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(p. 434) Working with States of Mindlessness in Substance-Abusing Mothers with Personality Disturbance 

(p. 434) Working with States of Mindlessness in Substance-Abusing Mothers with Personality Disturbance
Chapter:
(p. 434) Working with States of Mindlessness in Substance-Abusing Mothers with Personality Disturbance
Author(s):

Tessa Baradon

and Minna Daum

DOI:
10.1093/med:psych/9780199743100.003.0021
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Subscriber: null; date: 16 January 2019

Theoretical Framework

The clinical work described in this chapter is underpinned by a developmental approach to the acquisition of a capacity to “own” and understand states of mind and to see them as meaningful to ongoing behavior and actions (Fonagy & Target, 1997; Slade et al., 2005). From this point of view, an infant or child’s experience of being “held” benignly in the mind of the caretaking adult as a separate, dependent, and developing child is pivotal. Through this process, the child can “look into the eye (mind) of the mother” and see himself as himself—i.e., relatively undistorted by the parent’s state of mind or projections (Winnicott, 1971).

It is this experience of safely looking into another person’s mind that is often critically missing for children of substance abusing, personality-disordered parents. The model is one of deficit. Poor or tenuous reflective capacities in the parent tend to create similar deficits in the child, with consequent chaos in the mind (lack of connectedness and meaning). Frequently, the parent’s state of mind is labile and highly unpredictable—swinging from a position of feeling useless and hating, to feelings of omnipotence and idealized, merged love. Thus, the parent’s experience of being with their baby or child is either of being aligned and at one with the child, or persecuted by the child when s/he is seen as separate. As long as the baby is seen as an extension of the mother, the baby can be narcissistically loved. This is a position of safety for the mother. However, whenever the baby creates a separateness—for example, through crying—the baby becomes infused in the mother’s mind with malignant “ghosts” from the past (Fraiberg, Adelson, & Shapiro, 1975). This may also be true later on, when the child’s budding autonomy emerges in toddlerhood.

For the child, the rigid alternative of either being at one with the mother, or annihilated, is catastrophic. A core problem for the child is the resolution of ambivalence—his/her parallel representations of good mother/self and bad mother/self cannot be integrated. One response to the unpredictable and frightening absence of a containing parent is the development of a persona that diminishes the importance of adult assistance and care. The embodied expressions of these internal positions (Baradon & Broughton, 2010) can be seen in the first vignette of mother and baby. In the second vignette of a mother and a child aged six, verbal and behavioral manifestations of the dilemmas predominate. Presenting the two cases (p. 435) with children of different ages gives a snapshot of the developmental trajectory in response to derailed primary relationships as the child grows older.

Clinical Approach

The concept of mentalization is useful as a framework within which to focus the therapist’s gaze on the mind-to-mind interactions in the room. What the therapist is working with in the room is a state of “mindlessness” in the mother, in relation to both herself and her baby/child, and the child’s attempts to “be” in the face of this mindlessness. Therefore, the overall task is to assist the mother and child to “create” minds of their own—to become more aware of their own mental states, the mental states of the other, and the relationship between the two (for an overview of parental reflective functioning and programmers utilizing this approach, see Nijssens et al.,2012). A central motivating force for the mothers we work with is their identity as a mother. What is often lacking is the notion of being a mother to a specific child, which implies that the child has needs separate from her own. This is the gap that we are trying to address by giving the mother both the appetite and the tools for thinking rather than not thinking. The therapist’s verbal and nonverbal communications to the mother, through which the therapist creates a sense of safety and predictability, are pivotal to helping the mother begin to recognize her feelings, changes in mood, triggers for these changes, and how they relate to her life experiences. Through asking questions, wondering, being empathic, being surprised, and offering his own tentative thoughts, the therapist helps the mother create nuance, texture, and narrative around her experience.

In parallel to working with the mother on reflecting and guessing at meaning (mentalizing), the therapist is attending to the feelings and experience of the child and how s/he may be constructing understanding and nascent representations. With infants, the therapist may “mirror” and “mark” the baby’s affect (wherein the therapist reflects back to the infant his/her emotional experience, as his own; Fonagy et al., 2002), speak to the baby, or handle the baby (Baradon, Broughton, Gibbs, James, Joyce & Woodhead, 2005). Nonverbal communication and playing with the baby may bypass or supplement verbal communication. With an older child, the experience of being attended to in an age-appropriate way is often unique. The therapist acts as a thoughtful mind, asking questions and being playful, and thus enables the child to become aware of his/her feelings and to begin to make sense of them. For example, children’s hypervigilance in relation to unpredictable adults is not a reflective state. Helping a child identify and process his feelings of fear and rage can help free him/her from a frozen state and continue his/her developmental pathway, while remaining mindful of the parent’s unpredictability.

Alongside attending to the mind of the parent and the child respectively, the therapist works with their co-constructed relationship. Centrally, she relates to each as a separate but related entity. In doing so, she brings the baby/child alive in the mother’s mind as a being with a mind of his/her own, and validates the baby/child’s own mind. She may question or represent the state of one to the other (to the mother, “I wonder what your child feels when you say you want to kill yourself?” and to the child, “Maybe it’s very frightening for you when your mom says (p. 436) she is feeling so terrible, and then you hold onto mummy as tight as you can”). She may invite the mother to join her in wondering about the meaning of the child’s behavior. Nonverbal expressions of intersubjectivity are noticed, and moments of pleasurable interaction are highlighted in order to emphasize to them the possibilities of recognition and connectedness between them as two separate people.

Clinical Applications

Setting

The Anna Freud Centre in London serves high-risk populations in terms of parental mental health and consequent risk to children (aged 0–18). Treatments can be long- or short-term, or consist of assessments for the courts. Vignette 1 is taken from the Parent-Infant Psychotherapy program lasting two years. Mother and baby were seen together on a weekly basis by a psychoanalytically trained therapist (T. Baradon). Vignette 2 is taken from a multidisciplinary assessment requested by the court and tasked with making recommendations regarding the risk to the child of remaining in his mother’s care. The assessment consisted of 15 individual and family meetings carried out over a period of three months. Family sessions were conducted by a systemic therapist (M. Daum).

Vignette 1

Lena’s baby, Sid, was four months old when they were referred for parent–infant psychotherapy by their general practitioner, who was well acquainted with the mother’s history. Both her parents were diagnosed with mental health disorders. Lena, emotionally abused by her mother, had started drinking when young and, by her twenties, she “didn’t do anything but drink.” She reported that she had taken drugs as well, worked as a prostitute, and suffered domestic violence in her brief marriage. Hospitalized for attempted suicide, she was diagnosed with a personality disorder, depression, and obsessive-compulsive disorder. Lena claimed she had stopped drinking and taking drugs when she became pregnant.

In the first session, Lena explained her wish for help not to repeat with Sid her own mother’s violence towards her. Her mother was sometimes caring but sometimes “really evil,” and it had left her feeling worthless. Lena added that she was afraid of how Sid might treat her in the future. The following vignette occurred 15 minutes into the first session.

Sid is motionless, slumped in Lena’s lap, and has a blank expression on his face. Lena offers Sid the bottle. She shifts him so that he is reclining in her arms and places the bottle nipple in his mouth. Feeding is an ordinary occurrence in parent–infant psychotherapy, but the therapist had already been alerted to the mother’s concern that Sid did not eat enough, although she (therapist) does not think he looks to be a thin baby.

Sid latches on and draws in the milk noisily. There is a momentary silence. The therapist quickly becomes concerned that the opening in the teat is too big, not adjusted to Ben’s physical immaturity, and allowing too much milk through. In the therapist’s mind, (p. 437) the milk flow has symbolic meaning—that of the thrust of intergenerational, hostile, and dysregulated emotions.

The initial gusto of the feed is quickly broken as Sid alternates between taking the bottle and coming off it. He generates a sense of discomfort, which is unsettling for both his mother and the therapist.

Lena seems uncertain as to why Sid is not feeding smoothly and what to do to help him. She looks anxiously at the therapist. The therapist responds by leaning forward and looking at Sid, whose gaze locks with hers. With exaggerated facial expression and lilting tone of voice, the therapist mirrors his distressed tone, and then, in a slower and lower voice, suggests that he is taking the milk too quickly and could he slow down a bit? In her nonverbal actions, the therapist matches Sid’s heightened physio-affective state and tries to bring it down. Her verbal part of the communication, although spoken to Sid, conveys her thinking to Lena about the possible cause of Sid’s irritability in the feed.

There is a moment of silence when both adults gaze at Sid; it feels to the therapist that the adults have joined in the contemplation of his needs.

Lena pulls the bottle nipple gently out of Sid’s mouth. The therapist is unsure whether this is a positive incorporation of the therapist’s suggestion to slow down—by giving Sid a breathing space through removing the bottle—or a withdrawing and defensive gesture, turning from passive into active (possibly feeling criticized by the therapist about the milk flow and therefore pulling the bottle away from Sid) (Freud, 1934). The therapist watches closely for Sid’s response. He pulls his mother’s hand towards him in order to latch on again, thereby suggesting that he experiences his mother as collaborative at this point and could express agency in pulling her back into the feed. The therapist’s feeling of tension dissipates.

However, after a few gulps, Sid’s distress escalates. He pulls away from the bottle, his body tensing, his face puckered and red. His cries express extreme distress. It feels to the therapist that he is approaching a state of “unthinkable anxiety” (Winnicott, 1962), wherein he is in the grip of panic and pain. The therapist feels deep compassion for both Sid and Lena and expresses this, again, both in words and nonverbally. She leans in towards the dyad, body concave as though to embrace and hold, and says in a soft, concerned voice, “Oh dear, Sid, what has happened?” She sympathizes with mother: “mmm ….. it’s so hard for you, too.”

Lena silently seats Sid on her lap facing out and gently pats his back. Although his crying has stopped, he remains unsettled, fretting in a low-key manner. Lena tries the bottle again, asking meekly, “Do you want it?” Sid takes the nipple into his mouth but immediately turns his head away—his body rigid, arms lifted to the side, flapping.

Lena puts the bottle down and looks helplessly at the therapist. The therapist feels that Lena has become a child, too, appealing—like Sid—for a mother who can help. But the therapist is not sure how to helpfully respond and, while she hesitates momentarily, Lena places the dummy (pacifier) in Sid’s mouth. He sucks hard, cheeks puffing in and out. His body slumps and his head flops to the side. He gazes blankly, fixedly into space. To the therapist, he appears like a doll—body without a mind.

Reflections on Vignette 1

This clinical sequence illustrates the tension between complex, historically rooted emotions evoked in the mother and the collapse of her capacity for reflective (p. 438) functioning in relation to her baby. In the context of Lena’s attachment history, and her unresolved status in relation to it (Main & Goldwyn, 1984; Hesse & Main, 2006; Baradon and Steele, 2008), Sid appeared to represent in his mother’s mind trauma and abuse even before he was born. Her anticipation that he might mistreat her when he grows up was played out in her helpless, fearful position in their interactions (Lyons-Ruth, Bronfman, & Parsons, 1999; Melnick, Finger, Hans, Patrick, & Lyons-Ruth, 2008). This role reversal, in which Sid was seen to be more emotionally powerful than she, seemed quite fixed. He was experienced as ”persecutory’ in his cries, and, as his screams increased, so did Lena’s helplessness. Lena critically failed to reflect on what was happening to Sid in a way that could be experienced by him as containing and regulating of his emotions. The rapid escalation in Sid’s negative emotional state was linked to his mother’s inability to think about his experience. Consequently, emotional residues from the past held current interactions in their grip and, especially when negative emotions were heightened, interfered with the capacity to experience and represent Sid as a Baby: separate, developmentally vulnerable, and dependent.

With Lena’s embedded sense that she was worthless and useless, the bottle was continuously offered over her own body and mind. The therapist hypothesized that the concrete experience of being unable to regulate the current of milk was symbolic of being overwhelmed by her own unbearable feeling states. In the experience of the feed, therefore, physiological and psychological flooding were interwoven.

In parallel, Sid experienced a maternal mind that could not receive his feelings into her reverie (Bion, 1962), and he was forced to make do on his own (see also Crandell, Patrick, & Hobson, 2003). What did he do? Initially, he held onto a (by now) habitual pattern of inhibiting his attachment cues (slumped, blank). When this could no longer be sustained, he sought help by crying—he latched on to the bottle (whether hungry or not) and, when this proved overwhelming, he hung on to the succor of the stranger (therapist in their first session) for as long as possible. Then he fragmented (screaming, his body rigid, arms flapping). Finally he fell into a state of dissociation—a body without a mind.

It is interesting that ”oblivion’ was finally resorted to. Dissociation is a final response to terror (Perry, 1997; Schore, 2003, Schore & Schore, 2008). Oblivion was also the defense his mother resorted to through drinking and drugs. The sequence described illustrates the notion of co-construction of defenses between mother and infant through their interactions (Beebe, 2000; Beebe & Lachman, 1998).

The therapist was alerted to Sid’s struggle to hold on to himself through his extreme sensitivity to his mother’s intrusion (via the bottle), the speed with which his defenses of inhibition and self-soothing collapsed, and the rapid escalation of his distress. In moving closer to Sid, the therapist was trying to use her face, voice, and intonation (Trevarthen, 1979) to regulate his levels of disturbed and disturbing arousal. She was also giving shape to Sid’s experience through her body and in words, representing it to his mother, and at the same time modeling a more attuned response (Baradon et al., 2005). Moreover, the therapist’s enquiry into Sid’s experience—“What has happened?”—modeled the assumptions that his crying was a communication about his state of mind, that there were reasons for the crying—i.e., it was not random, these causes needed to be reflected on; and that she would help his mother respond to her baby’s cries with a sense of agency rather than defeat.

(p. 439) The therapist understood that Lena, too, desperately needed to experience a sense of safety with the therapist—of being heard, attended to, and joined with in ways she had not experienced or been able to take in for herself or in relation to Sid. As well as emotional resonance, the therapist offered her mind—the functions of observing, reflecting, linking, and reasoning. It is so interesting that when the therapist’s reflective functioning faltered, momentarily filled with emotion herself in the face of Sid’s acute distress and Lena’s fraught helplessness (see also Hobson, 2002), there was an enactment—Lena plugged Sid with the dummy-drug (pacifier) that induced oblivion. Perhaps the therapist’s silence triggered the panic of abandonment and failure in Lena. The sequence ends at this point, but the challenge for the therapist in the session was to regain the position of empathically holding both baby and mother in mind despite their competing claims on her. This entailed managing her concern for the baby, keeping mother on board while attending to him, and attending to mother’s helpless distress—thus sustaining the view that two separate people can both have their needs met. Yet she felt that there were sufficient cues from both, even in the first session, that there was potential to use her separate, different mind—her third-ness—in a restorative, creative way.

Vignette 2

William, aged six, and his mother Marina were referred to the Anna Freud Centre Court Assessment Service to assess William’s needs and to give an opinion about the risks to his development from remaining in his mother’s care. William’s parents had separated when he was two years old. He had recently spent some weeks in the care of his elder half-sister, after she raised concerns about her mother hitting William. Further worries were raised by adult mental health professionals about the poor physical state of the home. At the time, Marina was a frequent user of crack cocaine and cannabis.

Marina was of mixed heritage, born in the French colonies. Her mother, a prostitute, had abandoned her to her maternal grandmother’s care. She had been close to her grandmother, but was sexually abused as a young child by her maternal step-grandfather over a number of years. She had come to the United Kingdom as an adult; both her mother and her younger half-sister had subsequently committed suicide. At different times following his parents’ separation, Marina had made allegations to various professionals that William had been sexually abused by his father as a baby. The substance of her allegations changed over time. William’s contact with his father had been intermittent and sometimes withheld by his mother because of her fears that he would be abused again. There were concerns that William was out of his mother’s control. She attributed this to his supposed experience of sexual abuse at the hands of his father.

While she refused to discuss her drug use, describing it as a “cultural” issue, the theme of sleep, or oblivion, featured strongly in Marina’s narrative. She spoke of being exhausted by William and withdrawing into sleep (or, she implied, intoxication). At these times, she described keeping William next to her, to stop him from doing any damage, or leaving him to himself, locked in the apartment. When asked what gave her the most joy in being a parent, Marina evoked the image of her son asleep. It was apparent that she saw him as an abusive, persecuting figure far more powerful than she.

As part of the assessment, William was seen twice with his mother. The following interaction occurred about an hour into the first session.

(p. 440) Marina has spent the previous few minutes ”monopolizing’ the session with the therapist, telling her how exhausting and difficult it is to care for her son. William has distanced himself from his mother, and is playing at another table. After some minutes, at the therapist’s suggestion, they join William at the table. Marina, still in her coat, is standing behind William’s chair, her head bowed, looking at him, her hands clasping the back of his chair. She has an odd smile on her face, a smile that implies shame, or coyness. William is industriously building a train track on the table. The therapist sits near him, facing both of them to create a triangle. She is aware of anxiety in both William and his mother, and of William’s sense of aloneness in the room. The therapist’s intention is to assess William’s ability to give words to his experiences in his mother’s presence, and his mother’s capacity to attend to and reflect on what he says.

th: So do you worry about your mum?

w: I worry about her so much (genuinely serious tone) ” I forget about it (brittle, peremptory tone).

m: (laughs quietly)

th: So what do you worry about when you worry about your mum?

w: (cutting off the therapist) I forget about it.

th: Do you worry your mum’s unhappy?

w: Yes.

th: How do you know when your mum’s unhappy?

w: (Theatrical, self-parodying voice, clasps his hands to his heart and throws his head back, closes his eyes) Because I’m so sad of her feelings ”

th: So what does she do when she’s unhappy, your mum?

w: (Peremptory voice) She tells me off.

th: Does she? Does she do anything else?

w: [Singsong tone] Hold on tight, no.

th: Does she ever go to bed, go to sleep?

w: Hold on tight, no.

m: Yes I do. When I’m very tired I put him to sleep (laughs quietly, something like shame in her expression), isn’t it, William?

w: Hold on tight, yes.

th: And what do you do when your mum’s sleeping then?

w: (grins). I creep, and creep, until she’s sleeping. Then I steal her phone, delete all her pictures ” .

m: No, no, he never does that. I don’t give him any, my phone (she feels in her pocket to check that her mobile is still there).

th: Why would you want to delete all her pictures, anyway?

w: (Angry voice) Because I’m so STUPID.

m: (Angry voice) Because he breaks everything. All his toys ”

th: Is that what makes you feel stupid, when you break things?

w: Yeah. I’m so stupid. More stupider than a coward!

m: (Sniggers)

th: Well maybe it makes you feel stupid when you break things, does it?

w: (Theatrical, self-parodying voice again) It makes me a bit sad ” (mimes playing a violin).

(p. 441) William picks up the train track and flings it about. His mother, clearly irritated, grabs his arm roughly and says “Stop it now,” her tone hostile. William shrugs her off, then suddenly falls on the floor, writhing, saying his “nuts” hurt, then jumps up. Her voice almost a whisper again, William’s mum says he has broken his Nintendo DS. William chats with the therapist about DS games.

th: So how did you break the DS?

w: (Adopts a loud, declamatory tone, arms stretched wide): “Because the PRIME MINISTER TOLD ME TO!!!!”

th: (To mother): Does William listen to anyone?

m: I hope he listens to his teachers ”

th: Do you find it hard to be strict?

m: I have my rules and I wish he could do, but ” he doesn’t listen. I avoid hitting him, when I do, it’s because I, you know (wipes her brow).

th: You’re desperate?

m: Yes. But then he listens. What do I have to do to get you to listen, William?

w: You have to smack me so much, until, until, until, I HATE.

m: Yeah but I can’t do that. Because I’m not allowed to hurt you a lot.

william starts crying, sobbing, screaming, then smiles.

th: (To mum): Can you tell when he’s really upset?

william starts screaming again, she puts her hand over his mouth, he giggles. mother smiles.

Reflections on Vignette 2

Throughout this vignette, Marina presented as a depleted, waif-like character quite alone with the task of being a parent. She easily and repeatedly became an observer rather than a participant, regarding William with a kind of awe (when he was being precocious and ”clever’) or horror (when he was being impolite or aggressive). She saw herself as the helpless victim in an abusive relationship, as she called attention to William’s destructive qualities (see Silverman & Lieberman, 1999). At no point was there a hint of recognition of his young age and consequent vulnerability; instead, she experienced him as persecuting, and sought oblivion through (drug-induced) sleep. At moments when she displayed sudden hostility and loathing towards her son, her tone of voice changed and she resorted to physical means of control. Her hostility had an exhausted quality. Often, while babyhood allows the mother some hope that she can fulfill her baby’s and her own needs, as the child grows older, the mother is faced with the terrible loss of that hope.

William, an unusually intelligent child, also presented as a person quite alone, a pseudo-adult and omnipotent. Left in an uncontained, unpredictable situation with a care giver who was alternately withdrawn, disturbed, and hostile, his personality was becoming structured around a denial of vulnerability (what Anna Freud described as “identification with the aggressor”; Freud, 1936). William failed to ask for adult help when he needed it, used words and phrases he did not (p. 442) understand, and defied all authority. He used “forgetting” both to control his panic and to close down any exploration. His use of the phrase “hold on tight” had the quality of a talisman, a defense against meaning as well as an expression of having to hold himself together, and a cue to the therapist that he felt in real danger.

Associated with but going beyond this precocious presentation was William’s self-parodying take on emotional expression. The overall impression he gave was of a lack of emotional authenticity. This was understood as both a defensive posture—keeping painful emotions at bay—and an attempt to bridge (through identification) the gap between his mother’s gentle words and tone of voice on the one hand, and her palpable hostility on the other.

At an emotional level, Marina made no sense to William and in her non-mentalizing state, she had failed to help him gain any capacity to reflect upon or manage his own emotions (see Hobson, Patrick, Crandell, Garcia-Perez, & Lee, 2005). As a consequence, a simple and straightforward expression of emotion felt impossible, so William resorted to a brittle, pantomimic form of expression whenever the subject of his own or his mother’s feeling states was addressed. In adopting this self-parodying tone, William stepped outside of the emotional link with the therapist and demolished it. The therapist felt desperate for him as a vulnerable little boy who could not let himself be touched.

In relation to his mother, William’s behavior and words suggested that his attachment was becoming organized into what Lyons-Ruth et al. (1999) have described as a controlling-punitive stance. Under threat of abandonment—through her ”oblivion’—by his mother, he maintained his connection with her by humiliating, directing, and controlling her, often in a rather sadistic manner. At the same time, in the face of his own aggressive and uncontrolled behavior and his mother’s hostility, William experienced a degree of confusion and self-loathing, and saw himself as “stupid.”

Discussion

The developmental perspective anchors the development of the baby’s mind in his/her relationship with an active, adult mind that seeks to understand and scaffold it. This process also underpins the therapeutic work when deficits have occurred. In other words, the therapist’s central activity is to notice, try to understand, share, question, and revise her thinking with both the mother and the baby/child. In doing so, she is actively ”scaffolding’ emergent reflectiveness in the mother and child, and modeling this process to them. In a sense, it is the therapist’s mind that offers a therapeutic space within which this work can take place.

But there are ongoing challenges to the therapist’s stance. The overwhelming emotion in each of these cases, unmoderated by a thinking mind in the mother or child, requires that the therapist maintain a discipline of self-monitoring and self-regulation in order to sustain her capacity to reflect. First, the pervasive defenses in the parent–child relationship can ”hijack’ the therapist into a similar stance. For example, in watching the tape of the interview (Vignette 2), the therapist noted the strong pull towards ”oblivion’ or not hearing, such that, at times, she failed to hear important statements by William. Second, holding one’s position as equidistant in (p. 443) relation to both mother and child can be challenging, given the needs of each to be merged with the therapist, to the exclusion of the “third.” The mother’s palpable fear of abandonment and need to feel “at one” with the therapist exerts a pressure to join with the mother in an unboundaried, unthinking way.

In the case of William, the therapist experienced a pull from the mother to view William as she did, and William supported this by pushing the therapist away with his own self-denigrating attitude and behaviors. Fear of losing an often-tenuous connection with a suspicious, labile mother can compromise the therapist’s capacity to reflect from moment to moment, and crucially, to keep in touch with the child. In the case of Sid and Lena (Vignette 1), the pull was towards providing protection for the baby. A distressed baby kick-starts the therapist’s identifications as well as her own attachment system (Pally, 2005), and thereby she risks losing a sense of the mother’s vulnerability. An example of maintaining equidistance was when Sid’s cries escalated, and the therapist used her body and tone of voice to reflect both Sid’s and his mother’s difficulties with sympathy and concern.

Maintaining a Reflective Space

We have found three ideas helpful in addressing the challenge of maintaining a reflective space in the session: the need to de-escalate heightened affect, the importance of not assuming that the mother’s mental functioning is the same as the therapist’s own, and being as ”real’ as possible with the patient.

De-Escalating Heightened Affect

Heightened affects comprise not only negative affects, but also excitement, helplessness, and self-aggrandizement. All negate the capacity to reflect. The therapist might choose to not react (as when William’s therapist chats with him in an ordinary, age-appropriate way about his DS [handheld computer] rather than taking up his bizarre behavior), to wonder, to reframe, to move on, or to play. Any of these responses can help de-escalate emotion and open up, in due course, a space to think together about meaning. The main danger, however, is in the use made of the therapist’s reflective stance—for example, in the first vignette, the therapist’s silence triggered a panicked response in Lena to silence her baby’s cries.

Assumptions about the Mind

The assumption that the mind of the other person functions similarly to one’s own could be seen as a necessary part of human communication—making links, searching for meaning, seeing cause and effect. In working with these cases, however, one simply cannot assume that these very ordinary processes—which relate to establishing compatibility between the external and internal worlds so that experience makes sense—are taking place. For these mothers, what we see is attribution without reality-checking. There is also an absence of narrative, so that life is experienced by the mother as a series of traumatic events. This model of deficit (p. 444) is addressed by the therapist’s constantly offering her own thinking to be examined between mother/child and herself in the room. Anna Freud’s (1974) contribution to therapeutic interventions via “developmental help” (Edgcumbe, 2000; Hurry, 1998) addresses the therapist’s work with such mental deficits and can be important with mothers as well as children.

Being as ”Real’ as Possible

A significant part of offering developmental help to address these deficits is through being as ”real’ as one can with one’s clients. This involves adapting to their susceptibility to hypervigilance and their tendency to attribute negative intentions to the therapist, as well as sensitivity to non-genuine affect. The therapist will, in all realms of the interaction, make her thoughts and reasoning transparent to the patient. She may, for example, highlight what she has observed and check this with the mother. She may voice her thinking process to the patient to be reflected on together: “I am thinking xxx because of xxx.” Another way of being ”real’ relates to the realm of nonverbal communication. It is important to recognize how central our bodily communications are to these clients. If words and body language are incongruent, this will be picked up immediately and seen as hypocritical, uncaring, and untrustworthy.

One of the major questions raised in both vignettes is the extent to which there is room for people to be ”alive’ in the sense of being a separate person, in a relationship with the other. The therapist’s stance of keeping both mother and child in mind, being real in relation to both (adapting to the child’s age), and helping them feel that she can contain both of them at the same time, may, over time, address their dilemma around survival despite separation.

Summary

This chapter has described non-mentalizing states of mind in personality-disordered, substance-abusing mothers as a developmental deficit. Two clinical vignettes—a baby of four months and his mother, and a six-year-old boy and his mother—were presented. These illustrated the to-and-fro between states of mindlessness in the mother, the child’s response, and the mother’s non-reflective response to the child’s behavior—leading to escalating negative affects in each. The therapeutic work is conceptualized as the therapist holding on to and applying her own mind to help mother and child give meaning to (mentalize) their experiences of the self and the other.

References

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