“Object Usage”

Phillip Bromberg in his book, “Standing in the Spaces” (1998)  quotes a dream from a patient to illustrate Winnicott’s concept of “object usage”.

“I was leaning out of a window on the top floor of a tall building that was in flames. A fireman was climbing up a ladder to rescue me and I was throwing rocks at him.”

Bromberg explains the dream. “A person may feel himself so psychologically incapacitated and at risk in the world of people, that it is indeed similar to living alone in a burning building from which he needs to be rescued. But that particular burning building is the only one that exists as a self, and one’s individual selfhood, no matter how painful or unadaptive, must be protected at all cost as part of any rescue operation.” Hence, Winnicott’s “object usage” means that the therapist must respect the patient’s need to “throw rocks”. Some psychoanalysts call this phenomena “resistance,” but Bromberg prefers “object usage”.

A fictional patient comes to my mind.  Louise, fifty-five, lesbian, mother of two, professional comes in describing her relationship to Harry, sixty-four, single, never married, a plumber. “Harry treats me like I am his mother. He acts like I am extremely interested in everything that happens to him, but he hardly ever listens to me, and he hardly ever seems to care what is going on in my life. The relationship is so one-sided that I feel so angry when I am around him.” Louise says, clearly caring for Harry, but also really frustrated with the relationship. “It sounds like Harry is using you as a caring bosom, because he must need that, but he does not have insight into the fact that you may not want to be that for him.” I say, thinking about Winnicott’s concept of “object usage.” As with Harry and Louise, all relationships, to some extent, involve using the other person to get our personal needs met and thereby not seeing the other person as a unique individual. The more one can gain insight into their “object usage,” the more their relationships can deepen into a process of interpersonal exploration. “Do you think if you confronted Harry that the relationship is feeling lopsided, that maybe then things could get better?” I ask, wondering if Louise can help Harry get some insight into how the relationship feels to her. “I have tried that, and it helps for a short time, but then things go back to this mother/child dynamic.” Louise says, with obvious anger in her voice. “You are in a tough spot, because it sounds like the relationship has hit a wall,” I say, mirroring her frustration. “Relationships work better when ‘objects’ are appreciated and not ‘used’ ” I say, throwing in some jargon about their dynamic. “Yep,” Louise says, with the joy of feeling understood.

 

 

 

The Independence Journey

Tomorrow, in my “Play Class” we will talk about Winnicott’s paper (1963)  about emotional growth in “terms of the journey from dependence to independence”. In this essay he coins his famous phrase “primary maternal preoccupation,” the time in a mother’s life, third trimester pregnancy along with the first few months of infancy, where the mother can think of little else besides her baby. The significance of this concept is that a mother has the challenge to follow a parallel journey with her child; a journey which begins with a merger, and ends with separateness. This parenting process is hard because it is overwhelming to feel responsible for another human being, and then it is overwhelming again, to let go of that responsibility so that the child can develop his/her own ego. A mother/caretaker has to have the emotional sophistication to know when to be hovering and when to let go. This, the lay public might say, is a “mother’s instinct”. Winnicott teaches us that without a mature mother, a child is psychologically damaged because he/she does not have the opportunity for ego development, for coping skills. For example, if a mother is afraid of their child’s upset, then she might feed them continuously. If the child never gets hungry, then the child does not know how to cope with the need for self-care, possibly leading to an eating disorder. The process of development, of maturation, demands that the child experience frustration followed by gratification. Optimal frustration is the key to healthy growth, as the child learns that needs can be met with thought and patience. Without optimal frustration the child is vulnerable to feeling omnipotent, where every need is immediately met, and hence arrogance ensues. The proof of healthy development, Winnicott would say, is quality interpersonal relationships, where quality is defined by mutual satisfaction. In other words, the metric of good mental health, is socialization. The ability to cultivate relationships requires flexibility and compromise. This has to be learned  in the tender developmental years, and then again, throughout life. Winnicott’s theory still holds true, fifty years later. Let’s see if my students feel the same way.

“To Be Alone In The Presence of Another,” Winnicott (1958)

Therapy offers, as Winnicott eloquently says, a patient “to be alone in the presence of another.”  Deep relationships offer this as well. This is the  luxury of experiencing one’s internal world, while a caring person is present in the room, but not intrusive into one’s internal process. Parents provide this for their children, or at least most do. They allow their children to play, without interruption, but they are in the room, or in the house, representing a caring person who is content knowing that their child is entertaining himself. This model of relationships is especially critical to those who feel that their internal worlds are constantly disrupted by an intrusive other. “I want to kill my wife,” Ward, forty-one, says to me, not looking for a response, but wanting to experience his own feelings in my presence. To say, or even to think, “you don’t really want to kill your wife,” would invade his internal space of feelings and fantasies. This tolerant approach allows Ward to explore his frustrations, anger and disappointment with his relationship. To intrude, or to interrupt, would cause him to question his feelings leading to internal confusion and harsh superego judgment. Indeed, the art of deep relationships is to allow the other to be alone in your presence. A lay person might say this is about  ”giving him space,” and Winnicott would add-on by saying, yes, but while you are physically present. Winnicott shines again.

Relationships Heal: Fairbairn Comes Alive

“My dependence on my mother is so great, and she is so privileged in my eyes that it makes my rage more acute and more forbidden. Mommy is someone I cannot attack….My position with her is so precarious that I don’t risk upsetting the balance.” Karl, the name given to W. Ronald Fairbairn’s patient that he writes about in 1958 in his article entitled ‘Nature and Aims of Treatment’.  Karl continues with a dream. As Fairbairn describes the dream, “he was starving in the dream and there was no food available apart from the pudding. He knew, therefore, that if he did not partake of the pudding, he would die of starvation; but he also knew that the pudding was poisoned and that, if he ate it, he would likewise die. It goes without saying, of course, that the poisoned pudding symbolized his relationship with his mother.” Fairbairn used Karl as an example that not only does he need to understand his sense of deprivation from his mother, but he also needs to develop a therapeutic relationship with his therapist so that he can see that not all deep relationships consist of poisoned pudding. This notion was then re-branded by Kohut as Self-Psychology, where the theory purports the same therapeutic action.

W. Ronald Fairbairn (1889-1964) studied divinity and then served in the British Army in Palestine before returning to his native Scotland and becoming a physician. He spent most of his professional career in Edinburgh, which was quite peripheral culturally and politically to London, with the result that much of his work was not appreciated by the larger psychiatric and psychoanalytic community until late in his career.

Re-reading Fairbairn for my upcoming Journal Club with the Psychiatric Residents, I am once again struck by how his ideas, although poorly written, were not brought to the light of day until, thanks to Kohut, we could now begin to tolerate the notion that relationships are therapeutic, even without the attainment of insight. Sure, my issue with Kohut is that he writes as though Fairbairn did not state this years before, but at the same time, I credit Kohut for having the charisma to take these ideas to a broader audience. In essence, the packaging is almost as important as the product. Kohut was a better salesman. Fairbairn’s ideas kick started our movement towards understanding the importance of the two people in the consultation room: their relationship matters.

White Matter, Matters

http://www.latimes.com/news/science/la-sci-orphan-brains-20120724,0,1723553.story

“What they found was striking: Brains of children who had remained in institutions had less white matter — the type of tissue that connects different regions of the brain — than orphans who were placed in foster care or children living with their own families.

Reductions in white matter have been found in numerous neurological and psychiatric conditions, including autism, schizophrenia and attention deficit hyperactivity disorder, or ADHD.”

Children need families. This is news, seriously. The LA Times reported today of a randomized studies in which orphans were either sent to foster care or institutions. Those sent to institutions had less white matter in their brains, thanks to imaging studies. Now, we finally have proof that nurture, the factor that I struggle with in some of my posts, is critical to the developing brain. Brains need stimulation. To paraphrase Winnicott,  a baby is nothing without a mother.  Now, we can say with more certainty that intimate connections help a baby develop security by helping the brain develop white matter. The more white matter that develops, the less likely the child will suffer from numerous mental disorders including childhood anxiety. The attachment theorists are having a good day. This study supports the notion that a primary attachment is critical for development. This small window of time, infancy, is key to having the brain grow properly. Now, does this mean that if one misses out on a good attachment, and hence has less white matter, that he/she is bound to have psychiatric disorders? Maybe. Is it harder to compensate for this deficiency as one ages? Always. Still, understanding is still critical to our personal enhancement and empowerment. We now know that as a society, we should try to strengthen families, and not provide alternative ways of raising children. We also know that given an inadequate early childhood experience, mental disorders are more likely, and hence there might be a role for medication to attempt to compensate, however slightly, for these deficits. As a Child Psychiatrist, I feel excited to have data to support what children need from the moment they leave the womb until they are able to enter school. Now, we can have a public relations campaign……White Matter, Matters! You heard it here first!

 

Munchausen By Proxy-II

A mom makes her child sick and then acts like a wonderful and caring mother who devotes herself to her ill child. Her friends feel sorry for her because she has a “sick” child. Is this hard to believe? Only if you believe in the myth that all mothers want to see their children healthy and happy. Monique was giving her four-year old Ana a laxative and then taking Ana to multiple gastroenterologists complaining about Ana’s chronic diarrhea. Why would Monique do this? You ask. One reason might be that Monique craves the medical attention. She feels the medical attention given to Ana to be nurturing for herself. She might also appreciate the secondary gain of being seen as this “angelic” mother who cares so deeply for her “sick” child. This theme of parents destroying their children supports Freud’s ideas that rivalries can be vicious and the fight for much needed attention, at times, knows no boundaries. Is there any hope for Ana? You wonder. That depends, is my response. In extreme situations, there is no hope. Monique will  physically and/or emotionally kill off Ana’s potential for a healthy development. In more subtle situations, where Monique, when she is in her own personal struggle causes Ana physical harm, where the issue is more intermittent as opposed to chronic, then Ana has hope to rise above Monique’s desire to poison her. Still, even in that situation, Ana is in a bind of loving and depending on a caretaker who is, at times, trying to harm her. This bind can take years and years to unravel. Ana’s desire to protect Monique is at war with her hatred towards Monique. This internal battle is exquisitely painful and unspeakable. Monique’s friends and family see her as a very loving and wonderful mom, yet Ana knows a different narrative. This discrepancy causes the painful confusion which is seen with so many kinds of child abuse, including Munchausen By Proxy. Some mothers consistently love and care for their children. Some mothers consistently try to harm their children. Most mothers love and hurt their children, to some degree, but fortunately, on a much lighter level. Winnicott’s concept of the “good enough” mother comes to mind. The exception, the outliers, help us understand the more subtle issues of parenting. Seeing Munchausen By Proxy deepens this understanding of what parents can be capable of. The stories amaze.

See also…http://shirahvollmermd.wordpress.com/2010/09/27/munchausen-by-proxy/

The Holding Environment: Chicken Style

The French Art of Saying “No”: The Holding Environment-The French Way

Pamela Druckerman captures Winnicott’s holding environment concept well, as she describes how French parents are comfortable saying “no” to their children and thereby giving them the containment which is necessary for self-confidence and a feeling of internal security. In our overly child-centered culture, “kindergarchy” creates kids that are prone to anxiety because they do not know where the limits are. Knowing that the authority figures, the parents, are setting a frame, allows the child to have boundaries in which he/she can push up against in order to form a strong personality foundation. Without limits, anxiety can set in, causing the child to feel insecure and inhibited in their world. This insecurity, in turn, causes the child to miss out on experiences which could enhance his self-esteem. Old ways of parenting are not necessarily bad, and new ways are not necessarily good. No matter how much we know that, our brains tilt towards wanting to believe that new is somehow improved, and that old is outdated. In the case of parenting, Ms. Druckerman reminds us, by looking at French culture, that parental authority for young children, when done lovingly and consistently, is a good thing. I support that.  

 

http://online.wsj.com/article/SB10001424052970204740904577196931457473816.html

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Nature or Nurture: Will The Debate Ever End?

   Daniel http://shirahvollmermd.wordpress.com/2012/02/07/the-aggressive-child/ is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

The Aggressive Child

Daniel, six, with a two-year old brother, Jonathan, knew that Jonathan was the favorite. He was angry when Jonathan was born, very angry. Daniel acted out his anger with aggression, which further confirmed to Daniel’s parents, that he was the “bad child.” This was my theory as to why Daniel was so violent, both at school and at home. Many teachers, family members, and other professionals saw his aggression as either part of a “spectrum” disorder or an impulse-control disorder such as ADHD. In my office, Daniel was indeed quite aggressive. He would take off his shoes so that he could throw them at me. Yet, I saw his aggression as a way that he communicated that his emotional needs were not getting met, and he needed me to understand that. I explained to Daniel that throwing his shoes was unacceptable in that I did not want to get hurt and I  did not want him to hurt others. We could use my pillows to “play” in a way which might get out some of his aggression, but we could not use the pillows to hurt each other. He understood the fine line between physical play and aggression. Eventually, Daniel calmed down in my office, but he continued his aggression at school and at home. With that in mind, I began seeing his parents on a monthly basis. Both the mother and father agreed that Jonathan was a “much easier child,” suggesting that they did favor him at home. Jonathan made them feel like competent parents, whereas Daniel, partly because he was the first-born, and partly because he was more prone to acting out, made them feel like they were “parental failures”. I worked with the parents to help them see that as they felt like “parental failures”  where it came to Daniel, they then unconsciously encouraged Daniel to be aggressive as a way of denying their role in his behavior. As Daniel got into more trouble at school, the parents felt more relief that Daniel had “issues,” thereby taking away their feeling of “parental failure”. The cycle of parental inadequacy leading to the unconscious wish for Daniel to show that his issues are “organic” and not environmental caused the downward spiral of increasingly difficult behaviors. However, I pointed out to them that although Daniel’s behavior is getting worse, in my office, his behavior is getting better, suggesting that with appropriate limits, Daniel can calm down. Winnicott’s idea of a holding environment comes alive again. Daniel felt “held” in my office, so he did not need to be aggressive in order to feel understood that his emotional needs were not getting met. Daniel’s parents, for complicated reasons, were not able to create this “holding” environment at home. Violence is often a communication tool; a tool to wake up those around that the aggressor needs attention. Sometimes people do not want to be woken up. My work is to find a way to gently nudge a “wake-up” in these parents. I suspect that when I do arouse these parents, Daniel will be “cured”. We will see.