able to converse, is restricted or diverted by the responses and signs which came from the patient. The natural process has been subverted, as previously remarked.

176

Part III: Ampli®cation and integration

Coupling to what the patient gives to the therapist requires skill and a certain kind of attention. ``Coupling'' is a conversational linking to the most ``personal'' aspect or element of what has just been offered. In essence, the therapist is trying to respond to implicit or potential moments of aliveness. The most ``personal'' or alive elements are not necessarily words but these are the most usual currency of the exchange. Something is chosen in the verbal expression in which one senses emotional, imaginative signi®cance or which is spontaneous, however casual it appears or which is suggestive of metaphor. Hobson used Blake's expression, ``the minute particulars,'' to refer to the ®ne shifts in conversation, the actual words, the way they are said, the nuances, of feeling associated with them. By listening, in a particular way, to the exact words and the way that they are used, one may begin to be able to use words that are repeated, words that seem unusually loaded, or words that have a peculiar ring to them, as a means of entering into previously unexplored areas of psychic life. A particular word or phrase may contain within it a ``micro-history'' that can be ¯eshed out and enlarged, and, in some cases, illuminate a much larger area of the individual's ordinary existence. An example of the close attention to the minute particulars can be given through a consideration of the opening to a poem known by every Australian school child. It begins: There was a movement at the station, for the word had passed around That the colt from old Regret had got away. Let us consider Patterson's words and their effect. There was ``movement''. Why ``movement?'' It seems there is drama afoot. Why not use a word like ``bustle'' or ``¯urry'' or ``tumult'' to convey the consternation at the escape of the valuable horse? At ®rst sight, ``movement'' seems too slight. Yet when we think about it, it conveys a sense of vastness. It is as if we are somewhere in the sky, above the enormity of the Australian landscape. Down below, something is perceptible ± ``movement.'' We enter the region of the epic. This effect is compounded in the next sentence ± ``the word had passed around.'' There are no men in it. The word has its own life, ``passing around'' from group to group, in the manner of the epic, living on beyond the people who made it. Finally, ``the colt from old Regret.'' She is not called Bullitt or Raspberry or Sara, but old Regret. Into the spatial vastness comes time, time lost, time passing. It is interesting that a poem constructed as if it were an epic has become one. This diversion helps illustrate the value of pondering the use of particular words, of not losing sight of the actual text. This focusing, however, leads

Coupling, ampli®cation and representation

177

us to a paradox, many of which underlie the psychotherapist's stance. In addition to focusing on the ``minute particulars'' the therapist must also be unfocused and aware of a series of themes of sensations, perceptions, feelings, imaginings, and memories. This state includes the capacity to notice changes in one's self as the patient's story is being told and, as it were, to become a spectator to those experiences. Those with severe disorders of self often offer very little in the way of liveliness, very little which the therapist can join. This is so even when the therapeutic process is well established. For example, Marguerite begins her session with a sigh and says, in a dead voice: ``Not much change really.'' What can the therapist do? An inexperienced therapist might be affected by the implicit hopelessness and begin, for example, talking of the possible need for medication, or retreat into medicalization and inquire about a list of symptoms. In either case, Marguerite's feeling of failure and alienation is likely to be compounded. Another therapist, not wanting to ``reinforce'' hopelessness, might inquire about an occupation, or event, which he knew might be pleasurable. ``How did the picnic go?'' he asks. This could possibly work. It could also seem coercive. The therapist is only interested in happy occasions, therefore, Marguerite might say to herself, that is all that can be mentioned. A restriction is implicit. Everything will be experienced in the light of Marguerite's sense that the other knows she is useless and incompetent. Everything the therapist says has the potential for devaluation. The therapist wishing to diminish this risk might respond on a way which seems, at least to him, neutral, non-coercive and non-judgmental. ``Uh huh,'' he says. To Marguerite this means that what she has just said is uninteresting and of no value. The therapist is simply waiting, so she imagines, for her to say something more interesting. So what does the therapist say? He responds in a way that seems banal but which is necessary. He has to stay with her, and this will often depend upon using her own words and perhaps elaborating them, taking them a little further. In this case, such elaboration is not suitable. It would go beyond the offered remark in a way that threatens a sense of ``®t''. The responsiveness, as Howard Bacal would put it, must be optimal.4 It goes only a certain way. The therapist replies: ``Not much really.'' However, his response is not an echo, or an imitation. He changes the way in which she said ``really.'' He gives it an emphasis. The word ``really'' implies doubt. Perhaps there is some change. The main communicated factor in this response is phonological. Language is not just the use of a lexicon and an appropriate syntax. It also, and most importantly, involves phonology. The tone of the voice, together with facial expression and gesture, is the means of conversing during the ®rst 18 months or so of life during which an immense period of development has occurred. One experienced therapist, for example, although very aware of

178

Part III: Ampli®cation and integration

the complex psychopathology in which he was involved, conducted a conversation of a very fruitful and productive kind, in which his principal responses were ``Yeah'' and ``Uh, huh.'' Into each of these utterances he was able to compress a large range of meanings, of indications of wonder, of af®rmation, of disbelief, of speculation. The syntactical structure of the therapist's response to Marguerite is also important. It is abbreviated, and not strictly grammatical, in the manner of inner speech. He does not say, for example: ``So you've noticed no improvement!'' He omits both pronoun and verb. The response, in contributing to the development of the necessary ``fellow feeling,'' must connect with what is offered. The syntax of the conversation is an aspect of the connection, or its failure. The syntax both displays and structures the form of relatedness. A syntactical style which uses questioning, as in the medical mode, diminishes the sense of ``fellow feeling.'' It is important to develop a discipline of language in which questions are avoided. This is not possible to achieve in an absolute sense. Nevertheless, when an individual stops himself from uttering irritating clicheÂs like ``How did that make you feel?'' as used by the average intrusive television interviewer or reporter, and, instead, offers speculative attempts of understanding, the sense of connection will be fostered.

Amplification Did this therapist's attempt at coupling work? Although certain principles can be seen to be followed, or not followed, we can only judge the usefulness or effectiveness of a particular contribution, or series of contributions, to the therapeutic conversation by ``what happens next.'' She might say, for example: ``No. Just the same.'' The contribution has failed. There is no movement. Her actual response is different. Her voice becomes somewhat stronger and more animated as she says: ``Well except I ± I'm getting angry with Sam and I think ± I guess there's a bit of a change there.'' Her reply shows that, in some feeling way, he has linked to, or joined in with her opening remark. He has understood the mitigation implied in the word ``really.'' Her anger with Sam, her husband, is indeed good news, since he constantly reminds her of her hopelessness, uselessness and incompetence. There has been a change. She is standing up for herself. This is what the therapist af®rms. ``Aha,'' he says in a tone of acclaim and vitality. ``That ± that seems a good thing.'' This response is an ampli®cation. Ampli®cation typically includes the enhancement of positive affect, which is very often muted. Ampli®cation might also include the recognition of another affect which is less salient. For example, pleasure may be in the forefront of the expression but a sense of regret is also present. A third kind of ampli®cation, extends the sense or meaning and so forth, of the words which are spoken.

Coupling, ampli®cation and representation

179

A principal feature of ampli®cation is that it gives value. Hobson gives a beautiful example of such response. He had been referred an aggressive, delinquent 14-year-old boy, who, session after session, sat rigidly in his chair and glowered at the therapist ± a picture of dumb insolence. The therapist, however, eventually made contact by talking about cricket in an emotional way, full of the excitement of the game. Some weeks later the boy brought a dream: ``I was by a dark pool. It was ®lthy and there were all sorts of horrible monsters in it. I was scared, but I dived in and at the bottom was a great big oyster and in it a terri®c pearl. I got it and swam up again.'' Hobson responded to the boy's wonder and gave value to the experience. ``That's good. Brave, too. You've got it, though, and pearls are pretty valuable.'' He said nothing more. He did not try to be a clever therapist although quite aware that the monsters might represent sexual and aggressive wishes and of the symbolic signi®cance of the Pearl of Great Price. Nevertheless, in the following session the boy began to talk about his life, feelings, and frightening fantasies. He improved greatly and oriented in a new way towards his social milieu. Only once again, many months later, did the boy refer to the dream: ``It's queer about the pearl,'' he said. ``I suppose it's me in a sort of way.''5 Hobson's response was affectively positive and at the same time ®tted in with what was central to the boy's experience. The ®t is essential, because out of it is generated the feeling upon which a feeling of value is based. It is the sense of resonance, rather than the af®rmation itself which contributes to the development of value.

Representation So what happened next in the conversation with Marguerite? ``Well'' she says. The tone expresses doubt. ``It's not being objective, but it's a good thing for me because I don't think it helps to be hounded like that. Even though I understand his position and, you know, where he's coming from, but. . . .'' she sighs. There has been further movement. There is a small piece of evidence suggesting the emergence of something ``inner.'' This is her use of metaphor ± the word ``hounded.'' He replies: ``Aha,'' more of an ``I have understood'' response than his previous ``Aha.'' ``You ± you understand how he might be but still, not good for you, and so. . . .'' In a halting speculative way he is trying to represent something they both are sensing, but cannot clearly see. He tries to convey, using her own words ``understand'' and ``good,'' the apprehension that she lives in a double reality. One is ``objective,'' af®rmed by her husband. This is the imposed reality of the unconscious traumatic memory system. The second is the sti¯ed reality, more truly her own.

180

Part III: Ampli®cation and integration

What follows in this conversation will be described in the following chapter on empathy ± that crucial aspect of the representing function of the other, in which he or she tries to portray, in a metaphoric way, that which both partners are beginning to glimpse of an emergent inner world.6

Chapter 21

Empathy

The therapist's capacity for empathy is the principal agent of bene®cial change in the patient. The empathic stance depends upon an attentional shift on the part of the therapist analogous to the shift made by the parent as the child progresses from the stage of the proto-conversation to that of symbolic play. Attention moves to the ``third element'' spoken of in Chapter 5. The gaze of the partners moves from the face of the other to something else. In the case of the child, it is the world-to-be manipulated, the toys, objects and parts of the body with which the child plays. As maturation proceeds the world-to-be manipulated becomes internal. Actions become thoughts. Empathy is the attempt to grasp and represent the nature of these thoughts, when that word is shorthand for a whole range of feelings, ideas, memories, imaginings, wishes, and so forth. The gaze, in a ®gurative sense, shifts towards these unseen things, just as the eyes of the parent and child are turned towards the scene of symbolic play actually laid out on the living-room ¯oor. The empathic representation makes metaphorically visible that which is only dimly or partially glimpsed in the penumbra of consciousness. The patient begins to describe an experience and the therapist tries to follow him or her in an imaginative way into this region. I have visualized their joint activity in terms of a metaphoric screen.1 By means of words, the patient's thought processes are, as it were, projected and placed before the eyes rather as one watches the projection of images at a movie. It is, however, a curious ®lm, since it is being made as it is watched. As the patient throws upon the screen glimpses of half-seen forms, faint outlines, the therapist tries to ®ll in the gaps and make out the shapes. This description is of an ideal and not particularly common situation. Nevertheless, it represents that towards which the therapist strives. The therapist's task, together with that of the patient, is for insight into the patient's world ± insight being used in its original sense ± seeing with the eye of the mind, having inner vision.2 It may not always involve words. It might sometimes consist of a tone of voice or a facial expression. However,

182

Part III: Ampli®cation and integration

in its developed form it depends on words which ideally portray not only essential elements of the patient's expressed experience but also something beyond it which is an extension of it, and which is nascent or latent in this expression. In this portrayal, what is latent or implicit in the patient's words is turned into an image, and more completely, a scene. The use of metaphor is a crucial element in this process of transformation of thoughts into visual images. Metaphor is necessary to the empathic process since the intangible movements of inner life can only be conveyed by means of things that can be seen and touched.3 Emotions, at the bottom, are always expressed in terms of metaphor. Words for affect are dead metaphors. For example, sadness originally meant heaviness; joy meant brightness. The therapist needs to be sensitively aware of metaphors that do not have the extravagance of literary productions, but are unobtrusively hidden in the patient's expression. They may be the means of helping to enlarge and make real something of the inner zone. To visualize an experience is to place it in a different mode of mental processing to that depending upon words alone. Images and scenes are the basis of narrative. Metaphors of a peculiarly personal kind may change and progress in the manner of ``narrative progression.'' Hobson has spoken of the moving metaphor. The ultimate aim of the empathic representation is to open up a pathway towards a larger state of mind and the creation of a multi-thematic and evolving narrative of self analogous to, and larger than, the small personal story being told by the child immersed in symbolic play.

Duality and Erasmus There is one important aspect of the empathic stance not yet remarked upon. It is duality. The process is double in that the empathizer is not only a spectator, involved, as Kohut put it in a kind of vicarious introspection, but he or she is also in or part of that which is being ®guratively depicted. The earliest description of this state of mind may have come from Desiderius Erasmus. In his Praise of Folly (1511), Erasmus argued that ``the whole man'' had the capacity for a curious state of mind, which he likened to madness or folly, although not quite seriously. He also likened this state to love: He who loves intensely no longer lives in himself but in whatever he loves, and the more he can depart from himself and enter into the other, the happier he is. And when a mind yearns towards traveling out of the body, and does not rightly use its own bodily organs, you doubtless, and with accuracy, call the state of it madness.4

Empathy

183

This notion seems central to Erasmanian philosophy, but is also fundamental to an understanding of empathy. What is most important, in the state that Erasmus described is that one imaginatively inhabits the other person, at the same time retaining one's own ``soul.'' Michael Screech points out that his idea was revolutionary in that it reversed the teaching of St Paul. The Pauline assertion was ``I live, yet not I but Christ liveth in me,''5 whereas Erasmus suggests that the highest form of experiencing involves the capacity to ``migrate'' into another. For St Paul the movement was in the opposite direction, so that he was inhabited by Christ. Erasmus implies that this is a relatively low form of rapture, found, for example, in the pseudo-Dionysians. Put another way, it is the basis of cult formation. It is also one of the forms of sympathy, a subject to which we return later.

Vico and fantasia The next major exploration of empathy came from the Neapolitan philosopher, Giovanni Battista Vico (1668±1744). His ideas were novel, beyond the understanding of his own age, so that they had little in¯uence in his day and were virtually forgotten after his death but revived a century later. In 1724 he ®nished a treatise in which he refuted the view of rationalists like Descartes and Spinoza, and utilitarians such as Locke and Hobbes. Since these men were the most admired thinkers of their time, Vico's patron refused to fund the publication of the treatise. Vico eventually cut the book to a quarter of its size, including only his own positive ideas. This book The New Science was his masterpiece. The starting point of Vico's ideas was the conviction that the method of Descartes could not usefully be applied outside the ®eld of mathematics and the natural sciences. Disciplines such as psychology, history, and anthropology could not be approached simply by measurement and logic. As Berlin put it: Whatever the splendours of the exact sciences there was a sense in which we could know more about our own and other men's experiences ± in which we acted as participants, indeed authors, and not as mere observers ± than we could ever know about non-human nature which we could only observe from outside.6 This knowledge was gained by entering into the minds of others by means of fantasia ± ``man's unique capacity for imaginative insight and reconstruction.''7 We know little about another culture or period of history if our only information is a chronicle of events or a catalog of artifacts. We need, in addition, to know something of the mind of that society. How else, for example, could the rituals of an African or native American society be understood.

184

Part III: Ampli®cation and integration

A German, Johann Gottfried Herder (1744±1803), was perhaps the next major advocate for empathy. He added to the concept of Vico by emphasizing the role of feeling. He introduced the term Einfuhlen, maintaining that the scholar of any civilization is required to ``feel himself'' into the essence of its life.

Sympathy is not empathy It is customary to suppose that the concept of empathy was introduced into Anglo-American thinking through the concept of Einfuhlen, as described by Dilthey and Lipps8 who were writing a century after Herder. However, the American, Charles Cooley, described something similar at about the same time. He used the term sympathetic imagination to describe our capacity to look at things as others in different situations do and have the feelings others have in circumstances actually different from our own. Nevertheless, until quite recently, empathy has not fared well in the Anglo-American world. It appears only in a supplement of the Oxford English Dictionary. It was not included in Webster's Dictionary until quite recently. It is sometimes considered to be merely a synonym for sympathy.9 In order to show the difference between these two phenomena, we now turn to a brief consideration of sympathy. Something like sympathy can be observed very early in life. Soon after birth, babies in a nursery with other newborns cry when another infant cries.10 This is the earliest evidence of sympathy. It might be seen as something like contagion ± one of the features of the de®nition of sympathy. We might speculate, however, that the baby's actual experience is of someone crying within him or her, as if the baby who is crying and the baby whose crying has been triggered commingle. It might be that the baby senses in some primitive and unformed way the crying within him or her as a signal of distress and cries in response. As adults we may also see the baby's crying in response to another's cry as evidence of compassion. This would probably be an error of the kind Kohut has called adultomorphic. Nevertheless, it does appear that as sympathy develops, it seems to be based on something like a fellow feeling. Martin Hoffmann,11 for example, gave a description of a boy about 18 months old who when distressed would suck his thumb and pull his ear. One day, the little boy was upset when he became aware that his father was distressed. He went up to his father and began to pull his father's ear lobe at the same time sucking his own thumb. Again, there is a commingling of the individual and the other for whom compassion is felt. In this case, however, there has been a progression. Whereas the newborn child was inhabited by the cries of another or the experience of another, in the case of the 18-month-old the reverse seems to be happening. There are elements of identi®cation in this story. The little boy has put himself in the place of

Empathy

185

father and for a moment becomes him. When the child conceives more completely of the distinction between himself and those close to him, a more mature form of identi®cation occurs ± the individual puts him or herself in the place of the other and experiences those things that he or she, i.e., the individual, would feel in such a situation. This, however, is not yet empathy, since at this stage the identi®cation does not involve feeling as the other would feel. Certain essentials of empathy can be derived from such disparate sources as anecdotes of children's behavior, the model of play, and the history of the concept of empathy. From the model of play we gain the notion of perspective, the idea that empathy involves something like a view upon the experience of another. From Vico we are given the idea of a different kind of thought process being involved, that of fantasia. From Herder and his notion of Einfuhlen, we gain the essential ingredient of feeling ± we cannot truly know the experience of another unless somehow or other we feel the emotion that is at the core of it. Finally, from the children's studies we become aware that the identi®cation involved in empathy is a curious one because it is not precisely oneself who is placed within the experience of the other. What is required is a strange kind of identi®cation in which, as far as possible, one's own personal world of feelings, prejudices, wishes, and so on is removed. In this way, to return to Flavell's study of children's gift giving, the boy of 6 is able to abandon the belief that his mother might be especially excited to receive a toy truck as a present and realize that nylon stockings might be preferred. Empathy then requires a kind of identi®cation that is impersonal. At the same time it demands a perspective upon that identi®cation. The individual, in Piagetian terms, moves from the egocentric phase of early childhood to a position that is decentered, from which it can be appreciated that others have worlds that are quite different to one's own.12 In my view, this cannot emerge until there is a sense of one's own world which is conceived as distinct to that of others. Predictably, early pretend play in children has been shown to be signi®cantly related to those children developing an understanding of other people's feelings and beliefs.13 Also predictably, we ®nd those with disorders of self are often de®cient in the area of empathy. As a consequence, others frequently regard them as exploitative.

Clinical aspects We come now to some of the nuts and bolts of the clinical situation. First of all, it is necessary to say that empathy inevitably fails. Nobody can know, completely, the more personal and intimate aspects of the reality of another. In many cases the empathic failure is quite useful. It con®rms for the patient that his or her inner life is not totally accessible to others. Put

186

Part III: Ampli®cation and integration

another way, the failure has a value because it af®rms the distinction between an inner world and the outer one. The second way in which the failure is bene®cial is related. The patient comes to realize that the therapist is not omniscient and omnipotent. This discovery is something like that of the 5-year-old Edmund Gosse when his father failed to know of the boy's misdemeanor. Kohut emphasized the value of therapeutic failure, making an analogy between the effect of the undetected lie and empathic failure. He wrote: The place of the undetected lie is rather taken by the analysand's discovery that his own understanding of his mental states and attitudes is better at times than that of the analyst, that the analyst is not omniscient, that his empathy is fallible, and that the patient's empathy with himself, including, par excellence, his empathy with his childhood experiences, is often superior.14 Kohut's idea parallels that of Winnicott, who considered, as noted in previous chapters, that it was necessary for the child to go through a period of omnipotence. This must be related to a conception of the other as omniscient. It is necessary, as Winnicott pointed out, that following this phase, the child, in small doses, is exposed to disillusion. In this way, slowly the child begins to learn that there is a world that is different from his own and that might be called the real world. Indeed, toward the end of his life, Winnicott remarked that the purpose of his interpretations was to show the limits of his understanding. Not only is it important for the patient to know that the therapist is not fully able to comprehend his or her inner world, but it is often very helpful for the therapist to acknowledge that he was incorrect. He needs only say something simple like ``That wasn't quite right, was it?'' for something profound to occur within the patient. The reasons are several. First, nobody may have said such a thing before. Second, it is possible that the therapist, in making this remark, immediately establishes a reconnection with the patient through showing that he has actually understood what had happened at the moment; that although he had failed just before, the bond between them has not been lost. Anxiety falls. Not only is periodic empathic failure, at least to a certain degree, useful, particularly if corrected, but it is also helpful for the therapist to know that precisely accurate representations of the patient's more inward and hidden state can sometimes be damaging. The following is an example: A patient who had spent much of his early life in an orphanage and could not remember anything before the age of 10, began a session by announcing that his girlfriend was pregnant. This appeared to be ``no problem,'' since she would get

Empathy

187

an abortion. After a few connecting sentences, the patient, showing little affect, went on to say that he wondered whether some early memories were beginning to be recovered, since he had had ``images'' of himself as a terri®ed child being dragged from under a bed, presumably to be taken to the orphanage. The therapist then remarked that the forthcoming abortion seemed to have triggered feelings related to his being ``got rid of'' by his own mother. The patient said ``Good point'' in a rather pompous voice. He then recounted, without any apparent reason, successive incidents in which he had been physically attacked and injured while in vulnerable situations; had been humiliated after revelation of an emotional state; had felt ``paranoid''; and had been enraged.

After a disjunction it is always useful to listen carefully to a story that is being told which comes from another time and which concerns other people, because it may tell the therapist what happened at the time of the disjunction. It might also alert the therapist to the fact that a disjunction, which he or she has missed, has just taken place. In this case, the four incidents recounted describe different parts of this man's experience of being intruded upon and violated by the therapist. In this account of a succession of different incidents there is no narrative progression. They each describe, in a different way, the same experience. The therapist in this case seems to have been guided, or more accurately misguided, by a widely held idea. It is sometimes thought that the primary aim of therapy is to reveal or in some way decode the meaning of the patient's expressions. But in developmental terms, feeling is more fundamental than meaning. Privilege must be given to a sensitive awareness of feeling-tones without neglecting a meaning related to them. An empathic pondering of the feeling state in this case would have included a consideration of this man's guarded manner and remote lifestyle. This might have led the therapist to understand that his patient had a fear of being known. It is not the role of the therapist to be clever and accurately to tell the patient what he or she is thinking or feeling. The task is to bring into being a state like play, which must depend upon an understanding of experiences that are going on inside the patient. The therapist is not required to be an oracle or a seer, but a facilitator. The patient's material should not be used to display the therapist's brilliance, but rather as a means of ampli®cation of the patient's own awareness. The sense that the experiences are the patient's own must not be tampered with. The interpretations of the therapist should not steal or contaminate the experience by, for example, explanations and decoding. Dreams are examples of material which should not be acted upon in this way. Dream material is of value since it is personal and not produced

188

Part III: Ampli®cation and integration

by mere stimuli. The therapist, highly trained in the subject of symbolic representation, may be tempted to tell the patient about the patient's own dream. In my view, this is not a suitable approach. Rather, the therapist, who may have a very good idea of the signi®cance of the dream, should behave in a manner that allows the patient to explore the dream for him or herself. He or she should initially respond, not to the content of the dream and its meaning, but to some quality of the dream. A comment may be made, for example, on the creativeness, the beauty, the sadness, the strangeness of the dream. The approach has similarities to what Bruner15 called scaffolding in describing the mother's role or the child's play. While the child plays with objects, the mother helps. However, she does not do this by playing with the objects herself. Rather she arranges things, so that the child is better able to achieve a construction to which he or she seems to be striving. The therapist's contribution and the mother's activity both help the process to move on. Something happens that could not have happened without this social environment. The success, or otherwise of an attempted empathic representation is different to that of the man whose pompous ``Good point'' suggested that something had gone wrong. We return to the conversation between Marguerite and her therapist. They are now both in a zone of halfawareness, both beginning to turn towards the third thing, a recent interior state which they jointly try to depict. He is sensing, and in a tentative way, trying to describe, the con¯ict between her two realities. Her reply asserts, more strongly than before, the destructiveness of that which is imposed upon her. She says: ``Well he was like acid eating away at me, your know, with his sort of demolishing me really.'' In this passage, the metaphors concerning the erosion of her inner states by her husband show an intensity of her experience beyond ``hounding.'' There is something more internal and malignant about acid eating away. At this point, the difference between sympathy and empathy can clearly be shown. Sympathy is usually of little value. It is the response which might be made by the nextdoor neighbor. It is a response made from one's own view. A sympathetic response to an ``acid eating'' into one's sense of personal existence would be ``How terrible'' or ``How horrible.'' The empathic response, on the other hand, portrays what can be imaginatively understood of the inner life of someone other than oneself. Here is what the therapist said. ``Yes, an acid eating away at you is ± unreasonable?'' his voice rising in a querying tone in uttering the ®nal word. The therapist's response is empathic although, at ®rst sight, it is peculiar or even absurd. Of course, one might say, such a situation is obviously unreasonable, or worse. However, by the in¯ection of his voice the therapist conveys, in an extremely condensed way, her two realities. In the ®rst, her own, her husband is wrong, ``unreasonable.'' However the rising

Empathy

189

tone suggests doubt, another possibility, consistent with second, traumatic habitual reality. Perhaps, in a way, his behavior is ``reasonable?'' Her response to this remark is surprising. Her affect rises and she begins to talk about a part of her life in which she is not hopeless. She looks after her children well. Laughing she gives a somewhat ironic account of herself as a parody of the good mother. In this self-amused description she has become double. There is one Marguerite who is the viewer and descriptor of another Marguerite, the ``good mother,'' who is seen and described, as if on a stage. There has been a shift into dualistic consciousness. In entering this new state, the language becomes somewhat different. It is now more clearly structured as if directed towards the emergent third thing, the invisible cinematic screen. This structuring encourages further exploration and elaboration of what is beginning to emerge. The therapist's contributions tend to begin with sentences such as ``It might look . . .'' or ``It seems there's something else . . .'' Finally, the directing effect of the syntactical structuring encourages a most important element of maturation ± decentration. The empathic stance offers a way beyond entrapment and a life lived at the mercy of stimuli. A curious paradox now becomes evident ± the individual can only discover his or her own centre by being able to move outside it. This process is fostered when the therapist with whom the individual feels connected is constantly engaged in attempting to establish a duality that is central to empathy. The therapist, while maintaining the connectedness with the patient, is constantly moving the patient's awareness toward those ¯eeting glimpses of that which is inner. In terms of the basic metaphor, the therapist is trying to move the patient's experience from a world that is real to a world that resembles the playroom. The therapist's discipline is maintaining, as far as possible, a perspective upon the experience in which both partners are immersed encourages a movement toward the patient's being able to grasp the spatiality of his or her existence.

Chapter 22

Dissolving the trauma

When Freud began to work on developing his theory of psychoanalysis, he did so in an intellectual climate that Ellenberger,1 in his great book, has beautifully outlined. One of the principal ideas forming this climate is what Ellenberger has called the pathogenic secret. He traces the story of this model of psychological healing through a number of cultures. The patient is conceived as if he has within himself a bad experience that rots within him like a malignancy. It must be removed for cure to occur. In some cultures the badness is concretized as a foreign body. The shaman, at the end of the healing ritual, demonstrates to the sick person the thing that had been in his body and had been causing the illness. In other cultures the evil within is less concretized, perhaps as a spirit that has to be expelled through exorcism. In our own culture, confession has been one of the means of voidance of the secret. In Vienna, Moritz Benedict published a series of papers from 1864 to 1895 in which he suggested that neurotic illness was often caused by secrets, often pertaining to sexual life, and that cure came within their removal through catharsis. When Breuer and Freud produced Studies in Hysteria, which Brill2 called the ``fons et origo of psychoanalysis,'' they described a hidden experience, characteristically sexual, which was at the bottom of the illness. It had to be removed, in their words, ``like a foreign body.''3 The ``pathogenic secret'' remains a principal therapeutic focus. It is a nidus of negativity, diminishment, of destruction and self-destruction, including, at times, an apparently unstoppable drive towards death. I am speaking of that complex of psychic life organized around traumatic memory. It may have been the basis of Freud's formulation of the death instinct. Its positive counterpart I am calling the ``generative secret.''4 The latter holds the potential for enhanced aliveness. A main feature of the kind of therapy outlined in this book is that it appeals to moments of aliveness. There are, then two main forces at work in the therapeutic ®eld: one, a drive towards health and selfhood; the other, of which the historical forerunner is the ``pathogenic secret,'' derives from traumatic memory. In some individuals, personal existence is organized in a kind of Manichean

Dissolving the trauma

191

split between two domains of consciousness ruled by opposing imperatives as if between lightness and darkness, a dichotomy represented in Hindu theology by the two major deities, Vishnu and Shiva, the former cast as the principle of creation and life, the latter as destruction and death. The better known systems of psychotherapy tend to focus on one or other of these two domains. Jung, Rogers, Kohut and Winnicott, at least in their writings, make the emergence of self, or ``going on being,'' their main objective. On the other hand, the approach of Freud, Klein and, more recently, the cognitive behavior therapists,5 is mainly directed at the consequences of the traumatic past. In this chapter, it will be argued that these two main approaches need to be brought together, with priority being given to fostering the growth of self.

Transference interpretation Since the theory and practice which derives from Freud have been the most in¯uential of the various systems of therapy, we must begin with a brief consideration of an essential element of the psychoanalytic approach, the transference interpretation. It can be seen as essentially an attempt to alter the malignant ``facts'' of the traumatic reality. It is a widely held psychoanalytic view that insight through interpretation is ``the supreme agent in the hierarchy of therapeutic principles.''6 More speci®cally the centrepiece of psychotherapy, as conducted in the psychoanalytic tradition, has traditionally been the transference interpretation. This approach was most famously expressed by Strachey, whose concept of the ``mutative interpretation'' continues to be cited as authoritative guidance for the therapist.7 In this book the term transference is used in a restricted sense. The usage corresponds in a rough way with negative transference. Transference is seen here as the manifestation of unconscious traumatic memory as it intrudes upon the larger consciousness of self, breaking it up, stunting it, and even at times, taking it over entirely. Sometimes the effect is slight, shown, for example, in a deadened tone or a topic shift. On other occasions, when the impact is greater, the changed experience of the individual in relation to the other becomes salient. Transference phenomena are now more clearly observed. It is important, however, to understand transference not only as obvious ``distortions'' in the patient's experience of the therapist, but also in a larger way to include more subtle effects of the unconscious memory system. Not all of these are, at ®rst sight, clearly ``negative.'' The aim of the transference interpretation, as originally stated, was to reveal the pathogen, to make known to the patient those hidden aspects of psychic life which were the cause of the individual's troubles. In a lecture entitled ``Fixation upon Traumas: The Unconscious,''8 Freud stated that our therapy works by changing that which is unconscious into something

192

Part III: Ampli®cation and integration

conscious. However, he also pointed out, it is not as easy as this bald statement implies. The patient is not, in the typical case, relieved by the simple correction ``of a kind of, ignorance, a not-knowing of mental processes which should be known.'' Early research into the effect of transference interpretation seemed to con®rm a conviction that transference interpretation is of major therapeutic import. The most in¯uential study was conducted by David Malan.9 However, his research method, which depended upon therapists' accounts of their sessions, is unsuitable. The most recent studies involve taped recording of sessions. The ®ndings which have emerged from these studies,10 which generally show that transference interpretation correlates negatively with outcome, present a puzzle to the experienced clinician since they run counter to the sense that transference phenomena are central to the therapeutic process. Yet these ®ndings cannot be ignored. How are they to be explained? An answer to this question must be conjectural. However, two possibilities immediately present themselves. In both cases the interpretation contradicts the subject's immediate experience. In the ®rst case, what the therapist says may be ``true'' in the sense that the subject's experience at that moment does come from the past. However, since the traumatic memory system is, at this point, ``unconscious'', i.e., beyond the reach of re¯ective awareness, the patient's despair, anger or other emotional state is conceived as having its cause in the room, in the present and not the past. The interpretations contradict what the individual feels. A compounding dif®culty of this interchange is that it takes place in an emotional state in which the attributes of the subject in relation to the other, which were learned during the original traumatic events, are reactivated. He or she, for example, is helpless, stupid, bad and confronting someone who is controlling, critical and devaluing. The interpretation tends to be understood in terms of these ``cognitions,'' and as their repetition. Piper and his colleagues11 found that frequent transference interpretations may cause the patient to feel criticized and withdraw. This might contribute to the ``deterioration effect'' identi®ed by Bergin in the late 1960s. A second possible explanation for the failure of transference interpretations in these studies is that they may have been theory driven. As is well known, Freud found that at the bottom of hysteria, the condition upon which psychoanalysis was based, ``there are one or more occurrences of premature sexual experience.''12 Not long after writing this he came to mistrust his original data. He now concluded that rather than memories of actual trauma, the pathogenic factor was a phantasy, or series of phantasies relating to sexual wishes. He considered that transference phenomena make ``the patient's hidden and forgotten erotic impulses immediate and manifest.''13 The patient ``is obliged to repeat the repressed material as a contemporary experience.''14

Dissolving the trauma

193

Although the details of the repressed have altered and enlarged to include hostile and destructive wishes, the underlying principle of transference interpretation remains the same. The aim is to make conscious that which is unconscious. As Arlow put it in 1985, speaking from the context of the North American ego-psychological tradition: ``The essential principle of the entire psychotherapeutic approach . . . is to demonstrate to the patient the persistent effect of the unconscious wishes that originated during childhood.''15 More recently the conceptions of what is unconscious have broadened so that the manifestations of transference are seen, in a more general way, as ``distortions,'' leading ThomaÈ and KaÈchele, in their authoritative text, to state: ``The transference neurosis is said to be resolved by the patient's realization that his perceptions in the analytic situation are, to a greater or lesser degree, gross distortions.''16

Cognitions Freud's abandonment of his original ``seduction'' theory has led to an interpretive style which, in many cases, is theory driven. Interpretations are made about what the therapist believes is ``repressed.'' When Aaron Beck came to work with depressed patients, he did so under the in¯uence of Freudian theory and practice. He believed, at the time, that psychoanalytic formulations were ``correct'' and carried out studies designed to validate them. However, some of his ®ndings contradicted the theory, causing him to question the validity of the whole psychoanalytic edi®ce. At the same time he became aware that theory-driven interpretations were received adversely by his patients. Beck now changed direction and began to focus on the patients' descriptions of themselves and their experiences. Their ``cognitions'' had the quality of ``distortions.'' This led to the therapeutic practice of cognitive behavior therapy (CBT), in which the therapist systematically attempts to correct these distortions. The therapy in this way resembled the aim of the psychoanalytic interpretation. Beck's method, however, had the advantage. He was working with the patient's actual experience.17 This form of therapy, as is well known, has been shown to be useful. However its usefulness has its limitations, particularly in working with more severe disorders. A principal reason for this is suggested in the following section.

The effect of the relationship There is a limitation in therapeutic effect when cognitions are tackled alone. Distorted attributions are part of a complex of feelings, impulses, wishes and so forth, and a habitual form of relatedness. In addition, this whole traumatic complex is hedged about by anxiety-driven systems, including

194

Part III: Ampli®cation and integration

those of avoidance and accommodation. A further complexity is created by unconscious memory. The individual is not wholly aware of the attributions he gives to himself and the other in a particular situation. The response may be almost automatic. A considerable ¯eshing out of the whole experience is usually required before the malignant effect of the complex can be overcome. However, there is a fundamental characteristic beyond and more general than its various constituents which is central to the effect of the complex of traumatic memory. Janet touched upon it. He wrote: The power of such ideas depends upon their isolation. They grow, ``they install themselves in the ®eld of thought like a parasite'' and the subject cannot check their development by any effort on his part.18 Janet, like Charcot, portrays the traumatic and dissociated system as a parasite, a life form different from the ordinary ongoing consciousness of self. This notion, although ®guratively expressed, is crucial and supported by observations from research authorities such as Endel Tulving who considers that the various systems of memory are governed by different laws. What are the main differences between these two states of mind? First, the traumatic memory is ®xed in a hypertrophied and linear kind of mental activity that is necessary to dealing with the environment and which was mentioned in earlier chapters. The underlying brain function is manifest in a particular form of language. When traumatic experience underlies the conversation, the language becomes a limited kind of ``social speech,'' taking the form of ``chronicles'' or ``scripts.''19 The consciousness, as Janet put it, is constricted. A second major difference, of course, involves re¯ective awareness, which is lacking in the traumatic state. Traumatic memory is a form of psychic life alien to re¯ective consciousness. Because of its different nature, it remains sequestered, unable to mingle with the experience of self. Consciousness now becomes one thing or the other, a series of switching states, as if between black and white. A major therapeutic objective must be to help overcome this potential splitting in consciousness, a cardinal feature, as noted in earlier chapters, of the borderline condition. The traumatic memory system must change in its form so that it becomes more like re¯ective or dualistic consciousness, allowing it to mingle or, as it were, to dissolve in it. Janet described a method of dealing with traumatic memory which he called ``liquidation.''20 Since the approach outlined here does not replicate the Janetian method, I am using the expression ``dissolving the trauma.'' In order to allow the dissolution of the traumatic material into the consciousness of self, it is necessary to have a self present in the ®rst place, into which the destabilizing and diminishing memory system can be integrated. The establishment of self must be a priority.

Dissolving the trauma

195

Self, as previously remarked, is not a ®xed state. It comes and goes, according to the individual's interplay with the environment. A particular form of relatedness with others is necessary to the generation and maintenance of self. That kind of relationship has the quality of empathy. Unsurprisingly, it has been shown that outcome with CBT is robustly related to how empathic the patient feels the therapist to be.21 As a converse to this ®nding, we might predict that where the subject has the capacity to form good relationships the consciousness of self will be developed and so also will the capacity to process traumatic material. This prediction seems to be supported by a consideration of some of the data from the Piper study of transference interpretation.22 A group of 64 subjects were divided in terms of high and low ``quality of object relations'' (QOR) scores, which give a rough index of the capacity to enjoy satisfying relationships. In low QOR subjects, the greater the amount of so-called ``accurate'' interpretations, and the poorer the therapeutic outcome became. On the other hand, in those whose QOR was high, indicating the subjects' ability to establish good relationships, the volume of ``accurate'' interpretation was unrelated to outcome at termination of therapy. However, at follow-up there was a positive association between the level of interpretive behavior and general symptomatic improvement. This study suggests that the quality of relationship that an individual typically forms, and which will include the relationship with the therapist, in¯uences the capacity to ``use'' the therapist's interpretations. The data are consistent with a body of literature suggesting that the quality of the therapeutic relationship is strongly predictive of therapeutic outcome.23 Freud also remarked upon the signi®cance of the relationship. Having begun his work in the intellectual climate of the ``pathogenic secret,'' of which the af¯icted subject must be purged by means of catharsis, he later discovered something different. He wrote: ``The personal relation between doctor and patient was after all stronger than the whole cathartic method.''24 Aaron Beck had, at the outset of his endeavor, anticipated such a ®nding. He recognized that particular qualities of human relating are necessary to ``an optimum therapeutic effect.'' Following the humanistic approach of Carl Rogers, he identi®ed the desirable characteristics of the therapist as warmth, accurate empathy and genuineness.25

The model of mourning The original traumata were experienced as blows. The derision, the belittling, the derogation, or whatever it was, was felt like a hit. The triggering of the traumatic memory has a similar effect. There is a sharp and instantaneous feeling of distress of various kinds. This instant is not connected to the rest of life. It is an interruption in going on being. The

196

Part III: Ampli®cation and integration

sudden death of a friend or family member is felt in a similar way. The news brings an inrush of devastation. Recurring memory of the event evokes the stab of grief. Mourning is the means of dealing with an event which is part of human life. It is a universal practice which has many different variations across cultures. However, there are certain customs and behavior which are common to many rituals of mourning. They might act as a guide to dealing with trauma in general. Hobson's description of bereavement shows the resemblance between this event and other forms of trauma.26 There is, ®rst of all, shock. The individual might be as if stunned, and af¯icted, for a time, with a sense of unreality. This is followed by a period of disorganization in which ``there is commonly an interweaving of themes with ®ve characteristics, bodily distress, preoccupation with the image of the deceased, hostile reactions, guilt feelings, and loss of usual patterns of conduct.'' Finally, and slowly, there is reorganization. The individual re-enters the world of others with his or her life shaped anew. The traumata upon which the book focuses are not as severe as those of bereavement. They consist of the repeated hurts and slights which individually are innocuous but which leave their scars when accumulated over months and years. They are an effect of the pervasive atmosphere in which the subject grew up. Although each ``attack upon value'' is small, the consequence of its repetition is great, shaping an individual life, as exempli®ed by the story of Marguerite. Although seemingly different to bereavement, an approach to the traumatic memory system built up, as Janet put it, from ``a succession of slight forgotten shocks,'' ``from actual events that recur every day,''27 has similarities to aspects of mourning. The similarity is more obvious when the more severe forms of traumata are involved. The ``slight forgotten shocks,'' and the more severe traumata, such as sexual abuse, are both likely to play a part in the developmental background of those who suffer borderline personality disorder. These two categories of trauma are hidden in different ways. In the former case, the subject is unaware of the way in which his or her life is being undermined; in the latter, the hiddenness is typically conscious. The traumatized person has a phobia of the memory and, as a consequence, does not reveal it for fear of reliving the experience. One woman, for example, waited 30 years before she could tell her husband of a rape which occurred before their marriage and which affected her whole life. Another woman who had been sexually abused by her father was unable to reveal this ``pathogenic secret'' to those who treated her for repeated severe depression, which required hospitalization, and which recurred over 30 years. What she eventually revealed was not ``recovered memory,'' but memory that had persistently tormented her. Whatever the kind of trauma, the memory of the event or the events has to be changed, as Pierre Janet made clear in his description

Dissolving the trauma

197

of ``liquidation of trauma.'' It must be transformed from a sudden, almost instantaneous distress which slices into, and has no connection with the experiences of ordinary living, into an experience which can be integrated into the larger consciousness of self, including its past of memories and its future perspectives. ``Memory,'' said Janet, ``is an action; essentially, it is the action of telling a story.''28 The activity of this kind of memory comes with the emergence of dualistic consciousness. However, it does not usually come all at once, but in bits and pieces, haltingly. As the story is told in its different forms, it is linked up to the rest of life. Janet wrote: The action of telling a story, is, moreover, capable of being perfected in various ways. The teller must not only know how to do it, but must also know how to associate the happening with the other events of his life, how to put it in its place in that life-history which each one of us is perpetually building up and for each of us is an essential element of his personality. A situation has not been satisfactorily liquidated, has not been fully assimilated, until we have achieved not merely an outward reaction through our movements, but also an inward reaction through the words we address to ourselves, and through the putting of this recital in its place as one of the chapters of in our personal history.29 The important story of a life is not told as events recounted for legal evidence, but rather in the way the child tells it, engaged in symbolic play. Certain of the rituals of mourning portray something of the pathway towards integration. In these customs the loss of the dead person is linked up not only to the world of self but also to the world of others. The ritual plays out, in an overt and even exaggerated form, the state of the bereaved. The sense of isolation of the bereaved is ritualized in prohibitions which set this person apart, cut off from may aspects of usual living. Then, at the funeral ceremony itself, grief is highlighted by behaviors such as mourners gashing their bodies, weeping and wailing in a prolonged and organized way, so as to represent the experience of the bereaved, to lay it out before their eyes and ears.30 The character of the occasion then changes to become celebratory. Play and pleasure replace the manifestations of grief. The person is drawn into activities such as feasting, singing, and dancing. In this way, the subject is brought back into the fold of his or her social environment. A famous example is provided by the funereal procession of jazz bands going through the streets of New Orleans. Another example of this custom is the Irish wake, in which over a long period of drinking and talking, the mourners, sometimes laughing or crying, tell stories about the dead person. They themselves may be participants in these stories. These tales are an aspect of the ``recital'' of which Janet spoke.

198

Part III: Ampli®cation and integration

Aspects of treatment Awareness of the pathogenic signi®cance of psychological trauma has been attained relatively recently. As a consequence, effective treatment methods have had only a limited time to evolve. Current methods of treatment are likely to be re®ned and improved over the next few years. The model of dealing with traumatic memory which is brie¯y outlined here is based on experiences with people who have suffered developmental trauma. The approach differs from current methods of treating single critical incidents such as witnessing a murder or surviving a house ®re. Exposure is the most frequently used treatment in these cases. It is inappropriate and likely to be harmful to those people with whom this book is most concerned. In the following few pages, certain of the principles involved in ``dissolving the trauma'' are touched upon. The form of the relationship is an essential element of the process. The therapist must enter into the traumatic experience while, at the same time, maintaining a psychic ``doubleness'' through his or her perspective upon it. The therapist should not merely act like an observer, in a state of ``technical neutrality.'' Preparation and safety When treatment begins, explanations are given about the purpose of treatment and how it is to be carried out. It is helpful for people to understand something about the intrusion of unconscious traumatic memory into the therapeutic conversation so that they may better identify it when it occurs and feel able to talk about it when it does. Some practitioners ®nd it useful to explain, in simple terms, the hierarchy of memory and to give the person something to read which adds to the explanation. It is also important to let the person know that they will not be pushed into revelation if there are things which he or she would ®nd very dif®cult or painful to talk about. The time to talk of such things is when the person feels ready. It is imperative that an atmosphere of safety and trust is created prior to the processing of trauma. Setting the scene The intrusion of unconscious traumatic memory, described in earlier chapters, offers an opportunity to process the trauma, which is now alive in the present. It is not necessary, however, to pounce upon every piece of evidence which shows this intrusion. In some cases, one would be unable to develop any conversational ¯ow if such a practice were followed. The ®rst steps to take, when the intrusion has been disruptive, is, in some way, to make a correction, to right the ship. It is necessary to restore the system of self before any further processing is done. This may involve not

Dissolving the trauma

199

much more than what Kohut did with Miss F who, presumably was a person who had never been ``heard.''31 He showed that he had been listening by summarizing what she had been speaking of. Restoration of the sense of connection between the therapeutic partners, necessary to the experience of self, may be fostered by the therapist acknowledging his or her part in the disruption. If the therapist feels that re¯ection upon the incident is now possible and potentially useful, he or she can start the re¯ective process with a remark like: ``Let's have a look at what happened just then.'' The whole experience is then laid out, in as much detail as possible, including, most crucially, the feeling involved. A scene is now created which, has in it, the essential features of all the previous events of a similar kind which have occurred during the individual's lifetime. It is, to use Joseph Lichtenberg's expression, a ``model scene.''32 Play The person is now asked, using appropriate language, to use this scene as an object of play,33 to wander around in the mind in order to see where it leads, to ®nd links with other episodes of this experience. It may now lead to the remote past. The person is now helped to turn a general and verbal account into one which is speci®c and sensorily alive. For example, ``it was like when I was little'' becomes a particular episode, seen before the ``eyes of the mind.'' The image is more fundamental than the word. Changing the story The traumatic story must change for integration to occur. Janet often changed the story in a very direct and literal way. For example, Marie suffered an anesthesia of the left side of the face and blindness of the left eye. He discovered, under hypnosis, that the origin of this symptom was the loathing and alarm she felt as a child when forced to sleep, on one occasion, in the same bed as a child whose face on the left side was covered with scabs of impetigo. She was cured of this symptom after several more hypnotic sessions in which he convinced her that the child was free of the impetigo.34 Such a direct approach is not advocated here. The story is changed indirectly. First, the form of consciousness changes from non-re¯ective, to re¯ective consciousness. Second, the linearity of a story which connects with nothing else becomes a somewhat different story when experienced in a non-linear, associative and play-like state of mind in which links are made to other memories and imagings. Third, there is a change in the experience of the other. This comes initially in dealing with the disruption. The effect is

200

Part III: Ampli®cation and integration

compounded if the telling of the story is suf®ciently alive and immediate in its telling. The person who is with one in this experience is unlike the ®gure of the original traumatizer. The feeling at the core of the story is somewhat different. Each of these shifts in the form of consciousness must be correlated with a changed brain state.34 The changed feeling of relatedness is particularly important in those cases of revelation of a memory, say abuse, of which the person is phobic. After a period, when safety is established, the person may begin to tell of events which resemble the abuse, which may trigger the actual experience. The person will have previously avoided these topics for fear of this occurrence. Now a risk is taken. If the actual memory is activated it may release a ¯ood of terror, despair, and shivering helplessness, like that of a small child. The calmness of the other and the sense of safety in this re-experiencing allows a small shift in the transformation of the memory.

Narrative of self 36 The story is told in many different ways as it emerges, often in disguise. The telling extends to include the internal triggerings of the traumatic memories and also those ``satellites of trauma,'' the various systems of restoration, accommodation and avoidance and so forth which are related to it. This ampli®cation of a memory system, which was originally circumscribed, involves its placement ``in that life-history which each one of us is perpetually building up and for each of us is an essential element of his personality.''29 But this life history must become more than a chronicle. People can ceaselessly recount the traumatic events of their lives but nothing changes. The story must enter the zone of the symbolic and be retold, as previously remarked, in a way which is reminiscent of the story being told by the child at symbolic play. The person who tells this symbolic story does not know that he or she has done so. Typically he or she will not have read Jung, known of the myth of the hero, nor have an extensive education. The shift into the symbolic mode is entirely natural. The following is an example. A boy of 16 was referred by a lawyer because he had been charged with minor theft. He came from a semi-rural slum where he lived with his mother who had been abandoned by the boy's father. He was morose and monosyllabic. Therapy seemed a hopeless task. However, it emerged that he had a poster concerning Ned Kelly in his bedroom. The therapist felt it necessary to study the story of the Australian bushranger about which he became fascinated. He and the boy talked about Kelly. It was clear that in the story of Kelly's hard life, his tough mother, his rage and sense of persecution, his omnipotence and, against all odds, his emergence with heroic stature, was a tale which resonated

Dissolving the trauma

201

with boy's own deprivation and desire to overcome it. However, no direct connection was ever made between this symbolic narrative and the boy's own life. Nevertheless, something of a transformation occurred. The boy came alive and approached his future with unexpected optimism.

Chapter 23

A self-organizing system

This book has been about the emergence of certain kind of life, a form of consciousness, which is likely to be unique to the human primate. It is a state which is inherently frail and evanescent. In some people, the emergence is partial or stunted so that existence consists of the various other states of mind to which we have access. These states, although adaptive in their own way, are felt as diminishing. Not only is existence cramped and hemmed in by the rattle of the world, its impacts and the reactions to them, it is also deeply dissatisfying. There is a pervasive dysphoria which includes, to a greater or lesser degree, a feeling of deadness. The quest, in these circumstances is for a larger, or ampli®ed, sense of existence in which there is felt well-being and aliveness. The discovery, however, of this new state of consciousness is not a straightforward matter. It cannot be approached as a simple problem of correction by, for example, instruction. Just as Winnicott said of a baby,1 we can say that there is no such thing as consciousness. To talk of such a thing is to speak of an abstraction. A baby cannot exist in isolation, independent of a human environment. Neither can consciousness stand alone. It is an aspect of an ecology, or dynamism, of which the environment, particularly the human environment, is an essential part. The main point of the book can be summarized in the following way. The state we are calling self is one of the numerous different forms of consciousness which shift and change during ordinary existence. Every one of these states of consciousness arises out of the brain's interplay with the sensory environment. The most important part of the sensory environment, in terms of the experience of selfhood, comes from other people. Taking these two statements together we can say that the experience of self arises in the context of a particular form of relatedness. This particular form of relatedness is mediated by conversation. These various elements, the consciousness, the brain function, the conversation, make up an ecology in which a change in one element causes all the others to change. Conversely, no element can change unless the other components also alter. A new form of consciousness can come into being

A self-organizing system

203

only in the context of a particular form of relatedness which is constituted by, and manifest in, a particular kind of conversation. This way of talking together, and the relationship from which it emerges is, therefore, the transformational element. What this transformational conversation feels like is implicit in Piaget's description of symbolic play, that activity going on in the world which shows the origins of the state of mind which later on becomes self, involving a sense of innerness. His quotations from the speech of children playing in this way suggest that a funny kind of conversation is going on (Chapter 6). The child is speaking to himself and also to someone else, at the same time. As Piaget points out this language is ``undoubtedly a case of social relationship.'' The relationship, he believed is with the mother. The sense of her presence permeates all of the child's acts and thoughts. What he says does not seem to him to be addressed to himself but is enveloped with the feeling of a presence, so that to speak of himself or to speak to his mother appear to him to be one and the same thing. His activity is thus bathed in an atmosphere of communion or syntonization, one might almost speak of ``the life of union.''2 The atmosphere of union is curious and almost paradoxical. Piaget describes a feeling of intimate connection which is not one of fusion. The apparently oblivious child displays his or her own sense of aloneness in an absorption which gives an appearance of egocentricity. At the same time, the feeling of being with the other ``bathes'' the child's whole experience. Piaget's sensitive and empathic portrayal of the boy he observes depicts him in a relationship with his mother which is a forerunner of the mature relationship which Hobson called ``aloneness±togetherness.'' Hobson had written in the paper which launched the project of the Conversational Model in 1971: Much of the work of psychotherapy is concerned with establishing the state of aloneness±togetherness by resolution of an ``idealized'' fantasy of fusion which goes together with social isolation.3 This remark implies a revolutionary shift of therapeutic focus. The relationship is the primary therapeutic agent. The aim is to transform a relationship underpinned by alienation, however unrecognized, into another which has certain of the qualities of intimacy, and which is mediated by a different kind of conversation. ``Aloneness±togetherness'' is not the same as intimacy since it is asymmetrical. Something of the essential nature of this form of relatedness is seen in Erasmus's description of an apparently strange state of mind, which he likened to ``folly.'' However, the difference between Erasmian ``folly''

204

Part III: Ampli®cation and integration

and ``aloneness±togetherness'' is also essential. Erasmus spoke of a way towards understanding the world of another by ``entering into'' it. This state of ``migration'' into the other is, implicitly, that made by a single person. The state of being alone and together at the same time describes a shared state of ``innerness,'' an ideal towards which the therapy moves. Something is created in ``the space between,'' a concept Ainslie Meares appropriated from Japanese art. He remarked that in this zone of experience ``the meaning of closeness and distance becomes important.''4 Something of the form of this shared state is intimated by the notion of the metaphoric screen at which both partners, ®guratively gaze, attempting to glimpse and elaborate outlines of the kind of life that it portrays and which, at the same time, they are creating. The ``screen'' is the third thing of a triadic relatedness. The metaphor of the screen, however, does not quite capture the kinetic, or dynamic, element of the relatedness I am trying to describe. The reverberations which go on in the ``space between'' involve more than the interactions of a dyadic relationship. Resonance better describes the form of interplay. It can be ®guratively represented in terms of Mandlebrot's fractal geometry. Mandlebrot demonstrated how out of a simple reverberation between representations, complex and beautiful patterns could arise.5 Mandlebrot's equation starts with a representation Z, which is then squared, Z2, and a constant c, added to it. Z2 + c becomes the new Z which is squared and the constant c added to it and so on. Using this formula as a metaphor, we can call the subject's most immediate and fundamental experience Z. The therapeutic response, Z2, is a re-representation of this experience, made somewhat larger or clearer. This re-representation always includes something of the therapist, c. Z2 implies the constraint and focus of the therapist's contribution to the therapeutic conversation. It is linked to the experience of the other. Mandlebrot's fractal geometry is one of the forms of the mathematics of complexity which is now being developed as a means of gaining some understanding of living systems, these being conceived as self-organizing networks. Self, we might say, is a self-organizing system. Its essential iterative or reverberating nature is ®rst dependent upon the outer world, and the responsiveness of others. Slowly, the experience of the other is made internal, so that a consciousness which was originally single becomes double and an internal iteration or resonance is now possible.

Phase transition The characteristics of a self-organizing system are coupling, ampli®cation, and representation.6 These terms encompass, to a signi®cant extent, the

A self-organizing system

205

main features of the therapist's contribution to therapeutic conversation, which were touched upon in Chapters 20 and 21. The metaphor of complexity suggests that after a certain number of iterations, a phase transition occurs. Originally the term applied to the sudden changes in state which, for example, H2O makes when water turns into steam, or when non-magnet turns to magnet, or when conductor becomes superconductor.7 The term was later applied to fractals and that crossing of a threshold at which, unexpectedly, new patterns emerge.8 This kind of shift might be analogous to the emergence of dualistic consciousness out of a previous state of adualistic consciousness. The sudden change in Marguerite's form of conversation is an example (Chapter 21). Here is another. The patient, Vera, is in her thirties. Her history is a terrible one. She was conceived in rape and had to endure, for her entire life, her mother's hatred and continued accusation, ``You're just like your father.'' When Vera was about 4, the mother had married a kindly man. However, he died a few years later. Vera's adolescence was troubled. She, like her mother, was raped. In her twenties she developed the stigmata of a borderline personality disorder. There were overdoses, self-mutilation, hospital admissions, and dissociative episodes. Some of these episodes reached the severity of fugue and involved auditory hallucinosis. Despite this, she managed to stay in a marriage with a kindly older man who may have evoked the positive experiences with her dead stepfather. After eight months of treatment with Dr A, Vera has made remarkable progress. However, Dr A has been maintaining her on antipsychotics, which she was taking at the time of her referral. Seeing that Vera is now greatly improved, Dr A wants to modify this medication as a means of working toward its cessation. He remarks that he is ``anxious'' about its potential side effects. Vera, in a cheerful voice and in a teasing way, says, ``What, you suffer from anxiety? Is that what you're saying?'' Dr A laughs, reiterating that he is worried about her developing side effects. She is now also laughing, ``I was going to say that's different ± a doctor suffering from anxiety and trying to treat it.'' They now go into a kind of laughing banter they both enjoy. In a way, they are playing a game. Their behavior resembles that described by Ehrenberg and Feiner9 in their advocacy of ``play-like'' activity in therapy. It should be noted, however, that Dr A is acting with a double-awareness throughout the exchange. He knows what he is doing. He sees his responsiveness as something like the coupling and ampli®cation that the mother's resonance brings into conversational play.

206

Part III: Ampli®cation and integration

At the height of their enjoyment, laughing and ``joining in'' with her Dr A spontaneously tells a brief joke about a doctor in need of medical treatment. After their laughter dies down, the patient says ``He was forgetting he was a doctor himself?'' In what follows, Dr A judges the effect of his unorthodox behavior. There is a pause. Vera says, in a quiet and contemplative voice, ``I like this weather we're having.'' At this point, Dr A's judgement about the effect of his spontaneity is equivocal. On the one hand, Vera's attention is directed outward, suggesting a disjunction; on the other hand, there is a tone of positivity in the remark. The conversation continues: Vera: Dr A: Vera: Dr A: Vera: Dr A: Vera: Dr A: Vera: Dr A: Vera:

I love it when it rains. Mmm. I like the cooler weather, yeah; I don't like the heat. Yes, yes. Cold weather. Yes, and playing with the rain. And it's like a child, isn't it? Children like the rain. Mmm. Yeah, it feels very ± also when it's raining ± in the car ± it feels very secure like a security thing when I'm in the car. Yeah. And the rain's falling. And you're getting wet. Mmm. I've always felt like that, but I don't know why, but that's how it feels. Interesting. Mmmm. I've always felt like that, but I don't know why, and yeah, I remember when I was ± um ± I was in a pram, and I was as baby, and I remember my mother and walking one night, and I could see, you know, the traf®c lights changing colors and the cars, and it looked really pretty. I remember that. I remember feeling very secure and warm, sort of snuggly sort of thing.

In an individual whose conversation earlier in therapy was stimulus entrapped, replete with somatizing references and in the style of a chronicle, this is a remarkable movement. The beautiful autobiographical memory of the streetlights in the misty rain is the ®rst of its kind to emerge in this therapeutic conversation. It appearance indicates re¯ective activity. There has been a phase shaft from adualistic to dualistic consciousness. This extract shows that the terms coupling, ampli®cation and representation are to some extent abstractions, since they do not always appear in

A self-organizing system

207

pure form but in association with each other. Empathic representations ± ``and playing with the rain'' and ``you're not getting wet'' ± are woven into an interplay in which coupling and ampli®cation are also involved. It should also be noted that although the phase shift follows a particular contribution from the therapist, the movement towards ``higher order consciousness'' is not attributed to this contribution alone but to the series of responses which led up to it. The steps towards the overt appearance of re¯ective consciousness displayed, for example, in a way of remembering or imagining, are also sometimes shown in a series of remarks or stories that the patient brings to the conversation. As we have seen, someone whose personality development has been disrupted in early life begins treatment in a characteristic manner. Such people have been damaged in a way not immediately obvious. They live almost entirely in the zone of adaption. Experience comes, overwhelmingly, from the outer world. Consequently, the story they tell deals with events, troubles, and dif®culties rather than imaginings. In terms of the metaphor of the play space, they live in the real playroom. As this story is recounted, it is apparent both to the teller and the listener that although everything in it seems relevant, sensible, and necessary to be told, it is, in some fundamental way, entirely unsatisfactory. Such a historical record of an individual life, although real in terms of the happenings described, does not feel real. It seems to be about things going on outside. The task is to help this person discover another reality, which is personal and which comes from within. The change that comes about is analogous to the child's move from the real playroom to that which involves illusion. Activity is no longer, as Piaget put it, ``adaption to reality, but on the contrary, assimilation of reality to self.''10 The manifestation of this experience, however, is no longer evident in its relatively pure form, as it is in the child's chatter, which with its condensations of language, its associational quality and its improbabilities, resembles the structure of a dream (see Chapter 6). Rather, it has its effect below the surface, breaking it up. When in a session, an inner or private language begins to show itself, it has a nonlinear form, altering the patterns of secondary process. Rather than a seamless narrative, one can look back upon the session and see that it was made up of a number of apparently disparate stories, re¯ecting an underlying ¯ux of images, feelings, and memories. Essential features of this emergence are shown in the following rather typical story. The patient is a woman in her ®fties who has had a very hard life. The poverty of her parents caused her to be placed in an orphanage in a country town at the age of 3. She stayed there until she was 10. She had intermittent care from an aunt and after this, little schooling, then factory work. Over the years she

208

Part III: Ampli®cation and integration

was sexually exploited in various ways. She is now married, with two children, and the presentation is because of an intractable depression, not treatable by medication. Her characteristic conversation with her therapist is about the dif®culties of her life. The accounts of these problems are interspersed with a mirthless laugh, which seems to have the purpose, not of registering amusement, but of engaging the therapist. Each session she comes with a different catalogue of symptoms. The therapist constantly seeks to understand and respond to her immediate experience. After some months, a change begins to occur in her life. Instead of orienting herself entirely outward, toward others, she now thinks of her own development. She decides to take a course of study. Some weeks after this, she starts the session with the unexpected news that she feels well. Soon she is talking about issues of her course that interest her. They are, ®rst, women's issues and then language. Imperceptibly, she moves to the story of the maltreatment of the Australian aboriginal population by the white settlers. She then discusses a newspaper account of a disadvantaged man who has succeeded in a social sense. Her story then moves again, without clear linking, to the orphanage at night. She is lying awake and hearing a cow bellowing out in the ®elds. Then she said, ``I seem to have lost the point. I wonder why I thought of the cow just then.''

The point of this story is that she has not lost the point but has started to ®nd it. The past is there in her story, but it has an unusual aliveness. She is not telling the therapist something like ``I often felt lonely in the night at the orphanage.'' The memory is recovered in the eyes of the mind so that the past is with her in the present. She has entered a different zone of consciousness, the dualistic. Moreover, the image of a bellowing cow, who perhaps has lost her calf, and the related one of the little girl who cannot sleep, evoke echoes of isolation and coldness, implying layers of associations in the manner of poetry or dream. What has happened in this session? First, great changes have come about. One of the most important cannot be shown in a transcript. Whereas the therapist has for months had to overcome the feeling of boredom in the face of the endless clamor of everyday life thrust upon him by his patient, he feels differently during this session. His sense of interest is aroused, which, by the time the memory of the orphanage at night is reached, becomes compelling. We are reminded of the observations of Baldwin regarding the effect of interest associated with play. This positive affect is associated with the patient's changed state of consciousness. A second change involves the form of the conversation. In the past, her thought was undeviating, as if caught on a tramline, concerned with the

A self-organizing system

209

ceaseless quotidian. In this session, the account is nonlinear. It is made up of a series of episodes, which Barthes11 might call lexias and which super®cially may not be connected. Nevertheless, they are clearly linked. The movements between them are smooth, not made by jumps or sudden changes of topic. She touches upon what it is to be a woman, the signi®cance of language, the maltreatment of a deprived group, the struggle of an outcast, the loneliness of an abandoned child. These various episodes arise from something more fundamental, which underlies them. They all derive from the personal reality of a woman who has never been properly responded to and who has found no words to express what is essentially her own private experience. This series of lexias shows narrative progression. The episodes are linked as an evolving chain. They differ from the series which followed the intrusive interpretation which in¯icted upon the patient a sense of violation. In this session, the therapist, who admired the woman's courage, is rewarded for his patient efforts, made over months, to put into words what he has understood of her feelings and personal world. The mental activity that underlies play has been activated. What is evident, however, is not the behavior of the transitional child at play, but something different. The patient has moved into an experiential space, in which two forms of mental activity are working together. Public and private are coordinated, as described in Chapter 7. The conversation which, as previously stated, constitutes and manifests both a form of consciousness and a form of relatedness, has changed. These examples of phase transition occurring in the therapeutic conversation seem marked or even spectacular when highlighted as vignettes. However, the therapists themselves did not notice what had happened. They were aware of something more general, a feeling that the conversation had become more alive and that things were moving better. Small shifts are occurring throughout a conversation. We might suppose that the evolution towards a more satisfying kind of personal existence progresses through a large series of relatively small movements in the extent, the vitality,12 and the ``shape'' of psychic life. These small movements may be indicated by the appearance in the conversation of, for example, discrepancies, strange intrusions, unexpected memories and apparent condensations, perhaps expressed as a metaphor or an unusual word. It is hard to describe exactly what has happened at these points, just as it is dif®cult to depict in the language of prose the experience of a poem. In simple terms, however, we might say non-linearity is breaking into the linear speech of social discourse. Put another way, two forms of human language, displayed in early life in the two playrooms, have become coordinated so that within social speech and the form of language built for dialogue with the outer world there appears the embedded elements of another kind of speech through which self can be realized.

210

Part III: Ampli®cation and integration

Conclusion Models of mind are necessarily based on metaphor. Older models used the imagery of mechanics and hydraulics. A more recent vogue focuses on the computer. A computer, however, is not like the brain-mind system. Nor is it like life. In this book, self is conceived as a form of life. The model of its origins, which guide an understanding of its disruptions and its therapy, is taken from observations of human development. This conception is larger than play alone since, for the life of the self to emerge, another person is required. Out of the resonance of a particular kind of conversation between two people in which, crucially, there is a sense of ``fellow feeling,'' a larger consciousness comes into being, and is manifest in language. The form of the interplay resembles those systems out of which life evolves from its very smallest manifestations to the larger systems of ``the living Earth.''13 The emergence of the ``life of the mind'' is heralded by the individual sensing a change from monotony and stagnation to a state in which is sensed the movements and feeling of the Jamesian ``stream of consciousness.'' The therapeutic conversation might now show the elusive, capricious, associative shape of the ¯ow of inner life. AnaõÈs Nin remarked upon this change which arose during her treatment with Otto Rank. During another later therapy, she noted in her diary: ``Analysis has to do with ¯ow. I am ¯owing again.''14

Notes

Preface 1 The Conversational Model is one of the best validated of currently employed psychotherapies. An abbreviated version of the model has been manualised as ``psychodynamic-interpersonal'' (PI) psychotherapy. (Shapiro and Firth 1985; Shapiro and Startup 1990). PI has shown to be effective in depression (Shapiro and Firth 1987; Shapiro et al. 1994; Shapiro, Rees and Barkham 1995), in certain psychosomatic disorders (Guthrie et al. 1991) and to be cost-effective in treating repeated users of clinic services (Guthrie et al. 1999). A brief form of PI is useful in reducing repeated episodes of self-harm (Guthrie et al. 2001). The Conversational Model produces bene®cial effect and is cost-effective in the treatment of borderline personality disorder (Stevenson and Meares 1992a, 1992b; Meares, Stevenson and Comerford 1999; Stevenson and Meares 1999; Hall et al. 2001; Stevenson, Meares and D'Angelo 2005).

Acknowledgements 1 Meares, A. (1958). 2 Meares, A. (1961, 1962). 3 Hobson (1985).

1 Play and the sense of self 1 Harter (1983, p. 226). 2 Strachey (1961, p. 8) pointed out that Freud did not clearly distinguish between ego and self until late in his life. Hartmann (1939) is seen as the pioneer of ``the conceptual separation of the self from the ego'' (Kohut 1971, p. xiii). 3 Picabia was a star of the Armory Show of 1913, a highly in¯uential exhibition in New York, which presented European art to an American audience (Borras 1985). Malevic portrayed people constructed of cones and cylinders at about the same time as Leger produced very similar machine-like images (Gray 1986). 4 The idea that these men formed a loose intellectual grouping is illustrated by the index to an authoritative anthology of Piaget's work (Gruber and VoneÁche 1977). Only six people are referred to more than ten times. Edward ClapareÁde is one of them. He founded the Rousseau Institute in Geneva, which he eventually turned over to his pupil, Piaget. ClapareÁde had a close intellectual relationship with Baldwin, who is also one of the six. Baldwin was a friend of Janet. It is

212

Notes from pp. 4 ± 14

intriguing to learn that their ®rst meeting, since neither spoke the native language of the other, they resorted to Latin (Ellenberger 1970). Janet was also a close friend of Bergson, who was his advocate for a professorship at the ColleÁge de France. Both men are among the six to whom Piaget referred to most. The other two are his colleague, Barbel Inhelder, and Freud, with whom Piaget conducted a somewhat wary debate. It is of interest that the ®ve honorary members from Europe elected on the formation of the American Psychopathological Association in 1910 were ClapareÁde, Janet, Jung, Forel and Freud. 5 The shift in Zeitgeist which underpinned this state of the psychological sciences in the twentieth century is further discussed in Meares (2003). 6 This incident is recounted in Meares (1976, 1977). 7 James Mark Baldwin (1906) was perhaps the ®rst to put forward the idea that play is an important factor in human development. He anticipated many of the ideas of D.W. Winnicott (see Chapter 19). Johan Huizinga (1938) was also a pioneer of the view that play is important. He wrote: ``It is a signi®cant function ± that is to say, there is some sense to it. In play there is something `at play' which transcends the immediate needs of life and imparts meaning to the action'' (p. 19). He assumed ``that play must serve something which is not play, that it must have some biological purpose'' (p. 20).

2 The secret 1 2 3 4 5 6 7

8 9

10 11 12 13

Piaget (1929, p. 94). Piaget (1929, p. 34). Mahler, Pine and Bergmann (1975). Ellenberger (1970). Meares and Orlay (1988). Piaget (1932). Another means of determining the age at which the conceptualization of an inner world is achieved includes the study of false belief. For example, children are shown a box of Smarties (candies). When the children open it, they ®nd it contains pencils. The pencils are then put back in the box and the children are asked what another child who has not yet seen the box will think is inside it. Three-year-old children tend to say pencils (Gopnik and Astington 1988; Perner et al. 1987). The children respond as if there is nothing they know that other people do not know. This kind of experiment is the basis of studies of ``theory of mind.'' Peter Hobson (1991) has been critical of the use of this term. In a study of 50 children, performance on ``theory-of-mind'' tasks signi®cantly improved from ages 3.11 to 4.6, and again from 4.6 to 5.0 (Hughes and Dunn 1998). Simmel (1964). Jung (1961, p. 342) remarked that ``there is no better means of intensifying the treasured feeling of individuality than the possession of a secret which the individual is pledged to guard.'' Jung noted the importance of the act of secrecy in his own life, telling of a carved manikin he kept hidden in an attic. This episode ``formed the climax, the conclusion'' of his childhood (p. 22). Flavell (1968). Meares (1976). Gosse (1907, p. 58). St. Barbe Baker (1980). The quotation comes from a broadcast on the Australian Broadcasting Commission. His account of the soothing nature of his ``Madonna of the Woods'' is echoed by Jung (1961) in his description of his manikin: ``In all dif®cult situations, whenever I had done something wrong or

Notes from pp. 5 ± 21

213

my feelings had been hurt, or when my father's irritability or my mother's invalidism oppressed me, I thought of my carefully bedded-down and wrappedup manikin and his smooth, prettily colored stone. From time to time ± often at intervals of weeks ± I secretly stole up to the attic when I could be certain that no one would see me . . . I contented myself with the feeling of newly won security, and was satis®ed to possess something that no one knew and no one could get at. It was an inviolable secret which must never be betrayed, for the safety of my life depended on it. Why that was so I did not ask myself. It simply was so'' (pp. 21±22).

3 Self as a double 1 2 3 4 5 6

7 8 9 10 11 12

Armstrong (1981, p.59). Armstrong (1981, p. 63). Armstrong (1981, p. 65). Armstrong (1981, p. 67). James (1892, p. 176). The Jamesian ``I'' is not unlike the Freudian ego. Freud (1939). Freud described a mechanism that conducts an interplay between inner and outer worlds and operates as a complex decision-processing system. It is a conception that is larger than the I, for it determines not only consciousness, but also unconsciousness. However, it does not include the contents of consciousness. It contains nothing, neither memories, ideas, nor sensory impressions. James (1892, pp. 153±154). James (1892, p. 160). Hadamard (1945, pp. 142±143). AnaõÈs Nin (1939±1944, p. 264) noted this state of restoration during her treatment with Martha Jaeger. Meares (1980). Meares (1984).

4 I and the other 1 Zigmond et al. (1973). Konishi (1985) says that the study of birdsong has made signi®cant contributions to the development of modern ethology and that it has raised the controversial issues of instinct versus learning from the realm of semantic discourse and confusion to an experimentally tractable subject. 2 Bower (1974). 3 De Casper and Fifer (1980); Trevarthen (1987). 4 MacFarlane (1975). 5 Carpenter (1974). 6 McFarlane (1974). 7 Locke and Pearson (1990) describe the effects of deprivation of babbling. A child who had been tracheotomized was generally aphonic between the ages of 0.5 to 1.8. She was cognitively and socially normal, with near normal comprehension of language. Following decannulation, her utterances revealed a tenth of the canonical syllables that might be expected in normally developing infants. In this way, she was like a congenitally deaf child. Two months later (1.10), she produced only a handful of different words. It seems possible that hearing one's own babbling is a necessary precursor to the attainment of language. 8 Brazelton et al. (1975).

214

Notes from pp. 15 ± 30

9 Young (1974). McLean (1986) remarks that the behaviors of nursing and maternal care, together with audio-vocal communication for maintaining maternal±offspring contact, are forms of behavior that clearly mark the evolutionary dividing line between reptiles and mammals. He believes these behaviors are related to the activity of the cingulate gyrus and its subcortical connections. This system has no recognizable counterpart in the reptilian brain. 10 Klaus (1975). 11 Seifritz et al. (2003). 12 Trevarthen (1974). 13 Trevarthen (1983, p. 139). 14 Murray and Trevarthen (1985). 15 Baldwin (1897, pp. 338±339). In Kohut's terminology, the baby's conception of mother during this kind of interaction is not of an object who is a separate person, but of a selfobject, who is experienced as part of him or her, half of a single system made up of two major pieces. Noam et al. (1983) have pointed out the similarities between the conceptions of Baldwin and Kohut. 16 Penman et al. (1983). 17 Als et al. (1977). 18 Stern (1985). 19 Meares and Grose (1978); Meares (1980). 20 Perrett et al. (1987); Rossion et al. (2003). 21 Umilita et al. (2001). 22 Winnicott (1974, p. 131). 23 A failure to do so might lead to the subject's impaired recognition of emotional states, leading to make up what Stolorow and Atwood (1992, pp. 29±40) termed the ``unvalidated unconscious.'' 24 Beebe et al. (2003) extensively review research of the proto conversation in order to relate it to the therapeutic process. 25 Darwin (1872). 26 Izard (1971); Ekman and Friesen (1975). 27 Emde (1983).

5 The role of toys 1 2 3 4 5 6 7

Penman et al. (1981). Sorce et al. (1985). Bodle et al. (1996). Garvey (1977, p. 51). Piaget (1959, p. 243). James (1892, pp. 153±154). It is important to emphasize that the discussion here concerns conception rather than perception. The child of 3 years does not experience others as knowing of his or her inner states; he or she merely believes it. In this way is distinguished the putative world of the schizophrenic from that of the normally developing child. 8 Meares (1983).

6 Two playrooms 1 Piaget (1951). 2 Bornstein and Tamis-Le Monda (1997). 3 Piaget (1929).

Notes from pp. 31 ± 42

215

4 Winnicott (1953). 5 Cooper et al. (1985) and Morris et al. (1986) have found that borderline patients show behaviors that are soothing in a manner that has a transitional quality. Earlier papers, from Horton et al. (1974) and Arkema (1981), noted transitional relatedness in those with borderline personality. 6 Stevenson and Meares (1992); Meares et al. (1999). 7 This case is described in Meares and Anderson (1983). 8 Sorce and Emde (1981). Matas et al. (1978) found that infants who were securely attached at 18 months showed a signi®cantly greater amount of symbolic play at 24 months than those less securely attached. 9 Kohut (1971, p. 286). 10 Kohut (1971, p. 287). 11 Kohut (1984, p. 49). 12 A leading ®gure in the Kohutian movement, giving an introductory lecture on self psychology at an annual meeting of this discipline, explained to the audience that they were selfobjects to him. 13 Hobson (1985, p. 135). 14 Winnicott (1958). 15 The child's relative lack of a sense of ownership of his or her core experiences may contribute to the normal separation anxiety that is manifest between the ages of 6 to 7 months and 4 years (Meares 1986). This approach to separation anxiety is complementary to the Kleinian thesis, which depends upon the imagined power of the child's wishes. Both ideas can be derived from the more fundamental notion that before the age of 4, or thereabouts, the child does not conceive of an inner world. 16 Piaget (1959, p. 244). 17 Piaget (1959, p. 257). 18 Kohut (1977, pp. 171±219). 19 Piaget (1959, p. 242). 20 Piaget (1959, p. 243). 21 Vygotsky (1962, pp. 138±139). 22 Vygotsky (1962, p. 149). 23 Vygotsky (1962, p. 147). 24 Studies such as those of Herman et al. (1989), Zanarini et al. (1989) and Ludolph et al. (1990) suggest that very many people diagnosed as borderline in adult life were subjected to verbal, physical, or sexual abuse in childhood. The model for the development of borderline personality advanced here is consistent with Pine's ``Borderline-Child-to-be'' (1986). He states that the child who is destined to become borderline has had early experiences that have an effect equivalent to the creation of ``too much noise in the psychic system'' (p. 452).

7 Fragments of space and self 1 2 3 4

Rycroft (1987, p. 198). Erikson (1956). Anisfeldt (1984). Amsterdam (1972) borrowed a technique used by Gallup (1970), who worked with chimpanzees, to chart the development of self-recognition in infants. The children's noses were surreptitiously dabbed with rouge. The infants were then placed before a mirror and asked ``See'' and ``Who's that?'' They were considered to show self-recognition when they pointed to the discrepancy of the red spot. Lewis and Brooks-Gunn (1979) further developed the ``red spot'' strategy

216

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Notes from pp. 42 ± 55

in a systematic way, using mirrors, photographs and videotapes. They showed that infants ®rst clearly recognized themselves in a mirror between the ages of 15 and 18 months. By 21 to 24 months, children are able to recognize photographs of themselves, using their names and appropriate personal pronouns. Lewis (1990). Jung (1953). Money and Ehrhardt (1972). Lewis and Brooks-Gunn (1979). Lewis (1990, 1992). Gruber and VoneÁche (1977, p. 219). Spitz (1965). Piaget (1954, pp. 36±37). Bower (1971, p. 30). Lewis and Gunn (1978, p. 211). Schwartz et al. (1973). Bower (1974). Piaget (1954, p. 59). Winnicott, in his interesting essay on ``The Place Where We Live'' (1974, pp. 122±129) does not distinguish between transitional and cultural space. This distinction, it seems to me, is critical. The emergence of the symbolic function is complex and must be seen in the context of the social environment. The subject has been studied in detail by Peter Hobson (2000, 2002). Schiller (1801). Dunn et al. (1996). Bowlby (1969) distinguished between af®liation and attachment, but did not refer to intimacy which may have misled some later attachment theorists into an assumption that intimacy and attachment are synonymous. Piaget (1951).

8 Play, coherence and continuity 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Janet (1901). Putnam et al. (1986); Coons et al. (1988); Ross et al. (1989). Meares (1999a). Meares et al. (1999); Allan Schore (1994, 2003) has been building a case for ``sociogenesis'' by means of remarkable syntheses of current neurophysiological and developmental data. Wilson et al. (1993). Livingstone and Hubel (1988). De Yoe et al. (1994). Horgan (1993). Gazzaniga (1989); Carramazza and Hillis (1991). Peretz et al. (1994). Singer (1993, 1994). Janet (1901, p. 246). Schiller (1801, p. xv, 2). Schiller (1801, p. xv, 9). Groos, K. (1898). Schiller (1801, p. xxv, 2). Schiller (1801, p. xxvii, 4). Krebs (1975, p. 94).

Notes from pp. 55 ± 65 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

217

Holmes (1998, p. 218). Cited by James (1890, I, p. 255n). For example, Hobson (1988). Greenberg (1970). Greenberg (1981). Empson and Clark (1970). Tilley and Empson (1978). Poincare (1908, p. 35). Hobson based the title of his book Forms of Feeling (1985) on Suzanne Langer's conception of art (see Note 31). James (1890, I, p. 249n). James (1890, I, pp. 250±251). James (1890, I, p. 252). James (1890, I, p. 265). Langer (1957, p. 112). Gruber (1978). Gruber (1978, p. 135). This story is told in an intriguing article by Arthur Miller (1978). My account is based on that article. Cited by Miller (1978, p. 85). Cited by Miller (1978, p. 87). Cited by Miller (1978, p. 89). Miller (1978, p. 88). Miller (1978, pp. 74, 78). Cited by Miller (1978, p. 76). Miller (1978, pp. 76, 96). Gruber (1978, p. 122). Darwin (1859). Cited by Gruber (1978) from Darwin's notebooks. Gruber (1978, p. 136). Bowlby (1969). Desmond and Moore (1991, p. 651). Desmond and Moore (1991, p. 507). Desmond and Moore (1991, p. 638). Desmond and Moore (1991, p. 645). Peter Hobson (1993) has explored the special signi®cance of vision in relation to the development of self and symbolization. Janet (1928, p. 261).

9 Value and fit 1 A recent neuro-imaging study from Eisenberger et al. (2003), found support for the hypothesis that the brain bases for social pain are similar to those of physical pain. 2 Wylie (1979). 3 Robson (1988). 4 James (1892, p. 187). 5 James (1902, p. 478, Fontana edition). 6 Cooley (1902). 7 Harter (1990, p. 77). 8 Stern (1938, p. 474). 9 Jung (1935, p. 13). The term ``hedonic tone'' was introduced by Wilhelm Wundt

218

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Notes from pp. 66 ± 89

(1904) and his pupil Edward Tichener (1905). It fell into disuse following the demise of the introspectionist school. It has now been reinstated. Jung made frequent reference to Wundt. Sullivan (1953, p. 31). Sullivan (1953, p. 39). Sullivan (1953, p. 37). Sullivan (1953, p. 42). Sullivan (1953, pp. 203±216). Mahler et al. (1975, p. 221). Kohut (1971, p. 116). Elson (1987, pp. 62±63). Miller (1965, p. 81). Olds and Milner (1954). Scherer and Oshinsky (1977). Fantz (1963). Fantz (1965). Lewis (1969). Schaffer (1971). Ekman (1983). Beebe and Lachmann (1988, p. 15). Rhys (1967, p. 117). Russell (1971, p. 209). McLean (1969, p. 27). Cooley (1902, pp. 145±146). Kagan (1981, p. 57). Brown et al. (1986). Nicolson and Trountmann (1975, p. 434).

10 Body feeling and disjunction 1 This constellation of observations is termed the orienting response (see Sokolov 1960). 2 Individuals whose personal reality does not match the responses of others may become af¯icted with derealisation. Adolescents may be particularly vulnerable (Meares and Grose 1978). 3 Meares (1980). 4 Meares (1984). 5 Blanke et al. (2004). 6 Frith (2004). 7 Meares (1999a); for further discussion see Meares (2000). 8 See Chapter 9, Note 1. 9 James (1902, pp. 234±235; Longmans edition). 10 Descartes (1637 p. 105). 11 Kohut (1971, p. 288). 12 Meares and Hobson (1977). 13 Stern (1938, p. 485).

11 Stimulus entrapment 1 Ellenberger (1970). 2 Jung (1971, pp. 449±450).

Notes from pp. 89 ± 103

219

3 Hobson (1985, p. 17). 4 The idea that a zone of silence beyond impingement is needed in order to discover a sense of being is expressed in different ways in the work of Samuel Beckett (Meares 1973a). 5 Melzack and Wall (1982). 6 LeÂvi-Strauss (1979). 7 Miltner et al. (1989). 8 Bayer et al. (1991). 9 Leff (1973). 10 Katon (1984). 11 Simon and Von Korff (1991). 12 Meares (1985). 13 Whorf (1956). 14 Lipowski (1988). 15 Walker et al. (1991). 16 Henderson (1974). 17 Apley et al. (1978); Mechanic (1980); Shapiro and Rosenfeld (1986). 18 See Van Der Kolk (1996). Traumatized individuals do not show habituation of the acoustic startle response (Shalev et al. 1992). 19 Horvath et al. (1980). 20 James et al. (1989); James et al. (1990). 21 A remark made by Arnold Goldberg (1983). 22 Descartes (1637±1641, p. 116). 23 ClapareÁde (1911, p. 67). 24 James (1892, p. 153). 25 Kris (1951). 26 Lacan (1977, p. 239). 27 Buss (1980).

12 Transference and trauma 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15

Janet (1911, pp. 531±532). Brandchaft (1993) has described this system. Rycroft (1968, p. 168). This table appears in Meares (2004) and, in slightly different form, in Meares (1999b). Tulving (1972, 1983, 1993a). Tulving (1993b). Jackson (1931±2). Lee et al. (1995). Janet (1925, I, p. 599) quotes Morton Prince: ``The tendency to preserve complexes that have been organized with a certain amount of automatic independence varies greatly from person to person, but it can only be manifested to a high degree when there is a fundamental condition of mental disaggregation.'' Disaggregation, in this passage, might be seen as disco-ordination in terms of Jacksonian theory. Keenan (1992, p. 217). Keenan (1992, p. 64). Keenan (1992, p. 78). Keenan (1992, p. 129). Terr (1993). Gabbard (1995).

220

Notes from pp. 104 ± 118

13 Reversals 1 2 3 4 5 6 7

8 9 10 11

Freud (1915a). Freud (1924). Freud, A. (1966, p. 113). Freud, A. (1966, p. 110). Meltzoff and Moore (1977). Steele (1986, p. 285). Klein (1955, p. 141). Before the early traumatic environment of those with borderline personality disorder was clearly established, ideas derived from the work of Melanie Klein were often used to explain the shifting self states in this condition. Kernberg (e.g., 1975, 1984) is the most prominent of those theorists who understand the phenomena of severe personality disorder in terms of the defenses of splitting and projective identi®cation. Kernberg (1968) has observed what appears characteristic of borderline patients, that is, ``a rapid oscillation between moments of projection of a self-representation while the patient remains identi®ed with the corresponding object-representation, and other moments in which it is the object-representation that is projected while the object identi®es with the corresponding self-representation'' (p. 605). Kernberg (1968) gives an example that makes clear that this oscillation conforms to what I call a reversal. He describes a situation in which ``a primitive, sadistic mother image may be projected into the therapist while the patient experiences himself as the frightened, attacked, panic-stricken little child; moments later, the patient may experience himself as the stern, prohibitive, moralistic (an extremely sadistic, primitive) mother image, while the therapist is seen as the guilty, defensive, frightened but rebellious child'' (p. 605). This oscillation is seen to arise through projective identi®cation called upon to externalize aggressive self and object images. Kernberg has retained the essence of these early views in his later writings. The concept of projective identi®cation as it is currently described (e.g., Goldstein 1991) has a number of dif®culties. They are beyond the scope of this book. Thomas Ogden (1982) has authoritatively reviewed this ®eld. His concept of the ``subjugating third'' is I think, an exploration, using a different language and perspective, of the experience of reversal (Ogden 1994, pp. 97±108). Glasser (1986). Stern (1985, p. 164). Sandler and Rosenblatt (1962). Bacal and Herzog (2003).

14 The expectational field 1 The therapist is Robert Hobson. This meeting is described in some detail in order to give something of the ¯avour of a ®rst therapeutic encounter. 2 An outline of the aims and structure of therapy is an essential element of the process. 3 Anthony (1971). 4 Williams et al. (2001a); Williams et al. (2004). 5 Damasio (1994). 6 Liddell et al. (2004). 7 Evidence from ``split brain'' patients shows that emotionally laden visual stimuli produce greater autonomic responses when the subjects are not able to report on them than when they can (Ladavas et al. 1993). A single neuron study indicated

Notes from pp. 118 ± 137

8 9 10 11

12 13 14 15 16 17

221

greater activation in the amygdala to stimuli that the subjects could not recall than to those that they could (Fried et al. 1997). This ®nding is consistent with a recent study showing no activation of the orbito-frontal cortex or anterior cingulate in borderline patients in whom a traumatic memory had been activated (Schmahl et al. 2004). Morris et al. (1998). Williams et al. (2001b). Morris et al. (1999). Segal (1973, p. 27). Neville Symington (1985) puts forward a more modern understanding of this clinical phenomenon with his paper ``Phantasy effects that which it represents.'' Phantasy in this conception very roughly approximates to what I am calling an ``unconscious traumatic memory system.'' Freud (1914, p. 16). Galton (1883, pp. 203±204) discussed in ``Intimacy & Alienation.'' Freud (1920±22, p. 239). Jung (1935, p. 140). Jung (1935, p. 149). Gabbard (1995).

15 Restoration 1 2 3 4 5 6 7 8 9 10 11 12

Kohut (1977, p. 162). Kohut (1977. p. 163). Kohut (1977, p. 155). Kohut (1977, p. 165). Kohut (1977, p. 166). Kohut (1977, pp. 167±168). See example, Tulving and Thomson (1973); Bower (1981); Ellis and Hunt (1989). Freud (1905, p. 116). Gill (1985, p. 90). Meares (2001). This case is presented in Meares (1992). Persig (1974).

16 Impasse: Paradoxical restoration 1 Stolorow and Atwood (1992, p. 120). 2 Signi®cant formulations of the clinical and therapeutic relevance of attachment theory have come from Jeremy Holmes (1996) and Peter Fonagy (2001). 3 It is tempting to consider Sullivan's distinction between security and euphoria (Chapter 9) in terms of the difference between attachment and intimacy, the sense of security being characteristic of the former, and euphoria of the latter, kind of pair-bonding. This speculation leads to a further speculation that different affect systems drive these two forms of relatedness, anxiety being the fuel of attachment, while positive states are at the core of intimacy. 4 Freud (1926, pp. 136±137). 5 Meares and Hobson (1977). 6 Bibring (1954, p. 763). 7 Bergin (1966, 1967). 8 For example, Orlinsky et al. (1994). 9 Mitchell (2000).

222

Notes from pp. 138 ± 161

10 Sargant (1995, pp. 189±190). 11 Janet (1925, I, p. 660). 12 Brin Grenyer (2002) describes a therapeutic approach, based on Luborsky's work and supported by extensive research data, which identi®es the core con¯icts in psychic life, in order to lead to a goal of mastery over imposed and stunting roles.

17 False self 1 2 3 4 5 6 7 8 9 10 11

Winnicott (1948, p. 92). Winnicott (1948, p. 93). Winnicott (1960). Winnicott (1960, p. 145). Winnicott (1960, p. 146). Winnicott (1962, p. 61). Winnicott (1949, p. 244). Winnicott (1950±1955, p. 217). Winnicott (1950±1955, p. 212). Meares (1977, p. 169). Winnicott (1974, p. 80).

18 The mask 1 2 3 4 5 6 7 8

Meares (1976). Winnicott (1963, p. 145). Winnicott (1963, p. 187). Meares and Hobson (1977). Kohut (1977). Sullivan (1953). Winnicott (1960, p. 151). The caretaker self resembles what has been called, in children, ``role-reversed attachment disorder.'' 9 Winnicott's paper of 1960 touches on each but gives the impression that there is only one form of false self. This is evident in remarks such as: ``The False Self has one positive and very important function: to hide the True Self, which it does by compliance with environmental demands'' (Winnicott 1960, pp. 146±147). 10 Ogden (1995).

19 A drive to play 1 The features of borderline personality disorder, as identi®ed by DSM-1V criteria, can be grouped into ``self'' and ``trauma'' factors. The criteria which relate to failure of development of the self-system are as follows, using the DSM1V numbering: (1) ``Identity disturbance: markedly and persistently unstable self image or sense of self.'' This is the central feature. The term ``identity'' is mistakenly used here as if it were a synonym of ``self.'' (7) ``Chronic feeling of emptiness.'' The ordinary sense of going-on-being, and the feeling of the movement of the stream of consciousness is stunted or

Notes from pp. 161 ± 162

223

absent. Its loss leaves a void which is a principal, even frightening feature of personal existence. (1) ``Frantic efforts to avoid real or imagined abandonment.'' Since the experience of self depends originally upon the other, efforts to maintain connection with this necessary person are often truly frantic. The criteria relating to trauma are: (4) ``Impulsivity in at least two areas that are potentially self-damaging.'' Examples include gambling, reckless sexuality, substance abuse, shoplifting and dangerous driving. In many cases, these behaviors can be understood as attempts to ®ll an experiential void after a sense of disconnection from the necessary other. However, some of these behaviors do more than ®ll emptiness with sensation. They attempt to maintain the integrity of self through symbolically retaining of sense of connection with that ®gure upon whom existence depends. (6) ``Affective instability due to marked reactivity to mood.'' Since the borderline depends for his or her sense of existence upon the other, variations in this relationship, even of a subtle kind, may provoke profound changes and apparently inexplicable shifts in mood. (8) ``Inappropriate, intense anger.'' Although small disjunctions between self and other may result in transient mood changes, larger breaks might precipitate sudden anger. Also responses from others that seem to devalue, and in this way attack, essential aspects of a personal reality may be sensed as a physical assault, provoking rage and occasionally actual violence. (5) ``Recurrent suicidal behavior, threats, gestures or self-mutilating behavior.'' The result of varying combinations of intense futility, despair, annihilation, and the sense of abandonment. (2) ``A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.'' This item can be understood in terms of valuation and ``attacks upon value.'' When there is a sense of ``fellow-feeling'' the individual feels valued. However, when the person's past has involved traumatic devaluation, small slights can trigger this unconscious system of memories. One response is that of a reversal, in which the individual plays out the role of the original traumatizer and adopts a posture of disparagement and contempt. Devaluation is also prominent on the DSM-1V description of ``narcissistic personality disorder,'' another of the cluster of similar personality disorders which also include the ``histrionic.'' The names are historically determined and most unsuitable. All three, in my view, describe manifestations of disruptions of the same system. The borderline is the least stable and the histrionic the most, with narcissistic occupying an intermediate position. Depending on the interchange with social environment the individual can ¯uctuate between these diagnostic categories, even in a single session, as described by Brandchaft and Stolorow (1984). (9) ``Transient, stress-related paranoid ideation and severe dissociative symptoms.'' Dissociation is central to an understanding of the entire borderline condition. Paranoid ideation based on traumata is discussed elsewhere (Meares 1988). Traumatic disruption of self-boundary is a main element of the paranoid experience. 2 Jung (1935, p. 172). 3 Ornstein (1985). 4 Opie and Opie (1971).

224

Notes from pp. 162 ± 180

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

McLean (1986). Goodall (1971, pp. 146±147). Groos (1898). Groos (1901). Piaget (1951). Murphy (1972, p. 119). Jung (1971, p. 474). Also, Jung (1959) Jung (1971, p. 115). Fouts and Fouts (1987, pp. 631±633). Cheney and Seyfarth (1990). Kohler (1925), cited by Hobson (1985). Morris (1962). Eibl-Eibesfeldt (1988, p. 36). Baldwin (1906, p. 110). Baldwin (1906, p. 116). Baldwin (1906, p. 112). Hobson (1971). Described in Meares and Coombes (1994). There is a growing literature on the effect of maternal depression on child development: for example, Field (1995); Tronick and Field (1987); Murray and Cooper (1997); Weinberger and Tronick (1997). 24 Baldwin noted that freedom is an essential element of play. The child selects the semblant object and makes it what he or she wishes it to be (1906, p. 112). He also remarked on a negative form of freedom evident in play. He called it ``thedon't-have-to-feeling'' (1906, p. 113). Play cannot be prescribed.

20 Coupling, amplification and representation 1 2 3 4 5 6

Sorce et al. (1985). Meares et al. (1982, p. 84). Woolf (1925, pp. 23±24). Bacal and Herzog (2003). Hobson (1985, pp. 5±6). Representation is a main element of a psychotherapeutic approach to borderline personality which Fonagy has been developing in parallel to my own. The two approaches have much in common through the language is different. Fonagy calls his treatment ``mentalization.'' It aims to enhance re¯ective function, and an awareness of one's own mental states and those of others. ``It develops through a presentation to an individual of a view of their internal world which is stable, coherent, and can be clearly perceived by them and may be adopted as a re¯ective part of their self'' (Bateman and Fonagy 2004, p. 123). This approach is contrasted to that of Linehan which has a CBT base but goes beyond it through the development of ``mindfulness'' skills (Bateman and Fonagy 2004, pp. 122±123). The outcome of Bateman and Fonagy's borderline cohort appears to be superior to the Linehan outcome in that depression and suicidal ideation were diminished in the former group of patients but not in the latter. Also, clinical improvements persisted in the Bateman and Fonagy patients (Bateman and Fonagy 1999; Bateman and Fonagy 2001) while the persistence of improvement in Linehan's was not clearly demonstrated (Linehan et al. 1991; Linehan et al. 1993). Our own ®ndings, in the third of the main outcome studies of the treatment of borderline personality, resemble those of Bateman and

Notes from pp. 181 ± 194

225

Fonagy (Stevenson and Meares 1992; Meares et al. 1999b; Stevenson, Meares and D'Angelo 2005).

21 Empathy 1 2 3 4 5 6 7 8 9 10 11 12

Meares (1983). Oxford English Dictionary. Meares (1985). Erasmus (1970, p. 123). Screech (1988, p. 151). Berlin (1977, p. 12). Berlin (1977, p. 108). Lichtenberg et al. (1984). Olinick (1984) writes on the distinction between empathy and sympathy. Stern (1985) reviews several reports of this phenomenon. Hoffmann (1978). Although the ®rst evidence of empathy is found early in life, it is a capacity that enlarges with maturation. There is, for example, a sudden growth in empathic awareness during adolescence. A continuing growth in the capacity to understand the feelings and personal worlds of others throughout life enables one, ideally, to deal with the process of dying in a way that shows empathy with those who survive (Meares 1981). 13 Youngblade and Dunn (1995). 14 Kohut (1984, p. 72). 15 Bruner (1983).

22 Dissolving the trauma 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Ellenberger (1970). Brill (1937). Breuer and Freud (1895, p. 7). Meares (1987). Cognitive analytic therapy of Anthony Ryle (1990) unites Klein and cognitive behavior therapy. Bibring (1954). Strachey (1934). Freud (1915b). Malan (1976). Reviewed by Henry et al. (1994); Gabbard et al. (1994) showed that transference interpretations vary in effect, some having positive and others negative consequences. Piper et al. (1991) rated 22,500 therapist interventions in order to arrive at their conclusion. Freud (1896, p. 191). Freud (1912, p. 108). Freud (1920, p. 18). Arlow (1985, p. 117). ThomaÈ and KaÈchele (1987, p. 54). Beck et al. (1979, Preface). Janet (1911, p. 419). Janet quotes Charcot in this passage. Meares (1998).

226

Notes from pp. 194 ± 210

20 21 22 23 24 25 26 27 28 29 30 31 32 33

Janet (1925, I, pp. 589±698). Burns and Holen-Hoeksma (1992). Described by Henry et al. (1994). Orlinsky et al. (1994). Freud (1925, p. 27). Beck et al. (1979, pp. 45±50). Hobson (1985, pp. 219±224). Janet (1924, p. 275). Janet (1925, I, p. 661). Janet (1925, I, p. 662). Fison and Howitt (1880). Schwaber (1983) has written extensively on the signi®cance of ``listening.'' Lichtenberg (1989a, 1989b). This process resembles assimilation and ``transmuting internalization'' (Meares 1990). 34 Janet (1901, p. 285). 35 A changed brain-state may help to explain the bene®cial effects of eye movement desensi®cation described by Shapiro (1989a, 1989b). 36 The ``narrative of self'' has been explored in an experimental study of groups (Meares 1973b).

23 A self-organizing system 1 2 3 4 5 6 7 8 9 10 11

Winnicott (1965, p. 39n). Piaget (1959, p. 243). Hobson (1971, p. 97). Meares, A. (1967). Mandlebrot (1983). Capra (1996). Gleick (1988, p. 126). Gleick (1988, p. 236). Ehrenberg (1990), Feiner (1990). Gruber and VoneÁche (1977, p. 492). Barthes (1975) broke up a Balzac novella into a series of ``brief, contiguous fragments, which we shall call lexias, since they are units of reading . . . The lexia will include sometimes a few words, sometimes several sentences; it is a matter of convenience: it will suf®ce that the lexia be the best possible space in which we can observe meanings; its dimension, empirically determined, estimated, will depend on the density of connotations, variable according to the moments of the text: all we require is that each lexia should have at most three or four meanings to be enumerated'' (p. 13). 12 Ogden (1995) has written of the centrality of ``aliveness'' and Korner (2000) the ``vitality affects,'' in the therapeutic process. 13 An expression of James Lovelock (2003) who proposed the Gaia hypothesis (1979). 14 Nin (1939±1944, p. 264).

References

Als, H., Tronick, E., Lester, B. and Brazelton, T.B. (1977) `The Brazelton neonatal behavioral sssessment scale', Journal of Abnormal Child Psychology 5: 215±31. Amsterdam, B. (1972) `Mirror self image reactions before age two', Developmental Psychology 5: 297±305. Anisfeldt, M. (1984) Language Development from Birth to Three, Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Anthony, S. (1971) The Discovery of Death in Childhood and After, London: Allen Lane. Apley, J., Keith, R. and Meadow, R. (1978) The Child and His Symptoms, Oxford: Blackwell. Arkema, P. (1981) `The borderline personality and transitional relatedness', American Journal of Psychiatry 138: 172±7. Arlow, J. (1985) `Interpretation and psychoanalytic psychotherapy', in E.A. Schwaber (ed.) The Transference in Psychotherapy: Clinical Management, New York: International Universities Press. Armstrong, D. (1981) The Nature of Mind, New York: Cornell University Press. Bacal, H. and Herzog, B. (2003) `Speci®city theory & optimal responsiveness: an outline', Psychoanalytic Psychology 20: 635±48. Baldwin, J.M. (1897) Mental Development in the Child and the Race, New York: Macmillan. ÐÐ (1906) Thoughts and Things: or Genetic Logic, vol. 1, London: Macmillan. Barthes, R. (1975) S/Z, trans. R. Miller, London: Cape. Bateman, A. and Fonagy, P. (1999) `The effect of partial hospitalization in the treatment of borderline personality disorder ± a randomized control trial', American Journal of Psychiatry 156: 1563±9. ÐÐ (2001) `Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 19-month follow-up', American Journal of Psychiatry 158: 36±42. ÐÐ (2004) Psychotherapy for Borderline Personality Disorder, Oxford: Oxford University Press. Bayer, T., Baer, P. and Early, C. (1991) `Situational and psychophysiological factors in psychologically induced pain', Pain 44: 45±50. Beck, A., Rush, A.J., Shaw, B. and Emery, G. (1979) Cognitive Therapy of Depression, New York: Guilford Press.

228

References

Beebe, B. and Lachmann, F. (1988) Mother±infant in¯uence and precursors of psychic structure, in A. Goldberg (ed.) Frontiers in Self Psychology: Progress in Self Psychology, vol. 3, Hillsdale, NJ: Analytic Press. Beebe, B., Knoblauch, S., Thistin, J. and Sorter, D. (2003) `Symposium on intersubjectivity in infant research and its implications for adult treatment, Part I', Psychoanalytic Dialogues 13: 743±842. Bergin, A. (1966) `Some implications of psychotherapy research for therapeutic practice', Journal of Abnormal Psychology 71: 235±46. ÐÐ (1967) `The deterioration effect: rept to Braucht', Journal of Abnormal Psychology 75: 300±302. Berlin, I. (1977) Vico and Herder: Two Studies in the History of Ideas, New York: Vintage. Bibring, E. (1954) `Psychoanalysis and the dynamic psychotherapies', Journal of the American Psychoanalytic Association 2: 745±70. Blanke, O., Landis, T., Spinelle, L. and Seeck, M. (2004) `Out-of-body experience and autoscopy of neurological origin', Brain 127: 243±58. Bodle, J., Shou, L.Y., Shore, C. and Dixon, W. (1996) `Transfer of responsibility on parent±child play during the second year', Early Development and Parenting 5: 185±94. Bornstein, M. and Tamis Le Monda, C. (1997) `Maternal responsiveness and infant mental abilities: speci®c predictive relations', Infant Behaviour and Development 20, 3: 283±96. Borras, M.L. (1985) Picabia, New York: Rizzoli. Bower, G. (1981) `Mood and Memory', American Psychologist 36: 129±48. Bower, T. (1971) `The object in the world of the infant', Scienti®c American 225: 30±38. ÐÐ (1974) Development in Infancy, San Francisco: Freeman. Bowlby, J. (1969) Attachment, London: Hogarth. Brandchaft, B. (1993) `To free the spirit from its cell', in A. Goldberg (ed.) Progress in Self Psychology, vol. 9, Hillsdale, NJ: Analytic Press. Brandchaft, B. and Stolorow, R. (1984) `The borderline concept: pathological character or iatrogenic myth?', in J. Lichtenberg, M. Bornstein and D. Silver (eds) Empathy, vol. 2, Hillsdale, NJ: Analytic Press. Brazelton, T.B., Tronick, E.C., Adamson, L. et al. (1975) `Early mother±infant reciprocity', in M. Hofer and R. Porter (eds) The Parent±Infant Interaction, Amsterdam: Excerpta Medica. Breuer, J. and Freud, S. (1895) Studies in Hysteria, SE 2, London: Hogarth. Brill, A.A. (1937) `Introduction', in J. Breuer and S. Freud Studies in Hysteria, trans. A.A. Brill, New York: Nervous and Mental Disorders Monograph no. 61. Brown, G., Andrews, B., Harris, T. et al. (1986) `Social support, self-esteem and depression', Psychological Medicine 16: 813±31. Bruner, J. (1983) Child Talk: Learning to Use Language, New York: Norton. Burns, D. and Holen-Hoeksma, S. (1992) `Therapeutic empathy and recovery from depression in cognitive behavioral therapy: a structural equation model', Journal of Consulting and Clinical Psychology 60: 441±9. Buss, A.H. (1980) Self-Consciousness and Social Anxiety, San Francisco: Freeman. Capra, F. (1996) The Web of Life, New York: Anchor, Doubleday.

References

229

Caramazza, J. and Hillis, A. (1991) `Lexical organization of nouns and verbs in the brain', Nature 49: 788±90. Carpenter, G. (1974) `Mother's face and the newborn', New Scientist 61: 742. Cheney, D. and Seyfarth, R. (1990) How Monkeys See the World: Inside the Mind of Another Species, Chicago: University of Chicago Press. ClapareÁde, E. (1911) `Recognition and ``me-ness'' ', in D. Rapaport (ed.) Organization and Pathology of Thought: Selected Sources, New York: Columbia University Press, 1951. Cooley, C. (1902) Human Nature and the Social Order, New York: Scribner. Coons, P., Bowman, E. and Milstein, V. (1988) `Multiple personality disorder: a clinical investigation of 58 cases', Journal of Nervous and Mental Disorders 176: 519±27. Cooper, S., Perry, J., Hoke, L. et al. (1985) `Transitional relatedness and borderline personality disorder', Psychoanalytic Psychology 2: 114±28. Damasio, A. (1994) Descartes' Error, New York: Grosset Putnam. Darwin, C. (1859) The Origin of Species by Means of Natural Selection, London: Murray. ÐÐ (1872) The Expression of Emotions in Man and Animals, abridged edition, London: Watts, 1934. De Casper, E.J. and Fifer, W.P. (1980) `Of human bonding: newborns prefer their mother's voices', Science 208: 1174±6. Descartes, R. (1637±1641) Discourse on Method and the Meditations, trans. F. Sutcliffe, Harmondsworth: Penguin, 1968. Desmond, A. and Moore, J. (1991) Darwin, London: Michael Joseph; London: Penguin, 1992, latter edition cited here. De Yoe, E., Felleman, D., Van Essen, D. and McLendon, E. (1994) `Multiple processing streams in occipito temporal visual cortex', Nature 371: 151±4. Dunn, J., Creps, C. and Brown, J. (1996) `Children's family relationships between two and ®ve: developmental changes and individual differences', Social Development 5, 3: 230±50. Eibl-Eibesfeldt, I. (1988) `The biological foundation of aesthetics', in I. Rentscher, B. Herzberger and D. Epstein (eds) Beauty and the Brain: Biological Aspects of Aesthetics, Basel: Birkhauser, pp. 29±70. Ehrenberg, D. (1990) `Playfulness in the psychoanalytic relationship', Contemporary Psychoanalysis 26: 75±94. Eisenberger, N., Lieberman, M. and Williams, K.D. (2003) `Does rejection hurt? An FMRI study of social exclusion', Science 302: 290±92. Ekman, P. (1983) `Autonomic nervous activity distinguishes among emotions', Science 221: 1208±10. Ekman, P. and Friesen, W. (1975) Unmasking the Face, Englewood Cliffs, NJ: Prentice-Hall. Ellenberger, H.F. (1970) The Discovery of the Unconscious, London: Allen Lane. Ellis, H. and Hunt, R.R. (1989) Fundamentals of Human Memory and Cognition, 4th edn, Dubaque, IO: W.C. Brown. Elson, M. (ed.) (1987) The Kohut Seminars on Self Psychology and Psychotherapy with Adolescents and Young Adults, New York: Norton. Emde, R. (1983) `The prerepresentational self and its affective core', Psychoanalytic Study of the Child 38: 165±92. New Haven, CT: Yale University Press.

230

References

Empson, J. and Clark, P. (1970) `Rapid eye movements & remembering', Nature 227: 287±8. Erasmus, D. (1511) In Praise of Folly, trans. H.H. Hudson, Princeton, NJ: Princeton University Press, 1970. Erikson, E. (1956) Identity: Youth and Crisis, New York: Norton. Fantz, R. (1963) `Pattern vision in newborn infants', Science 140: 296±7. ÐÐ (1965) `Visual perception from birth as shown by pattern selectivity', Annals of New York Academy of Science 118: 793±814. Feiner, A. (1990) `Playfulness and the interpersonal ideology', Contemporary Psychoanalysis 26: 95±107. Field, T. (1995) `Infants of depressed mothers', Infant Behavior and Development 18: 1±13. Fison, L. and Howitt, A. (1880) `Funeral customs in Australia', in M. Mead and N. Calas Primitive Heritage, London: Gollancz. pp. 545±6. Flavell, J. (1968) The Development of Role-Taking and Communications Skills in Children, New York: Wiley. Fonagy, P. (2001) Attachment and Psychoanalysis, New York: Other. Fouts, R. and Fouts, D. (1987) `Primate language', in R. Gregory (ed.) The Oxford Companion to the Mind, Oxford: Oxford University Press. Freud, A. (1966) The Ego and the Mechanisms of Defense, New York: International Universities Press. Freud, S. (1896) `The aetiology of hysteria', SE 3: 189±221, London: Hogarth. ÐÐ (1905) `Fragment of an analysis of a case of hysteria', SE 7: 7±122, London: Hogarth, 1953. ÐÐ (1912) `The dynamics of transference', SE 12. ÐÐ (1914) `On the history of the psychoanalytic movement', SE 14, London: Hogarth. ÐÐ (1915a) `Instincts and their vicissitudes', SE 14: 111±40. ÐÐ (1915b) `Introductory lectures in psychoanalysis', SE 15, London: Hogarth. ÐÐ (1920±22) `Two encyclopedia articles (A) Psychoanalysis', SE 18, London: Hogarth. ÐÐ (1920) `Beyond the pleasure principle', SE 18, Hogarth: London: Hogarth. ÐÐ (1924) `The economic problem of masochism', SE 19: 157±70, London: Hogarth. ÐÐ (1925) `An autobiographical study', SE 20: 3±70, London: Hogarth. ÐÐ (1926) `Inhibition symptoms, and anxiety', SE 20, London: Hogarth. ÐÐ (1939) `An outline of psychoanalysis', SE 23, London: Hogarth. Fried, I., MacDonald, K. and Wilson, C. (1997) `Single neuron activity in hippocampus and amygdala during recognition of faces and objects', Neuron 18: 875±87. Frith, C. (2004) `The pathology of experience', Brain 127: 239±42. Gabbard, G. (1995) `Countertransference: the emerging common ground', International Journal of Psychoanalysis 76: 475±85. Gabbard, G., Horowitz, L., Allen, J. et al. (1994) `Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon', Harvard Review of Psychiatry 2: 59±69. Gallup, C.G. (1970) `Chimpanzees: self recognition', Science 167: 86±7.

References

231

Galton, F. (1883) Inquiries into the Human Faculty and its Development, New York: Macmillan. Garvey, C. (1977) Play, Cambridge, MA: Harvard University Press. Gazzaniga, M. (1989) `Organization of the human brain', Science 245: 947±52. Gill, M. (1985) `The interactional aspect of transference', in E.A. Schwaber (ed.) The Transference in Psychotherapy: Clinical Management, New York: International Universities Press. Glasser, M. (1986) `Identi®cation and its vicissitudes as observed in the perversions', International Journal of Psycho-Analysis 67: 9±17. Gleick, J. (1988) Chaos, London: Cardinal, Sphere. Goldberg, A. (1983) `Self psychology and alternative perspectives on internalization', in J. Lichtenberg and S. Kaplan (eds) Re¯ections on Self Psychology, Hillsdale, NJ: Analytic Press. Goldstein, W. (1991) `Clari®cation of projective identi®cation', American Journal of Psychiatry 148: 153±61. Goodall, J. (1971) In The Shadow of Man, London: Collins. Gopnik, A. and Astington, J.W. (1988) `Children's understanding of representational change and its relation to the understanding of false belief and the appearance±reality distinction', Child Development 59: 26±37. Gosse, E. (1907) Father and Son, Harmondsworth: Penguin, 1983. Gray, C. (1986) The Russian Experiment in Art 1863±1922, London: Thames and Hudson. Greenberg, R. (1970) `Dreaming and memory', International Psychiatry Clinics 7: 258±67. ÐÐ (1981) `Dream and REM sleep ± an integrative approach', in W. Fishbein (ed.) Sleep, Dreams & Memory, New York: Spectrum. Grenyer, B. (2002) Mastering Relationship Con¯icts: Discoveries in Theory, Research and Practice, Washington, DC: American Psychological Association. Groos, K. (1898) The Play of Animals: A Study of Animal Life and Instinct, trans. E.L. Baldwin New York: Appleton. ÐÐ (1901) The Play of Man, trans. E. Baldwin, New York: Arno Press, 1976. Gruber, H. (1978) `Darwin's ``tree of nature'' and other images of wide scope', in J. Wechsler (ed.) On Aesthetics in Science, Cambridge, MA: MIT Press, pp. 121±42. Gruber, H. and VoneÁche, J. (1977) The Essential Piaget, New York: Basic Books. Guthrie, E., Creed, F., Dawson, D. and Tomenson, B. (1991) `A controlled trail of psychological treatment for the irritable bowel syndrome', Gastroenterology 100: 450±57. Guthrie, E., Moorey, J., Margison, F., Baker, H., Palmer, S., McGrath, G., Tomenson, B. and Creed, F. (1999) `Cost-effectiveness of brief psychodynamicinterpersonal therapy in high utilizers of psychiatric services', Archives of General Psychiatry 56: 519±26. Guthrie, E., Kapur, N., Mackway-Jones, K., Chew-Graham, C., Moorey, J., Mendel, E., Marino-Francis, F., Sanderson, S., Turpin, C., Boddy, G. and Tomenson, B. (2001) `Randomised controlled trial of brief psychological intervention after deliberate self poisoning', British Medical Journal 323: 1±5. Hadamard, H. (1945) An Essay on the Psychology of Invention in the Mathematical Field, Princeton, NJ: Princeton University Press.

232

References

Hall, J. et al. (2001) `An economic analysis of psychotherapy for borderline personality disorder patients', Journal of Mental Health Policy Economics 4: 3±8. Harter, S. (1983) `Developmental perspectives on the self system', in P. Mussen (ed.) Handbook of Child Psychology, vol. 4, New York: Wiley ÐÐ (1990) `Causes, correlates and the functional role of global self-worth: a lifespan perspective', in J. Kolligan and R. Sternberg (eds) Perceptions of Competence and Incompetence Across the Life-Span, New York: Springer-Verlag, pp. 43±70. Hartmann, H. (1939) Ego Psychology and the Problem of Adaption, New York: International Universities Press, 1958. Henderson, S. (1974) `Care-eliciting behavior in man', Journal of Nervous and Mental Disease 159: 172±81. Henry, W., Strupp, H., Schact, T., Gaston, L. and Gar®eld, S. (eds) (1994) Handbook of Psychotherapy and Behavior Change, New York: Wiley, pp. 467±508. Herman, J., Perry, J. and van der Kolk, D. (1989) `Childhood trauma in borderline personality disorder', American Journal of Psychiatry 146: 490±495. Hobson, J. (1988) The Dreaming Brain, New York: Basic Books. Hobson, R.F. (1971) `Imagination and ampli®cation in psychotherapy', Journal of Analytical Psychology 16: 79±105. ÐÐ (1985) Forms of Feeling: The Heart of Psychotherapy, London: Tavistock. Hobson, R.P. (1991) `Against the theory of ``Theory of Mind'' ', British Journal of Development Psychology 9: 33±51. ÐÐ (1993) `Through feeling and sight to self and symbol', in U. Neisser (ed.) The Perceived Self Ecological and Interpersonal Sources of Self-Knowledge, New York: Cambridge University Press. pp. 254±79. ÐÐ (2000) `The grounding of symbols: a social-developmental account', in P. Mitchell and K. Riggs (eds) Children's Reasoning of the Mind, Hove, UK: Psychology Press. pp. 11±35. ÐÐ (2002) The Cradle of Thought, London: Macmillan. Hoffmann, M. (1978) `Towards a theory of empathic arousal and development', in M. Lewis and L. Rosenblum (eds) The Development of Affect, New York: Plenum. Holmes, J. (1996) Attachment, Intimacy, Autonomy, Northvale, NJ: Aronson. Holmes, R. (1998) Coleridge: Early Visions, London: Flamingo, Harper-Collins. Horgan, J. (1993) `Fractured functions: does the brain have a supreme integrator?', Scienti®c American 269: 16±17. Horton, P., Louy, J. and Coppotillo, H. (1974) `Personality disorder and transitional relatedness', Archives of General Psychiatry 30: 618±22. Horvath, T., Friedman, J. and Meares, R. (1980) `Attention in hysteria: a study of Janet's hypothesis by means of habituation and arousal measures', American Journal of Psychiatry 137: 217±20. Hughes, C. and Dunn, J. (1998) `Understanding mind and emotion: longitudinal associations with mental-state talk between young friends', Developmental Psychology 34, 5: 1026±37. Huizinga, J. (1938) Homo Ludens: A Study of the Play Element in Culture, London: Maurice Temple Smith, 1970. Izard, C. (1971) The Face of Emotion, Meredith, NY: Appleton-Century-Crofts.

References

233

Jackson, J.H. (1931±2) Selected Writings of John Hughlings Jackson, vols 1 and 2, J. Taylor (ed.), London: Hodder. Jacobson, E. (1964) The Self and the Object World, New York: International Universities Press. James, L., Gordon, E., Kraiuhin, C. and Meares, R. (1989) `Selective attention and auditory event-related potentials in somatization disorder', Comprehensive Psychiatry 30: 84±9. James, L., Gordon, E., Kraiuhin, C., Howson, A. and Meares, R. (1990) `Augmentation of auditory evoked potentials in somatization disorder', Journal of Psychiatric Research 24: 155±63. James, W. (1890) Principles of Psychology, New York: Holt. ÐÐ (1892) Psychology: Briefer Course, London: Macmillan. ÐÐ (1902) Varieties of Religious Experience, New York: Longman. London: Fontana-Collins, 1960. Janet, P. (1901) The Mental State of Hystericals, trans. C. Corson, New York and London: Putnam. ÐÐ (1911) L'EÂtat mental des hysteÂriques, 2nd edn, Paris: Alcan. ÐÐ (1924) Principles of Psychotherapy, London: George Allen and Unwin. ÐÐ (1925) Psychological Healing, vols 1 and 2, trans E. and C. Paul, London: George Allen & Unwin. ÐÐ (1928) L'Evolution de la meÂmoire et la notion du temps, Paris: Maloine. Jung, C. (1935) `The Tavistock lectures', in R. Hull, trans., C.G. Jung: The Collected Works, vol. 18, pp. 5±184, London and New York: Routledge & Kegan Paul. ÐÐ (1953) `The persona as segment of the collective psyche', in Two Essays of Analytical Psychology: Collected Works, vol. 7, London: Routledge & Kegan Paul. ÐÐ (1954) `The practice of psychotherapy', in Collected Works, vol. 16, London: Routledge & Kegan Paul. ÐÐ (1959) `The archetypes and the collective unconscious', in Collected Works, vol. 9, part 1, London: Routledge & Kegan Paul. ÐÐ (1961) Memories, Dreams and Re¯ections, New York: Pantheon. ÐÐ (1971) `Psychological types', revised R. Hull, trans. H. Baynes, in Collected Works of C.G. Jung, London: Routledge & Kegan Paul (®rst published 1921). Kagan, J. (1981) The Second Year: The Emergence of Self Awareness, Cambridge, MA: Harvard University Press. Katon, W. (1984) `Panic disorder and somatization: review of 55 cases', American Journal of Medicine 77: 101±6. Keenan, B. (1992) An Evil Cradling, London: Hutchinson. London: Vintage, 1993 (latter edition cited here). Kernberg, O. (1968) `The treatment of patients with borderline personality organization', International Journal of Psycho-Analysis 49: 600±19. ÐÐ (1975) Borderline Conditions and Pathological Narcissism, New York: Aronson. ÐÐ (1984) Severe Personality Disorder, New Haven: Yale University Press. Klaus, M. (1975) `Human behaviour following delivery: is this species speci®c?', in M. Hofer and R. Porter (eds) The Parent±Infant Interaction, Amsterdam: Excerpta Medica. Klein, M. (1955) `On identi®cation', in Envy and Gratitude and Other Works: 1946± 1963, pp. 141±75, London: Kegan Paul.

234

References

Kohler, W. (1925) The Mentality of Apes, London: Kegan Paul. Kohut, H. (1971) The Analysis of the Self, New York: International Universities Press. ÐÐ (1977) The Restoration of the Self, New York: International Universities Press. ÐÐ (1984) How Does Analysis Cure?, A.G. Goldberg (ed.), Chicago: University of Chicago Press. Konishi, M. (1985) `Birdsong: from behaviour to neuron', Annual Review of Neuroscience 8: 125±70. Korner, A. (2000) `Liveliness', Australian and New Zealand Journal of Psychiatry 34: 731±40. Krebs, H. (1975) `Proceedings of the Boehringer Sohn Symposium, Kronberg', in The Creative Process in Science and Medicine, Amsterdam: Excerpta Medica. Kris, E. (1951) `Ego psychology and interpretation in psychoanalytic therapy', Psychoanalytic Quarterly 20: 21±5. Lacan, J. (1977) EÂcrits: A Selection, trans. A. Sheridan, London: Tavistock. Ladavas, E., Grimatti, D., Del Pesce, M. and Tuozzi, G. (1993) `Emotional evaluation with and without conscious stimulus identi®cation: evidence from split and split-brain patient cognition and emotion', Cognition & Emotion 7: 95±114. Langer, S. (1957) Problems of Art, New York: Scribner. Lee, K., Vaillant, G., Torrey, W. and Elder, G. (1995) `A 50-year prospective study of the psychological sequelae of World War II combat', American Journal of Psychiatry 152: 516±22. Leff, J. (1973) `Culture and the differentiation of emotional states', British Journal of Psychiatry 123: 299±306. LeÂvi-Strauss, C. (1979) Myth and Meaning, New York: Schocken. Lewis, M. (1969) `A developmental study of information processing within the ®rst three years of life: response decrement to a redundant signal', Monographs of the Society for Research in Child Development 34, 9 (whole no. 133). ÐÐ (1990) `Self knowledge and social development in early life', in L. Pervin (ed.) Handbook of Social Psychology, New York: Guilford Press. ÐÐ (1992) Shame: The Exposed Self, New York: Free Press. Lewis, M. and Gunn, J. (1978) `Self-knowledge and emotional development', in: M. Lewis and L. Rosenblum (eds) The Development of Affect, New York: Plenum. Lewis, M. and Brooks-Gunn, J. (1979) Social Cognition and the Acquisition of Self, New York: Plenum. Lichtenberg, J. (1989a) Psychoanalysis and Motivation, Hillsdale, NJ: Analytic Press. ÐÐ (1989b) `Model scenes, motivation, and personality', in S. Dowling and A. Rothstein (eds) The Signi®cance of Infant Observational Research for Clinical Work with Children, Adolescents and Adults, Madison, CT: IVP. Lichtenberg, J., Bornstein, M. and Silver, D. (eds) (1984) Empathy, vol. 1, Hillsdale, NJ: Analytic Press. Liddell, B., Williams, L.M., Rathjen, J., Shevrin, H. and Gordon, E. (2004) `A temporal dissociation of sub-threshold versus supra-threshold fear perception: an event-related potential study', Journal of Cognitive Neuroscience 16, 479±86. Linehan, M., Armstrong, H., Suarez, A., Allman, D. and Heard, H. (1991) `Cognitive behavioural treatment of chronically parasuicidal borderline patients', Archives of General Psychiatry 48: 1060±64.

References

235

Linehan, M., Heard, H. and Armstrong, H. (1993) `Naturalistic follow-up of a behavioural treatment for chronically parasuicidal borderline patients', Archives of General Psychiatry 50: 971±4. Lipowski, Z. (1988) `Somatization: the concept and its clinical applications', American Journal of Psychiatry 145: 1358±68. Livingstone, M. and Hubel, D. (1988) `Segregation of form, color, movement and depth: anatomy, physiology and perception', Science 240: 740±49. Locke, J.L. and Pearson, D. (1990) `The linguistic signi®cance of babbling: evidence from a tracheotomized infant', Journal of Child Language 17: 1±16. Lovelock, J. (1979) Gaia, Oxford: Oxford University Press. ÐÐ (2003) `The living earth', Nature 426: 769±70. Ludolph, P., Westen, D., Misle, B., Jackson, A. et al. (1990) `The borderline diagnosis in adolescents: symptoms and developmental history', American Journal of Psychiatry 147: 470±76. McFarlane, A. (1974) `If a smile is so important. . .', New Scientist 62: 174. MacFarlane, J. (1975) `Olfaction in the development of social preferences in the human neonate', in M. Hofer (ed.) Parent±Infant Interaction, Amsterdam: Elsevier. McLean, P. (1969) `The paranoid streak in man', in A. Koestler and J. Smythies (eds) Beyond Reductionism, London: Hutchinson (Radius edition 1972 cited here). ÐÐ (1986) `Culminating developments in the evolution of the limbic system: the thalamocingulate division', in B. Doane and K. Livingston (eds) The Limbic System: Functional Organization and Clinical Disorders, New York: Raven. Mahler, M., Pine, F. and Bergmann, A. (1975) The Psychological Birth of the Human Infant, London: Hutchinson. Malan, D. (1976) Toward a Validation of Dynamic Psychotherapy, New York: Plenum. Mandlebrot, B. (1983) The Fractal Geometry of Nature, New York: Freeman. Matas, L., Arend, R. and Sroufe, L.A. (1978) `Continuity of adaptation in the second year: the relationship between quality of attachment and later competence', Child Development 49: 547±56. Meares, A. (1958) The Door of Serenity: A Study in the Therapeutic Use of Symbolic Painting, London: Faber. ÐÐ (1961) `What makes the patient better?', Lancet 1: 1280±1. ÐÐ (1962) `What makes the patient better?', Lancet 1: 151±3. ÐÐ (1967) `The space between', International Journal of Clinical and Experimental Hypnosis 15: 156±9. Meares, R. (1973a) `Beckett, Sarraute, and the perceptual experience of schizophrenia', Psychiatry 36: 61±9. ÐÐ (1973b) `Two kinds of groups', British Journal of Medical Psychology 46: 373±9. ÐÐ (1976) `The secret', Psychiatry 39: 258±65. ÐÐ (1977) The Pursuit of Intimacy: An Approach to Psychotherapy, Melbourne: Nelson. ÐÐ (1980) `Body feelings in human relations: the possible examples of Brancusi and Giacometti', Psychiatry 43: 160±67. ÐÐ (1981) `On saying good-bye before death', Journal of the American Medical Association 246: 1227±9.

236

References

Meares, R. (1983) `Keats and the ``impersonal'' therapist: a note on empathy and the therapeutic screen', Psychiatry 46: 73±82. ÐÐ (1984) `Inner space: its constriction in anxiety states and narcisstic personality disorder', Psychiatry 47, 2: 162±71. ÐÐ (1985) `Metaphor and reality', Contemporary Psychoanalysis 21: 425±45. ÐÐ (1986) `On the ownership of thought: an approach to the origins of separation anxiety', Psychiatry 21: 545±59. ÐÐ (1987) `The secret and the self: on a new direction in psychotherapy', Australian and New Zealand Journal of Psychiatry 21: 545±59. ÐÐ (1988) `The secret, lies and the paranoid process', Contemporary Psychoanalysis 24: 650±66. ÐÐ (1990) `The fragile spielraum: an approach to transmuting internalization', in A. Goldberg (ed.) The Realities of Transference: Progress in Self Psychology, vol. 6, Hillsdale, NJ: Analytic Press, pp. 69±89. ÐÐ (1992) `Transference and the playspace', Contemporary Psychoanalysis 28: 32±49. ÐÐ (1998) `The self in conversation: on narratives, chronicles, and scripts', Psychoanalytic Dialogues 8, 6: 875±91. ÐÐ (1999a) `The contribution of Hughlings Jackson to an understanding of dissociation', American Journal of Psychiatry 156, 12: 1850±55. ÐÐ (1999b) `The adualistic representation of trauma: on malignant internalisation', American Journal of Psychotherapy 53, 3: 392±402. ÐÐ (2000) Intimacy and Alienation: Memory, Trauma and Personal Being, London: Routledge. ÐÐ (2001) `What happens next? A developmental model of therapeutic spontaneity', Psychoanalytic Dialogues 11: 755±69. ÐÐ (2003) `Towards a psyche for psychiatry', in B. Fulford, K. Morris, J. Sadler and G. Stanghellini (eds) Nature and Narrative, Oxford: Oxford University Press, pp. 43±56. ÐÐ (2004) `The conversational model: an outline', American Journal of Psychotherapy 58, 1: 51±66. Meares, R. and Anderson, J. (1993) `Intimate space: on the developmental signi®cance of exchange', Contemporary Psychoanalysis 29, 4: 595±612. Meares, R. and Coombes, T. (1994) `A drive to play: evolution and psychotherapeutic theory', Australian and New Zealand Journal of Psychiatry 28: 58±67. Meares, R. and Grose, D. (1978) `On depersonalization in adolescence: a consideration from the viewpoint of habituation and ``identity'' ', British Journal of Medical Psychology 51: 335±42. Meares, R. and Hobson, R. (1977) `The persecutory therapist', British Journal of Medical Psychology 50: 349±59. Meares, R. and Horvath, T. (1972) ` ``Acute'' and ``chronic'' hysteria', British Journal of Psychiatry 121: 653±57. Meares, R. and Orlay, W. (1988) `On self boundary: a study of the development of the concept of secrecy', British Journal of Medical Psychology 1: 305±16. Meares, R., Penman, R., Milgrom-Friedman, J. and Baker, K. (1982) `Some origins of the ``dif®cult'' child. The Brazelton scale and the mother's view of her newborn's character', British Journal of Medical Psychology 55: 77±86. Meares, R., Stevenson, J. and Gordon, E. (1999a) `A Jacksonian and

References

237

biopsychosocial hypothesis concerning borderline and related phenomena', Australian and New Zealand Journal of Psychiatry 33, 6: 831±40. Meares, R., Stevenson, J. and Comerford, A. (1999b) `Psychotherapy with borderline patients, I: a comparison between treated and untreated cohorts', Australian and New Zealand Journal of Psychiatry 33: 467±72. Mechanic, D. (1980) `The experience and reporting of common physical complaints', Journal of Health & Social Behaviour 21: 146±55. Meltzoff A. and Moore, M. (1977) `Imitation of facial and manual gestures by human neonates', Science 198: 75±8. Melzack, R. and Wall, P. (1982) The Challenges of Pain, New York: Penguin. Miller, A. (1978) `Visualization lost and regained: the genesis of the quantum theory in the period 1913±1927', in J. Wechsler (ed.) On Aesthetics in Science, Cambridge, MA: MIT Press, pp. 73±104. Miller, H. (1965) Tropic of Cancer, London: Panther. Miltner, W., Johnson, R. Jr., Braun, C. and Larbig, W. (1989) `Somatosensory event-related potentials to painful and non-painful stimuli: effects of attention', Pain 38: 303±12. Mitchell, S. (2000) Relationality, Hillsdale, NJ: Analytic Press. Money, J. and Ehrhardt, A. (1972) Man and Woman: Boy and Girl, Baltimore: Johns Hopkins University Press. Morris, D. (1962) The Biology of Art, London: Methuen. Morris, H., Gunderson, J. and Zanarini, M. (1986) `Transitional object use and borderline pathology', American Journal of Psychiatry 143: 1534±8. È hman, A. and Dolan, R. (1998) `Conscious and unconscious learning in Morris, J., O the human amygdala', Nature 3, 93: 467±70. ÐÐ (1999) `A subcortical pathway to the right amygdala mediating ``unseen'' fear', Proceedings of the National Academy of Sciences of the USA 96: 1680±85. Murphy, L. (1972) `Infants' play and cognitive development', in M. Piers (ed.) Play and Development, New York: Norton. Murray, L. and Cooper, P. (eds) (1997) `Postpartum depression and child development', New York: Guilford Press. Murray, L. and Trevarthen, C. (1985) `Emotional regulation of interactions between two-month-olds and their mothers', in T. Field and N. Fox (eds) Social Perception in Infants, Norwood, NJ: Ablex. Nicolson, N. and Troutmann, J. (eds) (1975) The Flight of the Mind: The Letters of Virginia Woolf. Vol. 1: 1888±1912, London: Hogarth. Nin, A. (1939±1944) The Diary of Anais Nin, vol. 3, G. Stuhlmann (ed.), New York: Harcourt Brace Jovanovich, 1969. Noam, G., Kohlberg, L. and Snary, J. (1983) `Steps towards a model of self', in B. Lee and G. Noam (eds) Developmental Approaches to the Self, New York: Plenum. Ogden, T. (1982) Projective Identi®cation and Psychotherapeutic Technique, New York: Aronson. ÐÐ (1994) Subjects of Analysis, Hillsdale, NJ: Aronson. ÐÐ (1995) `Analysing forms of aliveness and deadness of the transference±counter transference', International Journal of Psychoanalysis 76: 695±710. Olds, J. and Milner, P. (1954) `Positive reinforcement produced by electrical

238

References

stimulation of the septal area and other regions of rat brain', Journal of Comparative Physiology and Psychology 47: 419±27. Olinick, S. (1984) `A critique of empathy and sympathy', in J. Lichtenberg, M. Bornstein and D. Silver (eds) Empathy, vol. 1, Hillsdale, NJ: Analytic Press. Opie, I. and Opie, P. (1971) `Games (young) people play', Horizon 13: 16±19. Orlinsky, D., Grawe, K. and Parks, B. (1994) `Process and outcome in psychotherapy ± Noch Einmal', in A. Bergin and S. Gar®eld (eds) Handbook of Psychotherapy & Behaviour Change, 4th edn, New York: Wiley, pp. 270±378. Ornstein, P. (1985) `The thwarted need to grow: clinical-theoretical issues in the selfobject transference', in E.A. Schwaber (ed.) The Transference in Psychotherapy: Clinical Management, New York: International Universities Press. Patterson, A.B. (Banjo) (1895) `The Man from Snowy River', in The Collected Verse of A.B. Patterson, Melbourne: Angus and Robertson. Penman, R., Meares, R. and Milgrom-Friedman, J. (1981) `The mother's role in the development of object competency', Archives de Psychologie 49: 247±65. Penman, R., Meares, R., Baker, K. and Milgrom-Friedman, J. (1983) `Synchrony in mother±infant interaction: a possible neurophysiological base', British Journal of Medical Psychology 56: 1±7. Peretz, I., Kolinsky, R., Tramo, M., Labrecque, R., Hublet, C., Demeurisse, G. and Belleville, S. (1994) `Functional dissociations following bilateral lesions of auditory cortex', Brain 117: 1283±1301. Perner, J., Leekam, S.R. and Wimmer, H. (1987) `Three-year-olds' dif®culty with false belief: the case for conceptual de®cit', British Journal of Developmental Psychology 5: 125±37. Perrett, D., Mistlin, D. and Chitty, A. (1987) `Visual neurones responsive to faces', Trends in Neuroscience 10: 358±64. Persig, R. (1974) Zen and the Art of Motorcycle Maintenance, New York: Bantam. Piaget, J. (1929) The Child 's Conception of the World, London: Routledge & Kegan Paul. ÐÐ (1932) The Moral Judgement of the Child, London: Routledge & Kegan Paul. ÐÐ (1951) Play, Dreams and Imitation in Childhood, London: Heinemann. ÐÐ (1954) The Construction of Reality in the Child, New York: Basic Books. ÐÐ (1959) The Language and Thought of the Child, 3rd edn, London: Routledge & Kegan Paul. Pine, F. (1986) `On the development of the ``borderline-child-to-be'' ', American Journal of Orthopsychiatry 56: 450±57. Piper, W., Azim, F., Joyce, S. and McCallum, M. (1991) `Transference interpretations, therapeutic alliance and outcome in short-term individual psychotherapy', Archives of General Psychiatry 48: 946±53. PoincareÂ, H. (1908) `Mathematical creation', in B. Ghiselin (ed.) The Creative Process, Berkeley: Mentor, University of California Press, 1952, pp. 32±42. Putnam, F., Guroff, J., Silberman, E., Barban, L. and Post, R. (1986) `The clinical phenomenology of multiple personality disorder: a new 100 cases', Journal of Clinical Psychiatry 47: 285±93. Rhys, J. (1967) Good Morning Midnight, London: Deutsch. Robson, P. (1988) `Self-esteem ± a psychiatric view', British Journal of Psychiatry 153: 6±15.

References

239

Ross, C., Norton, G. and Wizney, K. (1989) `Multiple personality disorder: an analysis of 236 cases', Canadian Journal of Psychiatry 34: 413±18. Rossion, B., Caldara, R., Seghier, M., Schuller, A.M., Lazeyras, F. and Mayer, E. (2003) `A network of occipito-temporal face sensitive areas besides the right middle fusiform gyrus is necessary to normal face processing', Brain 126: 2381±95. Russell, B. (1971) Autobiography of Bertrand Russell, vol. 1, London: Allen & Unwin. Rycroft, C. (1968) A Dictionary of Psychoanalysis, Harmondsworth: Penguin. ÐÐ (1987) `Dissociation of the personality', in R. Gregory (ed.) The Oxford Companion to the Mind, Oxford: Oxford University Press, pp. 197±8. Ryle, A. (1990) Cognitive Analytic Therapy: Active Participation in Change, Chichester: Wiley. St Barbe Baker, R. (1970) My Life, My Trees, Findhorn: Scotland. Sandler, J. and Rosenblatt, B. (1962) `The concept of the representational world', Psychoanalytic Study of the Child 17: 128±48. Sargant, W. (1995) Battle for the Mind, London: Heinemann. Schaffer, H. (1971) The Growth of Sociability, Harmondsworth: Penguin. Scherer, K. and Oshinksy, J. (1977) `Cue utilization in emotion attribution from auditory stimuli', Motivation and Emotion 1: 331±46. Schiller, F. (1967) On the Aesthetic Education of Man: In a Series of Letters, trans., eds, and intro, E. Wilkinson and L. Willoughby, Oxford: Clarendon Press (original work published 1801). Schmahl, C., Vermetten, E., Elizinga, B. and Bremner, J. (2004) `A positron emission tomography study of memories of childhood abuse', Borderline Personality Disorder 55: 759±65. Schore, A. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development, Hillsdale, NJ: Erlbaum Associates, Inc. Ð (2003) Affect Dysregulation and Disorders of the Self, New York and London: Norton. Schwaber, E. (1983) `A particular perspective on analytic listening', Psychoanalytic Study of the Child 38: 519±46. New Haven, CT: Yale University Press. Schwartz, A., Campos, J. and Baisel, E. (1973) `The visual cliff: cardiac and behavioural correlates of the deep and shallow sides at 5 and 9 months of age', Journal of Experimental Child Psychology 15: 86±99. Screech, M. (1988) Erasmus: Ecstasy and the Praise of Folly, Harmondsworth: Penguin. Segal, H. (1973) Introduction to the Works of Melanie Klein, New York: Basic Books. Seifritz, E., Esposito, F., Newhoff, J. et al. (2003) `Differential sex-independent amygdala response to infant crying and laughing in parents versus non parents', Biological Psychiatry 54: P1367±75. Shalev, A., Orr, S., Peri, T., Schrecber, S. and Pitman, R. (1992) `Physiologic responses to loud tones in Israeli patients with post-traumatic stress disorder', Archives of General Psychiatry 49: 870±75. Shapiro, F. (1989a) `Eye movement desensitization: a treatment for post-traumatic stress disorder', Journal of Behavior Therapy and Experimental Psychiatry 20, 3: 211±17.

240

References

Shapiro, F. (1989b) `Ef®cacy of the eye movement desensitization procedure in the treatment of traumatic memories', Journal of Traumatic Stress 2, 2: 119±23. Shapiro, D.A. and Firth, J.A. (1985) Exploratory Therapy Manual for the Shef®eld Psychotherapy Project, Leeds: Psychological Therapies Research Centre, University of Leeds, England, Memo 733. ÐÐ (1987) `Prescriptive v. exploratory psychotherapy: outcomes of the Shef®eld psychotherapy project', British Journal of Psychiatry 151: 790±99. Shapiro, D. and Rosenfeld, A. (1986) The Somatizing Child, New York: Springer Verlag. Shapiro, D.A. and Startup, M.J. (1990) Raters Manual for the Shef®eld Psychotherapy Rating Scale, Shef®eld: SRC/ESRC Social and Applied Psychology Unit, University of Shef®eld, Memo 1154. Shapiro, D.A., Barkham, M., Rees, A., Hardy, G.E., Reynolds, S. and Startup, M. (1994) `Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral therapy and psychodynamic-interpersonal psychotherapy', Journal of Consulting Clinical Psychology 62: 522±8. Shapiro, D.A., Rees, A. and Barkham, M. (1995) `Effects of treatment duration and severity of depression on the maintenance of gains following cognitive-behavioral therapy and psychodynamic-interpersonal psychotherapy', Journal of Consulting Clinical Psychology 63: 378±87. Simmel, G. (1964) The Sociology of George Simmel, K.H. Wolff (ed.) Glencoe, IL: Free Press. Simon, G. and Von Korff, M. (1991) `Somatization and psychiatric disorder in the NIMH catchment area study', American Journal of Psychiatry 148: 1494±1500. Singer, W. (1993) `Synchronization of cortical activity and its putative role in information processing and learning', Annual Review of Physiology 55: 349±74. ÐÐ (1994) `Putative functions of temporal correlations in neocortical processing', in C. Koch and J. Davis (eds) Large Scale Neuronal Theories of the Brain, Cambridge, MA: MIT Press, pp. 201±237. Sokolov, Y.N. (1960) `Neuronal models and the orienting re¯ex', in M. Brazier (ed.) The Central Nervous System and Behaviour, New York: J. Macey Foundation. Sorce, J. and Emde, R. (1981) `Mother's presence is not enough', Developmental Psychology 17: 737±45. Sorce, J., Emde, R., Campos, J. and Klinnet, M. (1985) `Maternal emotional signaling: its effect on the visual cliff behaviour of 1-year-olds', Developmental Psychology 21: 195±200. Spitz, R. (1965) The First Year of Life, New York: International Universities Press. Steele, B. (1986) `Notes on the lasting effects of early child abuse throughout the life cycle', Child Abuse and Neglect 10: 283±91. Stern, A. (1938) `Psychoanalytic investigation of and therapy in the borderline group of neuroses', Psychoanalytic Quarterly 7: 467±89. Stern, D. (1985) The Interpersonal World of the Infant, New York: Basic Books. Stevenson, J. and Meares, R. (1992) `Psychotherapy in borderline personality disorder', American Journal of Psychiatry 149: 358±62. ÐÐ (1999) `Psychotherapy with borderline patients, II: a preliminary cost bene®t study', Australian and New Zealand Journal of Psychiatry 33: 481±5. Stevenson, J., Meares, R. and D'Angelo, R. (2005) `The ®ve-year outcome of treatment of borderline patients', Psychological Medicine 34: 1±9.

References

241

Stolorow, R. and Atwood, G. (1992) Contexts of Being: The Intersubjective Foundations of Psychological Life, Hillsdale, NJ: Analytic Press. Stolorow, R., Brandchaft, B. and Atwood, G. (1987) Psychoanalytic Treatment: An Intersubjective Approach, Hillsdale, NJ: Analytic Press. Strachey, J. (1934) `The nature of the therapeutic action of psychoanalysis', International Journal of Psychoanalysis 15: 127±59. ÐÐ (1961) Editorial note, SE 19: 8. Sullivan, H.S. (1953) The Interpersonal Theory of Psychiatry, New York: Norton. Symington, N. (1985) `Phantasy effects that which it represents', International Journal of Psychoanalysis 66: 349±57. Terr, L. (1993) Unchained Memories, New York: Basic Books. ThomaÈ, H. and KaÈchele, H. (1987) Psychoanalytic Practice. I Principles, Berlin: Springer Verlag. Tichener, E. (1905) Experimental Psychology: A Manual of Laboratory Experiments, New York: Macmillan. Tilley, A. and Empson, J. (1978) `REM sleep and memory consolidation', Biological Psychology 6: 293±300. Trevarthen, C. (1974) `Conversations with a two-month-old', New Scientist 62: 230±35. ÐÐ (1983) `Emotions in infancy: regulators of contacts and relationships with persons', in K. Scherer and P. Ekman (eds) Approaches to Emotion, Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. ÐÐ (1987) `Mind in infancy', in R.L. Gregory (ed.) The Oxford Companion to the Mind, Oxford: Oxford University Press. Tronick, E.Z. and Field, T. (1987) Maternal Depression and Infant Disturbance, San Francisco: Jossey-Bass. Tulving, E. (1972) `Episodic and semantic memory', in E. Tulving and W. Donaldson (eds) Organization of Memory, New York: Academic Press. ÐÐ (1983) Elements of Episodic Memory, Oxford: Clarendon Press. ÐÐ (1993a) `What is episodic memory?', Current Directions in Psychological Science 2: 67±70. ÐÐ (1993b) `The mental representation of trait and autobiographical knowledge about the self', in T. Srull and R. Wyer (eds) Advances in Social Cognition, vol. V, Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Tulving, E. and Thomson, D. (1973) `Encoding speci®city and retrieval processes in episodic memory', Psychological Review 80: 352±73. Umilita, M., Kohler, E., Gallese, V., Fogassi, L., Fadiga, L., Keyers, C. and Rizzolatti, G. (2001) ` ``I know what you are doing:'' a neurophysiological study', Neuron 31, 1: 155±65. Van Der Kolk, B. (1996) `The body keeps the score', in B. Van der Kolk, A. McFarlane and L. Weisaeth (eds) Traumatic Stress, New York: Guilford Press, pp. 214±41. Vygotsky, L.S. (1962) Thought and Language, eds and trans. E. Hanfmann and G. Vakar, Cambridge, MA: MIT Press. Walker, L.S., Garber, J. and Greene, J. (1991) `Somatization symptoms in pediatric abdominal pain patients: relation to chronicity of abdominal pain and parent somatization', Journal of Abnormal Child Psychology 19: 379±94. Weinberger, N.K. and Tronick, E.Z. (1997) `Maternal depression and infant

242

References

maladjustment: a failure of mutual regulation', in J. Noshpitz (ed.) The Handbook of Child and Adolescent Psychiatry, New York: Wiley. Whorf, B. (1956) Language, Thought and Reality, New York: Wiley. Williams, L., Phillips, M., Brammer, M., Skerrett, D., Lagopoulos, J., Rennie, C., Bahramali, H., Olivieri, G., David, A., Peduto, A. and Gordon, E. (2001a) `Arousal dissociates amygdala and hippocampal fear responses: evidence from simultaneous fMRI and skin conductance recording', Neuroimage 14: 1070±79. Williams, L., Senior, C., David, A., Loughland, C.M. and Gordon, E. (2001b) `In search of the ``Duchenne'' smile: evidence from eye movements', Journal of Psychophysiology 15: 122±7. Williams, L.M., Liddell, B., Rathjen, J., Brown, K., Shevrin, H., Grasy J.A., Phillips, M.L., Young, A.W. and Gordon, E. (2004) `Mapping the time course of non conscious and conscious perception of fear: an integration of central and peripheral measures', Human Brain Mapping 21: 64±74. Wilson, F., Scailaidhe, S. and Goldman-Rakie, P. (1993) `Dissociation of object and spatial processing domains in primate prefrontal cortex', Science 260: 1955±8. Winnicott, D.W. (1948) `Reparation in respect of mother's organized defence against depression', in Collected Papers: Through Paediatrics to Psychoanalysis, London: Tavistock, 1958. ÐÐ (1949) `Mind and its relation to the psyche-soma', in Collected Papers: Through Paediatrics to Psychoanalysis, London: Tavistock, 1958. ÐÐ (1950±1955) `Aggression in relation to emotional development', in Collected Papers: Through Paediatrics to Psychoanalysis, London: Tavistock, 1958. ÐÐ (1953) `Transitional objects and transitional phenomena', in Playing and Reality, Harmondsworth: Penguin, 1974. ÐÐ (1958) `The capacity to be alone', in The Maturational Processes and the Facilitating Environment, New York: International Universities Press. ÐÐ (1960) `Ego distinction in terms of true and false self', in The Maturational Processes and Facilitating Environment, New York: International Universities Press, 1965. ÐÐ (1962) `Ego integration in child development', in The Maturational Processes and Facilitating Environment, New York: International Universities Press, 1965. ÐÐ (1963) `Communicating and not communicating leading to a study of certain opposites', in The Maturational Processes and Facilitating Environment, New York: International Universities Press, 1965. ÐÐ (1965) The Maturational Process and the Facilitating Environment, London: Tavistock. ÐÐ (1974) Playing and Reality, Harmondsworth: Penguin. Woolf, V. (1925) The Common Reader, London: Hogarth. Wundt, W. (1904) Principles of Physiological Psychology, New York: Macmillan. Wylie, R. (1979) The Self Concept, vol. 2, Theory and Research on Selected Topics, Lincoln, NE: University of Nebraska Press. Young, J.Z. (1974) Introduction to the Study of Man, Oxford: Oxford University Press. Youngblade, L. and Dunn, J. (1995) `Individual differences in young children's pretend play with mother and sibling: links to relationships and understanding of other people's feelings and beliefs', Child Development 66: 1472±92.

References

243

Zanarini, M., Gunderson, J., Marino, M. et al. (1989) `Childhood experiences of borderline patients', Comprehensive Psychiatry 30: 18±25. Zigmond, R., Nottebohm, F. and Pfaff, D. (1973) `Androgen concentrating cells in the mid-brain of the song-bird', Science 179: 1005±7.

Author index

For multi-authored publications, referencing is only given, in general, for the ®rst author. Aichorn, 106 Als, 214 Amsterdam, 215 Anderson, 215 Anisfeldt, 215 Anthony, 220 Apley, 219 Arkema, 215 Arlow, 193, 225 Armstrong, 15±18, 213 Astington, 212 Atwood, 214, 221 Bacal, 177, 220, 224 Baldwin, 3, 4, 23, 24, 37, 166, 208, 211, 212, 214, 224 Barkham, 211, 212 Barthes, 209, 226 Bateman, 224 Bayer, 219 Beck, 193, 195, 225, 226 Beckett, 219 Beebe, 70, 214, 218 Benedict, M., 190 Bergin, 137, 192, 221 Berlin, 225 Bergson, 3, 4, 212 Berlow, 1, 183, 225 Bibring, 221, 225 Binswanger, 4 Blanke, 218 Boccioni, 4 Bohr, 59, 61, 142 Bodle, 214 Bornstein, 214

Borras, 211 Bowlby, 61, 134, 162, 216, 217 Bower, G., 221 Bower, T., 45±46, 213, 216 Brandchaft, xiv, 219, 223 Brazelton, 23, 213 Breuer, 190, 225 Brill, 190, 225 Briquet, 91 Brooks-Gunn, 46, 215, 216 Brown, G., 72, 218 Brueghel, 162 Bruner, 188, 225 Burns, 226 Buss, 4, 95±96, 219 Capra, 226 Carpenter, 213 Carramazza, 216 Charcot, 194, 225 Cheney, 224 ClapareÁdeÁ, 3, 95, 211, 212, 219 Clark, P., 217 Coleridge, 55 Cooley, 3, 63±4, 72, 184, 217, 218 Coombes, 224 Coons, 216 Cooper, P., 224 Cooper, S., 215 Comerford, 211, 225 Damasio, 117, 220 D'Angelo, 211, 225 Darwin, 25, 60±61, 69, 214, 217

246

Author index

De Casper, 213 Descartes, 84, 94±95, 183, 218, 219 Desmond, 217 De Yoe, 216 Dilthey, 184 Dunn, 212, 216, 225 Ehrenberg, 204, 226 Ehrhardt, 216 Eibl-Eibesfeldt, 224 Einstein, A., 18 Eisenberger, 217 Ekman, 69±70, 214, 218 Ellenberger, 8, 190, 212, 218, 225 Ellis, 221 Elson, 218 Emde, 33, 214, 215 Empson, 217 Erasmus, 182±183, 203±204, 225 Erikson, 42, 63, 215 Fantz, 69, 218 Feiner, 204, 226 Field, 224 Fifer, 213 Firth, 211 Fison, 226 Flavell, 185, 212 Fonagy, 221, 224 Forel, 212 Fouts, 224 Freud, A., 106±107, 110, 136, 220 Freud, S., 7, 38, 41, 55, 88, 101, 104, 119, 123, 130, 136, 162, 190, 191, 192, 193, 195, 211, 212, 213, 220, 221, 225, 226 and separation anxiety, 134±135 Fried, 221 Friesen, 214 Frith, 218 Gabbard, 103, 104, 219, 221, 225 Gallup, 215 Galton, 221 Garbutt, 142 Garvey, 214 Gazzaniga, 216 Gill, 130, 221 Glasser, 220 Gleick, 226 Goldberg, A., 219

Goldstein, 220 Goodall, 162, 163, 224 Gopnik, 212 Gosse, 12±13, 17, 186, 212 Gray, C., 211 Greenberg, 55, 217 Grenyer, 222 Groos, 54, 162±163, 216, 224 Grose, 214, 218 Gruber, 58±60, 211, 216, 217, 226 Gunn, 46, 216 Guthrie, 211 Hadamard, 213 Hall, 211 Harter, 63±64, 211, 217 Hartmann, 211 Heisenberg, 59 Henderson, 219 Henry, 225, 226 Herder, 184 Herman, 215 Herzog, 220, 224 Hillis, 216 Hobson, J., 217 Hobson, R.F., xii, xiii, 36, 89, 137, 166, 176, 179, 182, 196, 211, 215, 217, 218, 219, 220, 221, 222, 224, 226 and aloneness-togetherness, 203±204 Hobson, R.P., 212, 216, 217 Hoffmann, 184, 225 Holen-Hoeksma, 226 Holmes, J., 221 Holmes, R., 217 Horgan, 216 Horton, 215 Horvath, 219 Howitt, 226 Hubel, 216 Hughes, 212 Huizinga, 212 Hunt, 221 Inhelder, 212 Izard, 214 Jackson, J. Hughlings, 88±89, 100, 164, 170, 219 James, H., 3 James, L., 219

Author index James, W., xii, 3, 4, 7±8, 28±29, 83, 84, 88, 210, 213, 214, 217, 218, 219 ``duplex'' self, 17 feeling, 57, 60, 63 memory, 98 ownership, 95 self-esteem, 63±64 ``warmth & intimacy'', 65 Janet, 3, 4, 53, 61, 194, 211, 212, 216, 217, 219, 222, 225, 226 and attachment to trauma, 140 and bodily memory, 102 and changing the script, 199 and developmental arrest, 97, 161 and dissociation, 82±83, 194 and hierarchy of consciousness, 88±91 and hysteria, 91, 93 and integration, 41, 51±53 and liquidation of trauma, 194, 197 and secrecy, 7±8 and trauma, 100, 196 and traumatic memory, 194 Jung, 4, 11, 53, 65, 161, 191, 197, 212, 216, 217, 218, 221, 223, 224 and individuation, 89 and participation (or contamination), 124 and secrets, 212±213 and symbols, 163 KaÈchele, 193, 225 Kagan, 72, 218 Katon, 219 Keenan, 100±101, 219 Kernberg, 220 Klaus, 214 Klein, 109, 119, 191, 215, 220, 225 Kohler, 164, 224 Kohut, 5, 67, 85, 150, 182, 184, 191, 199, 211, 214, 215, 218, 221, 222, 225 and bipolar self, 37 and grandiosity, 37 and idealization, 37 and mirroring, 25 and Mr W., 127±8 and self esteem, 67 and selfobject, 34±36 and undetected lie, 186 and value, 25 Konishi, 213 Korner, 226

247

Krebs, 54±55, 216 Kris, 95, 219 Lacan, 95, 219 Lachmann, 70, 218 Ladavas, 220 Langer, 58, 217 Lee, 219 Leff, 219 Leger, 4, 211 LevõÂ-Strauss, 90, 219 Lewis, M., 43, 46, 69, 215, 216, 218 Lichtenberg, 199, 225, 226 Lidell, 220 Linehan, 224 Lipowski, 92, 219 Lipps, 184 Livingstone, 216 Locke, 213 Lovelock, 226 Ludolph, 215 Macfarlane, J., 213 Mahler, 7, 67, 212, 218 Malan, 192, 225 Malevic, 4, 211 Mandelbrot, 204, 226 Matas, 215 McFarlane, A., 213 McLean, 71±72, 162, 214, 218, 224 Mead, 3, 4 Meares, A., xiii, 204, 211, 226 Meares, R., 211, 212, 213, 214, 215, 216, 218, 219, 221, 222, 223, 224, 225, 226 Mechanic, 219 Meltzoff, 220 Melzack, 219 Miller, A., 217 Miller, H., 68, 218 Milner, 68, 218 Miltner, 219 Mitchell, 221 Mondrian, 4 Money, 216 Moore, J., 217 Moore, M., 220 Morris, D., 164, 224 Morris, H., 214 Morris, J., 221 Mozart, 55 Murphy, 163, 214, 224 Murray, 22, 214, 224

248

Author index

Newman, B., 4 Newson, E & J., 27 Nicolson, 218 Nin, 210, 213, 226 Noam, 214 Noland, 4 Ogden, T., 220, 222, 226 Olds, 68, 218 Olinick, 225 Opie, 223 Orlay, 212 Ornstein, P., 162, 223 Oshinksy, 68, 218 Orlinksy, D., 221, 226 Patterson, ``Banjo'', 176 Pearson, 213 Penman, 214 Perner, 212 Peretz, 216 Perret, 214 Persig, 133, 221 Piaget, 4, 37, 163, 166, 185, 203, 207, 211, 212, 214, 215, 216, 224, 226 and animism, 31 and ``life of union'', 28, 33, 203 and lying, 8 and magic, 30±31 and object perminance, 44, 46 and omnipotence, 31 and play, 28, 30 and self-boundary, 7 Picabia, 4, 211 Picasso, 59 Pine, 215 Piper, 192, 195, 225 Planck, 59 PoincareÂ, 56, 217 Prince, Morton, 100, 219 Putnam, 216 Rank, 210 Rees, 211 Ribot, 88 Rhys, 70±71, 218 Rizzolatti, G., 25 Robson, 60, 217 Rogers, 191, 195 Rosenblatt, 111, 220 Rosenfeld, 219 Ross, 216

Rossion, 214 Royce, 3 Russell, B., 71, 218 Rycroft, 41, 215, 219 Ryle, A., 225 St. Barbe Baker, 13±14, 212 Sandler, 111, 220 Samir, 93 Sapir, 92 Sargant, 138, 222 Schaffer, 218 Scherer, 68, 218 Schore, 216 Schiller, 49, 53±54, 216 Schmahl, 221 Schmideberg, 95 Schrodinger, 59 Schwaber, 226 Schwartz, 216 Screech, 183, 225 Segal, 119, 221 Seifritz, 214 Seyfarth, 224 Shalev, 219 Shapiro, D., 211 Shapiro, F., 226 Simmel, 212 Simon, 219 Singer, 216 Sokolov, 218 Sorce, 33, 214, 215, 224 Spitz, 43, 69, 216 Startup, 211 Steele, 108, 220 Stella, 4 Stern, A., 64, 217, 218 Stern, D., 24, 111, 214, 220, 225 Stevenson, 211, 215, 225 Stolorow, 214, 221 Strachey, 191, 211, 225 Sullivan, 4, 65±67, 70, 218, 222 Symington, 221 Tamis-LeMonda, 214 Terr, 102, 219 ThomaÈ, 225 Thomson, 221 Tichner, 218 Tilley, 217 Trevarthen, 21±22, 36, 214 Tronick, 224

Author index Troutmann, 218 Tulving, 98±99, 194, 219, 221 Umilita, 214 Vaillant, 100 Van der Kolk, 219 Vico, 183±184 VoneÁche, 211, 216, 226 Von Korff, 219 Vygotsky, 38, 55, 215 Wall, 219 Walker, 219 Weinberger, 224 Williams, Lea, 116±118, 220, 221 Whorf, 92, 219 Wilson, 216

249

Winnicott, 5, 38, 55, 144±146, 149, 150, 151±152, 166, 186, 191, 202, 212, 214, 215, 216, 222, 226 and false self, 116, 138, 143±148, 222 and the ``gesture'', 145±6 and mirroring, 25 and generative secret, 148 and transitional object, 31±33, 36 and transitional space (See ``space'') Woolf, V., 72, 174±175, 224 Wundt, 217 Wylie, 217 Young, 214 Youngblade, 225 Zanarini, 215 Zigmund, 213

Subject index

Abuse (see also ``Trauma''), 108 Accommodation (See ``False Self''), 194 Adaption, zone of, 38±40, 170, 207 Affect, 91±92, 170±171 and the face, 25 and ``words'' 25±26 development, 30, 43 social emotions, 43 Af®liation, 50, 216 Agency, 18, 72 Aliveness, 152, 176±7, 190, 208, 226 Aloneness, 36 Aloneness±togetherness, 142, 203±204 Amygdala, 71, 117±118 Ampli®cation, 25, 54, 58, 141, 172, 178±9, 187, 202, 204, 205, 207 Anger, development of 43 Animism, 31 Annihilation, 84±85, 138 Anorexia Nervosa, 122 Anxiety (see also ``Infant Anxiety''), 66, 82, 90, 92, 106, 108, 110, 124, 175, 193, 194 and abandonment, 84±85 and false self, 146±147 and restoration, 128 and risk, 142 and separation, 115, 134±135 Assimilation & Accommodation (see also ``Coherence & Continuity''), 111 Attachment, 50, 93, 134±136, 162, 216, 221 intimacy, 50, 221 non-intimate, 11, 141 symbolic play &, 215 to trauma, 136±138, 140 Attribution, 174 Avoidance, 143, 149±158, 194

Babbling, 21, 213 Binding problem, 52±53 Birdsong, 20±21, 213 Body feeling (see also ``False Self''), 18±19, 42, 70±71, 79±87 Borderline Personality, 3, 11, 39±40, 53, 54, 62, 64, 80, 86±87, 89, 93, 104, 109, 111, 112, 122, 126, 161, 194, 196, 205, 215, 220 abuse, 215 features of, 222 ±223 Chronicle, 88±90, 194, 197, 205 Cognitions, 191, 193 Coherence & Continuity, 18, 51±61, 96, 100, 101, 145 Consciousness (see also ``Self''), 15±16, 94, 131 dualistic, 50, 88 ±89, 99, 101, 103, 112, 132, 189, 194, 205±208 ecology of, 202±203 hierarchy of, 88, 100 introspective, 16 multiple, 103 Contamination, 124 Conversation, 61, 175±180, 188±189, 202±210 and forms of language, 38±40 and trauma, 194 child, 50 empathic, 189 inner, 12±13, 37±38, 60 Conversational Model, xiv, 211 Coupling, 25, 172, 175±178, 204, 205, 207 Deadness, 145, 152, 161 Decentration, 185, 189

252

Subject index

Depersonalization & derealization, 85, 136, 173, 218 Deterioration effect, 137 Developmental arrest, 32, 91, 97, 161, 170 Disjunction, 79±87, 105, 109±110, 187 Dissociation (see also ``Janet''), 51±52, 82, 91 Dreams, 55±56, 187±188, 207±208 Ego, 4, 20, 211, 213 Einfuhlen, 184, 185 Emotional Tone (see also ``Feeling tone''), 19, 37 Empathy, 11, 181±189, 195, 225 Emptiness, 3, 34±35, 84±86, 89, 107, 161, 222±223 Expectational Field, 102, 109, 114±125, 174 Face, the, 24, 25, 69±70 False self, 116, 138, 143±148 and body feeling, 145±147 and therapeutic impasse, 147 Feeling tone (see also ``Emotional Tone''), 37, 65±7, 187, 217±218 forms of, 56±58 Fellow feeling, 33±36, 80±81, 133, 165, 178, 184, 210 Gamma hypothesis, 52±53 Grandness, 37 Hippocampus, 71 ``I'', 20, 27 and engagement, 27±29 and self, 27 Idealization, 37, 98, 164±165 Identi®cation, 110±111, 184, 185 Identity, 41±43, 47 Imagination, 54, 55, 59, 89, 101, 132, 166, 181, 183 Imitation, 24±25, 107, 111 Impasse, 35, 134±142, 147 Infant anxiety, 31, 43, 46 exploration, 28 memory, 16, 44 perceptual abilities, 20, 21 Insight, 131, 181

Integration (see also ``Janet'' and ``Coherence and Continuity''), 51±61, 131 Intersubjectivity, primary, 22, 36 Intimacy, 50, 163, 203 and attachment, 50, 221 and empathy, 11 and exchange, 11, 49 and ``®t'', 70±71 Introjection, 110±113 Interation, 60 Language (see ``Conversation''), 175±178 affects &, 91±93 child lexicon, 42 disjunction &, 85 two forms of, 37±40, 209 Lying, 8±9 Magic, 30±32 Malevolent transformation, 66, 151 Mastery, 72±75 Match±mismatch, 24, 62, 79±80 Memory, 18, 50, 57, 89, 102, 194, 197 Hierarchy of, 98±100 Janet &, 197 Metaphor, 58, 92, 133, 176, 180, 182, 188, 209±210 ``Minute particulars,'' 176±177 Mirroring, 24±25, 70, 171 & ``meaning'', 25 Mirror neurons, 24±25 Mother±infant interplay, 20±26, 214 Mourning, 195±198 Multiple mothers, 45±46 Multiple personality, 51 (dissociative identity disorder) Music, 68±69 Narrative, 56, 58±61, 101, 133, 163, 182, 197, 200±1, 207±209, 226 & personal myth, 133, 200 Object permanence, 44, 46, 47 Omnipotence, 37 Ownership, 32, 36, 94±96, 145 Separation anxiety &, 215 Pain, 90±94, 217 Participation, 90±94

Subject index Participation, 124 Persecutory spiral, 136±138, 147±148 Phase shift, 204±209 Play (see also ``Piaget''), 6, 162±164, 214 associative (Einstein), 18 Baldwin &, 166. 224 categories of , 30 chimpanzees &, 162 coherence & continuity, 51±61 exchange &, 50 games &, 162 inner life &, 162 magic &, 30±32 narrative &, 61 representation &, 38, 40 Schiller &, 53±54 self &, 27 symbolic, 28±29, 31, 54, 61, 163 toys &, 27±29 Play space, 33, 50, 94, 166±167 ``fragile'', 39 inner space &, 29 metaphor of, 6, 40, 103, 132, 161±162, 164, 189, 207 ``reality'' &, 38±39, 80±81 therapeutic space &, 89 Primates, 162±164 Privacy, 11±14, 29, 50, 94 pathologies of, 11±12, 66 Private self, 29 Proto-conversation, 21±24, 27, 34, 214 Projective identi®cation, 41, 119±121, 220 Quantum theory, 59 Re¯ective function, 54, 57, 83, 88±89, 99, 101, 112, 123±4, 132, 194 Repression, 119, 134, 192±3 Representation, 25, 172±175, 179±180, 204, 224 Empathic, 181±189, 207 ``meaning'' and, 173±4, 179 Resilience, 100±101 Restoration, 126±142 Reverie, xiii, 121 Reversals, 104±113, 141 Scaffolding, 188 Scripts, 194

253

Secrecy, 7±14 Secrets, 151 attacks upon, 82 exchange &, 11 false, 12 generative, 13±14, 133, 141, 148, 190 intimacy &, 11 Jung &, 212±213 pathogenic, 190, 191, 196 Secret society, 11 Self (see also ``James W.'' & ``narrative''), xii, 3, 6, 27 agency, 18, 72 body feeling &, 18, 19 coherence &, 18, 41±50 consciousness &, 16±19 damage to, 5, 12 de®nition of, 17±19 duality of, 13, 15±19, 88±89 emotional tone &, 19 engagement &, 20±26 ¯ow &, 18, 29, 71, 132 ¯uctuance &, 19 form, 18 innerness &, 7±14, 30 integration &, 51±50 memory &, 16, 18, 98±100 relatedness &, 195 secrecy &, 7±14 space &, 17, 18, 19, 29, 41±50, 82, 189 ``substance'', 3, 5 things &, 27, 29 unity &, 24 Self-boundary, 7±14, 29 Self-esteem, 62±76 Self mutilation, 109, 126 Selfobject, 34±36, 127, 214 Self organizing system, 202±210 Self-recognition, 215±216 Semblant object, 166, 224 Separation anxiety, 115, 134±137 Shame, 43, 83, 216 Signs, 49 Smiling, 21, 43, 69±70 Social referencing, 173 Somatization, 91±94 Space, 17, 18, 19, 29, 41±50, 82, 166±167, 189 Cultural, 48, 49, 216 Transitional, 33, 47, 49, 209, 216

254

Subject index

Splitting, 33, 41, 194, 220 Stimulus entrapment, 88±96, 146 and memory, 16 Stockholm Syndrome, 135±136 Sublimal perception, 116±119, 220±221 Symbols, 49, 57, 92, 163, 164, 216, 217 Sympathy, 184±185, 188 Third element, 27±28, 133, 173, 181, 188, 189, 204 Theory of mind, 212 Toys, 27±29, 84 Transference, 97±103, 165, 191 Transference interpretation, 103, 130, 191±193, 195, 225 Transitional object, 31±33, 36 borderline patients &, 215 diary &, 32±33 Transitional space, 47, 140, 209, 216

Trauma, 5, 100±2, 107, 141, 149, 219 affects of, 81±85 attachment to, 138±140 reversal &, 108 separation anxiety &, 135 Traumatic Memory System (see also ``Janet''), 83±85, 87, 97±103, 118±119, 122, 124, 129, 130, 190±201, 219, 221 indications of, 129 James &, 83 Unconscious, 119±121, 130, 214 (see ``Hierarchy & memory'', 98±100; ``subliminal perception,'' 116±119; ``traumatic memory system'') Value, 5, 6, 13, 25, 60, 62±76, 172, 174, 179 Attacks upon, 82±83, 84±85, 108±110, 139 Kohut &, 25, 35