Simon Peacock. Therapeutic Communities (1999) Vol. 20(4)
ABSTRACT: This paper examines the notion of an ‘internal mental space’ in which to carry out therapeutic work in everyday situations with children and young people. The issues involved are discussed firstly from a theoretical perspective, examining some of the aspects that characterise the internal mental space. Secondly, the idea is viewed from a practical perspective using an example of an incident with a child that describes some of the difficulties the author experienced in creating and maintaining an internal mental space.
How do you, as a childcare worker, learn about and understand what is going on for the children that you are looking after but whom you may not know very well at all? Some workers seem intuitively to have an uncanny rapport and understanding of children’s emotional needs. Sometimes I feel like I have to work very hard at it and often miss the point.
Occasionally, a child will have expert therapy sessions to help him deal with emotionally traumatic experiences and the therapist will provide a report telling you what the child is experiencing. However for most children in emotional need the luxury of regular and expensive psychotherapy or play therapy is not available. The work on understanding the child has to be done by the ‘ordinary’ but no less professional childcare worker when the opportunity arises in the course of everyday work with the child.
Hoxter (1977, p.210) wrote that, “the art or gift of the therapist appears to be related to the extent to which she is able to provide an internal mental space”. The majority of what is written about creating an internal psychotherapeutic space is written from the point of view of the professional therapist. Much less is written from the point of view of the residential worker trying to work, not just in a task-centered, caring way but in a manner that is also therapeutic. Dockar-Drysdale (1988), Lanyado (1991) and McMahon (1995) in particular have tried to illustrate how the techniques of psychotherapeutic communication can be used effectively in everyday settings. I too believe that the techniques involved in creating an internal mental space in which to provide therapeutic help should not be seen as the sole preserve of ‘expert’ therapists but can be employed by any childcare worker who has the ability to think.
The internal mental space
I believe there are three fundamental aspects that are important for the creation and maintenance of an internal mental space. These are primary maternal preoccupation, unconditional positive regard and an understanding 2 of the issue of transference and counter-transference. The factors that hinder the maintenance of the space are those of impingement, lack of empathy and poor communication.
Primary maternal preoccupation
The first aspect to consider in creating an internal mental space according to Lanyado (1991) is that of Winnicott’s ‘primary maternal preoccupation’. For the ordinary mother and the child this is the ability of the mother to be aware of and to anticipate her baby’s state of being and thereby meet the baby’s needs. Maternal preoccupation is of course not necessarily gender-specific. It might just as easily be termed ‘paternal or parental preoccupation’ or even ‘therapeutic preoccupation’ when considered in other professional settings. Primary maternal preoccupation might be seen as an almost intuitive or unconscious response to the child. Winnicott wrote of primary maternal preoccupation that it:
“… gives the mother her special ability to do the right thing. She knows what the baby could be feeling like. No one else knows. Doctors and nurses may know a lot abut psychology, and of course they know a lot about body health and disease. But they do not know what a baby feels like from minute to minute because they are outside this area of experience”. (1960, p15).
Of course, no one can know absolutely how another is feeling. However, it is possible to imagine and, with increasing experience and familiarity, it is possible to imagine with more certainty how a particular child might be feeling. An example of this is the infant who spends time with a regular child-minder. A professional and competent child-minder will soon develop a preoccupation with and understanding of the child he or she is caring for. For the childcare worker working with an unrelated child an intuitive maternal preoccupation such as a mother might have with her baby is unlikely to exist but with the development of a professionally close relationship something very similar is possible.
Symington (1986) and Lanyado (1991) describe the important link between how the state of containment of anxieties by the mother being in tune with her baby, as described by Winnicott, and the concept of ‘reverie’ which involves a more conscious aspect of thinking about the baby, as described by Bion (1962), can be transposed to the therapeutic situation.
“The person of the analyst bears the anxiety, then, the interpretative words bind the psychic parts together, at the analyst’s disposal are the communications of the patient and his own psychoanalytic theories. Every interpretation reflects a theory, every interpretation is embedded in a meaning structure; the more theories, meaning systems that he has available the better. In order to interpret he gives himself over to ‘reverie’ or ‘free floating attention’. His imaginative processes are stimulated by the patient, otherwise he is a victim of his own preoccupations. Ultimately however the patient has to construct his own individual personal world-view” (1986 p.48).
This last sentence is important for it connects with Winnicott’s view that it is not only the interpretation by the therapist that brings about help but the moment of surprise and realisation by the child. That is, the child ultimately makes sense of his own feelings. Winnicott (1971 p.86) wrote, “I think I interpret mainly to let the patient know the limits of my understanding”.
Unconditional positive regard
Winnicott’s view of interpretation and realisation is reflected in Rogers’ belief that every child has a capacity to grow emotionally from within if the nurturing circumstances are right. Standal’s (1954) concept of ‘unconditional positive regard’ as adopted by Rogers conveys the essence of the state of mind the worker has to achieve in order to offer a mental space to the child. Rogers writes:
“it involves an acceptance of and a caring for the client as a separate person, with permission for him to have his own feelings and experiences, and to find his own meanings in them. To the degree that the therapist can provide this safety-creating climate of unconditional positive regard, significant learning is likely to take place” (1961 p.283).
Symington (1986) writes similarly of ‘free floating attention’ and explains that the worker’s position in relation to the child has to be one of reverie. That is, the worker cannot have a predetermined theory or key with which to try and understand the child. Such a predetermined position would screen the worker from receiving unconditionally what the child has to communicate and block any new understanding of the child. He concludes that, “…the state of reverie essentially means what the analyst is prepared to be changed by his patient (Symington, 1986 p.291).
If the making of a response to the child is conditional on a smile or a frown from the child then the child will perceive it as conditional. Vice versa, being told verbally or non-verbally what he or she is permitted to feel or express does not facilitate the child’s free communication. The child must receive an unconditional and accepting response in order to figure out for himself what he feels and thinks. The communication of a positive regard tells the child not only that he is safe but that he is valued as a person and that what he has to say is of value. The moment that conditions are applied to the provision of the space then the sooner it is open to corruption or impingement.
In essence, the worker’s intuition and thinking must be put into suspension for a time until he has received what the child is communicating. Paradoxically, the worker must bring himself both personally and professionally to bear on the mental space because unconditional positive regard both helps to create the internal space and protects it and maintains it. Unconditional acceptance does not mean liberal permissiveness. It conveys an idea of receptivity and openness rather than defensiveness and is a closed mind.
Transference and counter-transference
Greenson’s definition of transference is:
“… the experiencing of feelings, drives, attitudes, fantasies and defences toward a person in the present which do not befit that person but are a repetition of reactions originating in regard to significant persons of early childhood, unconsciously displaced onto figures in the present. The two outstanding characteristics of a transference reaction are: it is a repetition and it is inappropriate” (1967 p.155).
While the transferred feeling may be inappropriate, Brown and Peddar (1991 p.55) argue that it can nevertheless be useful when, in transference phenomena, patients begin to experience feelings towards the therapist as if he or she were a significant figure from the past, “transference then becomes a tool for investigating the forgotten and repressed past”. Symington describes it as an unwritten contact with his patient.
“You may hand some of this excess anxiety over to me and this will help us in our work.” The resistant, anxious part of the personality which the patient wants to be rid of is then projected on to the analyst. This is the phenomenon which we know as transference” (1986 p.47).
Counter-transference is an emotional response by the therapist or worker to the transference, ie the worker’s feelings about what he is experiencing emotionally. For example, if you physically threaten me because your are frightened of me, I may become frightened of you (the transference of a feeling of fright or anxiety). I may also feel like reacting aggressively because I am frightened. This is an emotional response on my part, giving some validity to your projected feeling. This is the counter-transference of a feeling of fright rather than a recognition and empathy with your feeling of anxiety.
The importance of this for the worker is that if he or she can recognise that his or her reaction to the threat is defensive (ie conditional on the threat) then the worker can make an informed guess about the feelings that the child may be experiencing. The ability of the worker to sort out mentally what are his or her own feelings and what are the child’s feelings is central to maintaining an internal mental space which will be of use to the child.
Winnicott (1988) describes the effect of impingement on the emotional development of the child. In terms of practical therapy, impingement from an external source is regarded as detrimental and potentially harmful. Impingement may be as tangible as someone entering the room unexpectedly, interrupting whatever interaction is going on between adult and child or it may be much more intangible such as day dreaming or falling asleep when listening to a child.
Casement argues that in most ordinary relationships between parent and child there cannot be freedom from influence.
“The need, in analysis, for mental and emotional space is highlighted by the comparative absence of space in other relationships. To be healthy, every intimate relationship needs space and personal boundaries and a corresponding respect of each person for the ‘otherness’ of the other. Frequently, however, this space is either lacking or contaminated by intruding influences. All parents however well-intentioned will impose pressures upon a child that comes from needs and wishes of their own”. (1990 p.160).
Rogers (1961) describes how the therapist needs to be a fairly well integrated person in order to defend his emotional space from impingement. In organisations which do not actively support a culture that is protective of the kind of work required to offer a mental space to a child this is considerably difficult for the worker. If the primary task is not therapy then immediately impingement becomes obvious because the worker will be distracted by some other demand on his or her preoccupation.
An example of protecting a mental space from impingement in a professional setting is that of supervision. The supervision setting which is allowed to be interrupted by callers or telephone calls inevitably disrupts the attention of the supervisor and the experience of the person being supervised who may feel that the supervisor’s attention is elsewhere.
The internal mental space
The internal mental space is an area of the mind which the worker can put aside for however long is needed to think about and imagine the experience of the needs of someone else; not just anyone, but the particular person who requires help. The physical and emotional environment must first protect both the worker and the child from interruption by external sources.
The internal mental space must be free from interruption (impingement) by internal sources such as distracting thoughts about other people or about oneself. The internal mental space must allow for an imaginative capability so that the childcare worker can appreciate and hold onto an idea and understanding of the feelings that the other person is experiencing, even if the worker is not experiencing directly those feelings himself. Dockar-Drysdale’s (1965 p.96) definition of empathy is an important concept here, “… it is one thing to get into someone else’s shoes, but quite another to understand what it is like for the other person in his shoes while remaining in one’s own. “This means that the worker must have some idea of what he or she is feeling, and what he or she might feel in response to the various things he or she might hear, see or experience from others. Often this is an ideal state of being that is difficult to achieve.
In practical terms for the childcare worker this may mean that the space needs to be created, in some instances conjured up, and maintained. The technique I use in trying to become preoccupied, offer unconditional positive regard and sort out me from the child is to consciously ask myself questions such as, “What is happening in your life and what is happening in mine?” I have on occasions asked questions verbally of a child so that both the child and I were driven to think about what might be going on in the child’s life that might be giving rise to anxieties. For example, in conversation I might say something like, “I know you have just moved foster placement/had a change of Social Worker/just seen your mum and dad”. Very often the child will deny that these issues matter to him and just as often that denial can mean that I have hit the nail on the head.
The purpose of this process is to try and connect with the context in which the child finds himself. It is important to do this in both immediate and then in wider terms, looking at the present and then the past, thinking about and listing things mentally, trying them out through suggestion or questions, and trying to imagine the feelings which may be connected with these fragments of knowledge. This kind of process helps me to tune into the child. I cannot always know immediately but with experience and familiarity I begin to tune in more and more quickly to the child I am working with. Usually I have to think hard in order to become preoccupied and understand. Occasionally there comes a time when this process becomes almost intuitive because I do not have to think actively in order to know how the child is likely to be feeling about a given set of circumstances.
An internal mental space in which the child can express powerful, potentially hurtful, destructive, annihilating feelings as well as pleasurable experiences is a safe place. A child can feel helped and held safely in an emotional sense.
Case study: Michael
This description is of an incident with a child in a residential therapeutic community setting but the incident could just as easily have occurred in a fieldwork setting, for example on a car journey with a child.
The Cotswold Community is a residential therapeutic community for boys diagnosed as being ‘unintegrated’ (Winnicott, 1988 p.116). The boys live in groups of ten in four separate households in a village-like campus based around an old farm. The treatment philosophy of the Cotswold Community incorporates Dockar-Drysdale’s (1990) application of Winnicott’s theories in its approach to the treatment of unintegration. Many of the boys have suffered emotional, physical and sexual abuse or have been deprived and neglected. The boys exhibit considerable disruptive behaviour, are prone to frequent destructive outbursts of panic and rage and find it very difficult to live and function in a group.
The incident described is an example of the ‘life space interview’ technique (Wineman, 1959) or of ‘opportunity led work’ (Ward, 1993). That is, an incident, which is not a formal or structured therapeutic session, but one that was an immediately available opportunity for work with a child in a moment from every day a life. However, this incident illustrates the issues that required the use of an internal mental space and the difficulties I experienced in achieving it. All identities are disguised.
Michael (12) and his twin brother Matthew joined the community and were initially placed in separate houses. (I cannot remember now why this was but whether it was just a matter of available space or a deliberate decision is not relevant to this discussion. However, the effect of this early separation for Michael is important as will become clear. This incident took place very shortly after Michael moved to my unit in order to be placed together with his brother. Michael and Matthew are black British children. There are no other black people in the household.
It was Colin’s eighth birthday. He came to the house meeting after tea wearing a bum-bag that he had received as a present. Greg (13) also appeared at the meeting wearing a bum-bag, a fact to which Colin took great exception.
John, the house manager, made the point to Greg that Colin’s bag was important and special for him as it was the only birthday present he had received from outside the community. John said that for Greg to wear his bum-bag at this particular moment was upsetting for Colin and wondered if Greg was finding it difficult to cope with the fact that it was Colin’s birthday and that he might be feeling envious of this. Greg was asked not to wear his bum-bag around the house and initially protested about this decision.
Discussion followed and John asked other boys what they thought. For the most part boys were in support of John’s argument because in effect it was representative of protecting everyone’s right to have an individual special experience, especially a birthday! Greg eventually acceded to John’s request and removed his bum-bag. Michael however remained very angry about what John was saying and tried to draw other boys into rubbishing the home and adults in general. After the meeting Michael needed to be separated from the group because he remained angry and continued to disrupt the other boys’ activities. I was asked to spend some time with Michael.
When I went into his room, Michael was whipping one of his teddies with a chain. The teddy was suspended from the ceiling by a string tied round its neck. The teddy was a present from Walter, Michael’s previous key worker from the unit to which he had first been admitted.
SP: Why are you whipping … um …. (I couldn’t remember the name of Michael’s teddy at this point. I was immediately a little panic stricken by this and wondered how I was going to get alongside Michael if I couldn’t even remember the name of his teddy.) … your Ted?
Michael: He’s been naughty.
SP: What’s he done?
SP: Does he deserve to be hit then?
Michael: Yes. He needs to be punished.
Michael began swinging the chain around a bit more freely and was in danger of hitting me. I stopped him and took the chain telling him he was getting dangerous. Michael pulled the teddy down, stabbed him with a pencil and threw him out of the open window. He then threw all his other teddies out of the window and sat on the bed playing with a Rubik cube with his back to me. Michael began whistling the same tune over and over again. After a couple of minutes he looked at me and said, “What are you waiting here for?”
(I had made a deliberate point of not saying anything to Michael during the previous few minutes as I thought he was defending himself against conversation by whistling and that for me to attempt to talk with him would just lead to a competition with his whistling.) Michael lay on the floor with his back to me and played with his fire engine.
SP: Well, I was wondering if you understood what John was saying in the meeting?
Michael: Yes, but I think Greg should be allowed to have his bag. Lots of people have bags like Colin’s.
SP: (A) John was not saying Greg could not have the bag. He started the meeting by asking me how I thought Greg should use his bag and whether Greg needed to keep it in his room because Colin was upset by the fact that Greg had a bag like his.
We carried on arguing this point back and forth for what seemed like a long time but which were probably only a few minutes.
Michael: John didn’t let me say what I wanted to say.
SP: (B) I remember John asking other boys what they thought.
Michael: But he missed me out.
SP: You had a say. (I sat down on the floor beside Michael at this point.)
Michael: But I had something else to say and he wouldn’t let me.
SP: (B) You were rubbishing the house because John was saying that it was important for Colin to have his bag kept as something special for him as it was the only birthday present he had.
Michael: So! That’s my opinion and he wouldn’t let me say it cause he left me out.
SP: (C) I think it’s important that the grown-ups protect boys’ special things by saying that no two boys can have the same special thing. I think it is important that for boys who perhaps haven’t got very much we make sure that what they have got is special for them.
Michael: (Angry outburst, kicked his shelf and waved his arms at the room). Look at me. I haven’t got very much. (Michael tearful and angry.)
SP: (D) That must feel awful. (I was quite anxious at this point about which way Michael would go – to be sad or to be angry and start breaking things and needing to be physically restrained).
Michael: I don’t care. I don’t need special things.
SP: Perhaps you wish you had something that was special for you?
Michael: I don’t need special things.
SP: Well, I know in the other house you had special things and when Walter comes to visit you here that’s something special for you, which you enjoy.
Michael: (Angry and tearful again). I’ve only had one meeting with Matthew since I came here, one cooking time and no meetings on my own.
I reacted defensively to this rather than empathising, perhaps feeling guilty, and explained about the temporary arrangement of me acting as Michael’s key-worker until Francis (another worker) could take over this role on a permanent basis. I explained that Francis was about to start working with him and all of the activities which he said were not happening for him, and about which he was complaining, were now taking place.
Michael: Can I go and watch the video now?
I did not answer this because I was still thinking about what he had said, knew I needed to go further with him and was not sure what to do next.
Michael: (Angry). See! You don’t even answer my question.
SP: (Rather lamely). I’m sorry. What did you say?
Michael: Why am I being kept in here? Why am I being punished for saying my opinion? John’s rubbish. All adults are rubbish.
SP: You are not being punished, but I am wondering if you are feeling angry about being left out, not having meetings, etc.
Michael: I don’t care.
SP: Well you were angry earlier on and were rubbishing the house because we were saying that boys’ special things needed to be kept special.
Michael: But why am I being punished? (Tearful).
SP: I’m sorry if it feels like that but all I am trying to do is help you understand what John was saying in the meeting and why it is important. I also think you need to understand that you might be feeling angry about feeling left out and that might remind you of other times when you’ve been missed out. Perhaps you are angry that you have nothing special at the moment because you haven’t been in this house very long, whereas you did have special things before in the other house.
Michael was sad and tearful at this point. I had the sense that he had reached some recognition of what his angry feelings were about. Perhaps more importantly I was beginning to reach a better understanding of what Michael’s feelings were about. Michel asked me if I would go and fetch his teddies from the garden. I was struck by the fact that I immediately remembered the name of his teddy … “Stanley” … as I went out of the back door (E).
In the example above there are several strands which I struggle with. Firstly, in terms of primary maternal preoccupation, this is a child who I have been allocated to as key worker for only a very short time. I do not know him very well. It is clear at the beginning of this incident that I am not primarily preoccupied with Michael but much more with my adult role within the unit. I do not know how he is feeling and I am struggling to even anticipate what those feelings might be. All the way through this incident I was distracted by the fact that I couldn’t recall the name of Michael’s teddy and was worried by this. I felt I hadn’t helped Michael in a very skillful way and further felt that some unconscious block prevented me from empathising more freely with his feelings. I wondered whether this was linked with the fact that I couldn’t remember the name of his teddy and was feeling guilty about this so that I could not ask him. I felt I should have known the name.
Secondly, and very early on in this example, I struggle to give Michael unconditional positive regard. At the point marked (A) in the text I am defending John’s position rather than being receptive to Michael’s situation.
At the point marked (B) I make the same mistake. A better response might have been something like, “What else did you have to say?” Even if Michael was not able to put this into words it might nevertheless have 11 communicated to him that I could tolerate what he wanted to express. Similarly, the tune Michael was whistling early on in the confrontation might have been a significant piece of communication had I been thinking hard enough to listen and remember what it was!
At the point marked (C) I am not really speaking to Michael but to myself but it has the effect of reminding me of what I am supposed to be trying to do, ie empathising. To paraphrase Winnicott, I was at the limit of my understanding at this point.
However, the effect of this lecture to myself is to start clearing a space in my own mind for Michael, rather than for all the other things which I am defending, and allows me to make a much more empathic response at (D). Containing my own anxiety at this point allowed Michael to express his very powerful feelings of anger and hurt. By not reacting punitively to the shelf being kicked over I was able to give Michael permission to have the feelings he had, unconditionally.
Finally there is the issue of transference and counter-transference. Put simply again, there is a lot of anger and pain coming my way from Michael. I don’t feel comfortable with it so I variously defend myself against it, avoid it or respond with an attack. Michael’s circumstances are these: he has been separated from his twin for several weeks; he is a black child in a predominantly white household; he is living many miles from his family home. In order to empathise with Michael I need to be able to imagine what it feels like to be a black child in a white culture setting to have been separated from my twin brother for a period of weeks; to be a newcomer to a setting in which my brother has already established relationships and become quite familiar.
Intellectually I can work all this out but in this instance I am initially blocked from doing so on a feeling level by several other preoccupations. In short I don’t have the first idea about what any of these experiences might feel like but I do pick up on the feeling of anger from Michael. This feeling is potentially threatening and might hurt me. Like most people, I believe pain hurts, we don’t enjoy it and we will avoid it if we can. Even if I stay with imagining it for only a few minutes I know enough of the feeling not to want to continue to feel this pain. For Michael the experience of being different – of being black or of being new to the house or of being unheard when others appear to have been heard is painful.
If the interaction is viewed in its entirety then it becomes apparent that there is a battle going on between Michael and me about who is going to win this dispute. There are issues of power resonating in this incident whether they are racial in terms of white versus black, or in terms of adult versus child. It is only when I begin to get an idea of how Michael is feeling that the battle becomes irrelevant and I only get an idea of how Michael is feeling when I begin to stop thinking about myself. My engaging in these potential battles is a counter-transference reaction which does not help either of us understand what is going on at the time.
The final aspect of this incident is that despite what I felt to have been a nottoo well-handled piece of work, just the small bit of understanding which I was able to communicate to Michael was enough to convey some degree of trust in me that I did understand and that therefore I could help. Hence at (E) I was asked by Michael to go and rescue his teddies from the garden.
The incident with Michael is a personal account of a typical situation, with which I am sure many workers can identify. The use of the internal space is important not only in formal psychotherapy but also in every day social work or residential work with children. The incident I have described is not held up as an example of particularly skilled practice but it does show what is required and the difficulties experienced in trying to create an immediate space and in attempting to maintain it and protect it from impingement.
In Michael’s case this was one of many such incidents where he needed workers to be able to tolerate and receive unconditionally his powerful feelings of injustice, loss and anger arising from his earlier life experiences. Over the following months and years Michael’s relationships with others became slowly more trusting.
Clearly in any situation other than a parent/child relationship, whether that is as psychotherapist, social worker, residential childcare worker or foster carer there is a greater effort to be made to get in touch with what is, to all intents and purposes, an unknown quantity – a child who is not known to the adult. There is however considerable scope for use of the techniques in other settings as I have indicated.
Docker-Drysdale (1988 p.119) describes the use of interpretation outside the psychoanalytic session. She says, “communication is regarded as the main form of therapy, other than concern and reliability”. This has relevance to the everyday therapeutic treatment of children whether in residential settings where workers are likely to be in contact with a child for a significant portion of the day, or even in a field social work setting where contact may occur anywhere between daily to three monthly. I am not suggesting therapy can be done at three monthly intervals but the difficulties in keeping intact the therapist’s or social worker’s internal mental space for such a child from one meeting to the next are clearly enormous.
In other social care settings the worker may be trying to keep in touch with more than one child. Often the worker has to keep in touch not only with all of the children but also with other staff members. This has been described to me as, “like holding twenty invisible threads, each in touch with a different individual, and quite likely to be leading in a different direction”. Keeping in mind the psychological well-being of others in this sense is clearly a huge and complex task.
Preserving a state of preoccupation is not only one internal mental space but in many is an achievable but complex task. 13 In order to work in a therapeutic manner with children I believe it is necessary to have the ability to create an internal mental space. In order to achieve this the worker needs to be able to combine the fundamental aspects of primary maternal preoccupation, unconditional positive regard and an awareness of the issues of transference and counter-transference. Other therapeutic skills such as empathy, communication and protection of the space from impingement are also necessary. These techniques may be an art or a ‘gift’ but I believe they can also be developed and mastered as professional skills to be used in everyday, opportunity led situations with children and young people.
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