I recently attended a continuing education workshop focused on oral narrative, narrative therapies and trauma - It reminded me of this case, and this paper I wrote about integrating narrative therapy and Winnicottian theories a gazillion million years ago - probably in the late ninties and published in the New York State Society for Clinical Social Work's Metropolitan Forum - mailed out on paper - from the time before everyone had a website and there was no such thing as a digital newsletter)
I still use writing, narrative, and storytelling as part of my clinical practice - and in my own processes, (as this blog obviously demonstrates.)
What follows below is a Winnicottian case study using writing therapy with a client who had suffered trauma and attended a daily out patient program for adults with psychosis.
The client's name, the client's stories, and identifying data have been changed and disguised to reflect the spirit of the work while protecting the client's privacy and confidentiality.
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THE STORY OF ROBERT ALONE:
At the time I began seeing “Robert” - fresh from social work school - I operated on beginner’s instinct with little theoretical grounding beyond a vague understanding of ego-supportive process. I saw myself as lending patients my ego strengths; as undermining maladaptive defenses and supporting adaptive ones in hopes of forestalling rehospitalization. Working under a medical model, I reluctantly began to view my patients as a mass of ego-deficits and developmental failures.
A deeper exploration of object relations theory, and Winnicott in particular, provided me with a far more meaningful and useful model for work with psychosis, allowing me to reorganize my understanding of the completed work. What follows is a summary of my relationship with Robert, conducted in the spirit of fearless idealism only readily available to new clinicians. A discussion of Winnicott’s model reveals the phases of Robert’s emotional development, his capacity for creativity, his use of transitional phenomena, and of the importance of play in the therapeutic relationship.
HISTORY
“Robert” is a thirty year old man. His skin is clear and dark, his eyes black, and the gray at the temples of his curly black hair makes him look somehow distinguished if you catch a glance of him in a still moment. He is rarely still, Parkinsonian symptoms and Tardive dyskenisia twist and jerk him about; his tongue juts in and out past his teeth, his head falls forward as though a hinge in his neck has come loose. His fingers splay open and shut when he is excited or agitated. He speaks with a heavy island dialect.
The treatment relationship took place in the context of a therapeutic milieu, five days a week from 8:30 a.m. to 2:30 p.m., where he received a variety of services including: medication, group and individual therapy. We began at the day program the same week. I left the agency and transferred Robert to a new therapist in three and a half years later.
I met with Robert twice weekly for individual treatment, twice a week in group therapy, as well as informal contact throughout the day on the treatment floor.
Robert had been hospitalized many times for paranoid delusions and auditory hallucinations. He reported hearing up to seven different voices, both male and female, who he insisted were "real people in from home." He was also preoccupied with intrusive, obsessive thoughts, which he called "dangerous stories" He would "listen and watch as they play through my head."
Robert is one of the middle children of twenty-one siblings by one father and three mothers. He describes his father as having had three families: each living in a separate house built on adjoining property. He remembers falling asleep while his father told all of the children bedtime stories. His father died when Robert was eight years old.
His mother, the second wife, began experiencing psychotic symptoms sometime before his father took on a third wife, and was hospitalized, intermittently throughout Robert's childhood, latency, and adolescence. He was never told where she was or why she was gone. Her children were absorbed by the other two households during her institutionalizations. Robert remembers being beaten by his older half-siblings when he misbehaved.
TREATMENT
In my first months with Robert, I felt invisible to him, without a therapeutic partner in the session. Communicating with him was nearly impossible. His world consisted of slips and slides, bizarre responses and loosened associations. The past and present jumbled together in a tangle of primary process. His thick accent further obscured his illogical statements. In the countertransference I experienced an overwhelming ennui, a numbing, rhythmic, almost dizzying boredom. This quality of boringness is at the core of Robert's illness according to Winnicott; more debilitating than the hallucinatory symptoms associated with schizophrenia (Winnicott, 1971, p. 66, & Winnicott, 1972, p. 1).
Yet, I sensed that Robert was attempting to share something important about himself with me; a frightening gift, which I was, in essence, rejecting. Unable to tolerate the chaos, I would cut him off, hoping to find surer footing by soliciting details of his day to day reality. Robert’s “essential lack of true relation to external reality” creates initial transference difficulties, in Winnicott’s view, which must be dealt with in order for the therapeutic relationship to proceed. In infancy and in adult illness, hallucinatory fantasy is seen as an attempt to gratify primary needs which external relationship have failed to fulfill (Winnicott, 1992, p. 152 ). Like a child who prefers the thumb to the mother’s breast - Robert's stories disrupted his relationships to people and to daily reality. Nothing of the present could exist once the stories began, not me, my office, or his fellow group members. They were truly the stories of Robert alone, and unrelated.
One day, I tentatively asked Robert about his hallucinatory world, releasing a flood of content and rapid pressured speech. The psychiatrists which lead our team strongly discouraged direct exploration of hallucinatory content, I feared that if Robert left my office more agitated and disorganized than when he came in, that we would both in some trouble.
He began telling me a dangerous story that “starts up in his brain” - consuming him entirely. He demanded that I write the story down verbatim, serving as his scribe with a day-glow green pen which he had selected for the purpose.
Queasily reviewing the pages of green ink, I felt even more disturbed by the glimpse of Robert's internal life. It was clear that no external connection to me or the group could be as compelling as these hallucinated relationships. The stories were too psychotic - full of disjointed nightmare images of broken doors and angry dogs. The voices were too vivid, frighteningly alive and defined personalities. I wondered if he could be hospitalized; I wanted to put him away from me, and cast these entities out from my office. I felt frightened, revolted, and sick to my stomach. Robert had left me in a fragmented muddle, a countertransferential experience of madness (Winnicott, 1965, p. 147).
Across the top of my notes, Robert had written in his perfect elementary school printing "THE STORY of The Man Who Protected Robert." The disjointed third-person tale that followed told of Robert and his close friend “Haad”. At the center of the story, Robert finds himself in trouble. He has lost the night deposits of an office where he works as an errand boy. Only his friend Haad comforts him: “‘It's all right. I know the boy.’ I know the boy. This is what Haad said to me!” At the story’s end - Haad is killed in a car accident - and Robert believes that he is not dead - he is alive and protects Robert from all danger. The final words are: “It is finished” written in Robert’s own hand.
His struggle to formulate a consolidated identity seemed central to Robert's story. He had created the story to say: "I know the boy" protecting him from an even deeper sense of fragmentation. By viewing his ability to organize the story as a developmental achievement, I could support the story’s ability to consolidate a sense of Robert’s own thoughts, feelings and impulses.
The creative impulse is something which can be looked at as thing in itself, as something that is present when anyone - baby, child, adolescent, adult, old man or woman - looks in a healthy way at anything or does anything deliberately, such as making a mess with feces or prolonging the act of crying to create a musical sound (Winnicott, 1971, p. 69).
The next session Robert made it clear to me that we were on the right track. He asked me to tell the story back word for word. Robert was particularly concerned that I understood the story to be true, not made up, and not crazy. He stated, "This is True. This is what happened, Do you believe that this is a true story?" I said I trusted that Robert had told me exactly how it had felt to him.
He then regretted telling me the story. I might tell the insurance company, I might send him to the hospital, the dangerous story could be stolen by those who might hurt him. He also worried that I might be injured somehow because I knew the story. I reassured Robert repeatedly that I did not want to hurt or hospitalize him. Moreover, I had to demonstrate to him that I was strong enough to contain and protect both of us from the aggressive impulses within his story. We would only approach the stories in a way that made us both feel safe.
I offered a suggestion. Perhaps we could close the story by stapling or folding it and then locking it in my file cabinet. After testing the lock on the cabinet, as well as my locked office door, Robert appeared convinced. The story could be left safely with me; it would remain in the therapeutic setting, and would not emerge to surprise, hurt or frighten him outside of the program.
Robert's internal relationship with Haad, both historical and hallucinatory, reflects his yearning for protective holding. He used to sense Haad's protective presence "all around" him, in the walls of the room, in the air that he breathed. Haad provides Robert with a holding “environment mother” who has formed an attuned identification in order to soothe and regulate the environment (Winnicott, 1965, p. 33).
As Robert's and my relationship progressed, I began to take on Haad's holding functions. I literally held the stories, the locks on the drawer and the office door serving as concrete symbols of the protective holding environment. He began to look to me as an environment mother, warding "off the unpredictable" and actively providing "care in handling and in general management" (Winnicott, 1965, p. 75).
Moreover, the environment mother is needed to "to continue to be herself, to be empathic toward her infant, and to be there to receive the spontaneous gesture and to be pleased" (Winnicott, 1965, p. 76). These are the very functions that he could not find in his own psychotic mother; a mother unable to regulate the environment for herself or her child; a mother who was not able to be reliably there, due to her own illness and hospitalizations.
The reliability of the treatment environment, and the structure of the story work, held Robert suspended safely, as if in a medium, "like the oil in which the wheels move" (Winnicott, 1972, p. 188). This holding started off fairly simply, as a consistent time, my general empathy and attention, allowing Robert's story to emerge. Perhaps my ability to face and survive Robert's projected psychotic anxieties distinguished me as a mother who would not breakdown and abandon him. In the weeks ahead, Robert began, very slowly, to tell a "more dangerous" story to me, as I wrote it down.
PROCESS: STORYING AND RESTORYING
The Story of Robert Alone
Robert's sister said to get a job. Robert went to a department store. He applies to be a porter, putting out the garbage. The form asks why he left his last job. Robert thinks of the insurance company and writes: "Because of the deposit bag." He didn't want to go to the bank at night because this is too much for him.
One day, a lady who worked in the office said Robert to pick up the empty bank bags. This was too dangerous, like before with the insurance company.
He was all alone: no father no mother no brother and no Haad.
Then the manager told Robert "Its cold out, bring your hat" and Robert thinks of Haad. There must be danger if Robert needs protection. Robert quit this job. It was too much.
Robert has honesty.
It is finished.
Eventually, Robert told me all of the dangerous stories that had consumed his attention. The process repeated itself each time: telling, scribing, repeating. The stories were always locked in the file drawer at the close of each session, and he would check the locks before leaving. Winnicott predicts that this holding "steadily becomes extremely complex, yet remains just the same, a holding" (Winnicott, 1965, p. 228). This was demonstrated in Robert's increasing demands that I mirror him word for word, that I enact a protracted complicated ritual around closing the stories, week after week, without error.
When I first met Robert he was entrapped hallucinatory omnipotence, with no real experience of me or of his external environment. This also speaks to his inability to retain good enough internal objects, as evidenced in the Story of Robert Alone, with "no father no mother, no brother and no Haad;" no internalized object to rely upon for comfort or safety.
Haad, says "I know the boy" representing Robert's attempt to maintain a distinction between Robert and not-Robert, to identify himself as unique and embodied.
Our relationship could be said, in Winnicottian terms, to reflect Robert's recent development of the capacity to be alone, his progress from 'I', to 'I am', to 'I am alone' (Winnicott, 1965, p. 33).
In this phase of our relationship, and the story work, Robert and I formed a relationship which, in hindsight, can be seen as a good example of Winnicott's ego-relatedness: “Ego relatedness refers to the relationship between two people, one of whom at any rate is alone; perhaps both are alone, yet the presence of each is important to the other”(Winnicott, 1965, p. 31).
If Robert could not come out of the story to meet and relate to others, I would have to go in and join him there. Maybe he would eventually trust me enough to follow me out into the present. In short, I would have to convince Robert of the real advantages of accepting consensual present realities - that despite its many failures and frustrations, it offers many real consolations and comforts. In Winnicott’s words: “Real milk is satisfying as compared with imaginary milk (Winnicott, 1992, p. 153).”
Robert arrived one day complaining of "heat in my head" because the story had not been locked up securely enough. I suggested that if I told him my own story about the department store, it might help. Robert agreed, and sat down to listen. What follows is my re-storied version of The Story of Robert Alone.
The Story of How Robert Took Care of Himself
Soon after Robert moved to the United States, his family wanted him to get a job, and he wanted to get working again too. He applied for a job at a department store. He tries to tell them on his application that he doesn't want a job that has to do with errands or bank deposits. He had a job like that before and it had been too scary, and his thoughts had gotten all confused. He sure didn't want to go through that again. He asked for a job as a porter and he got the job. He was very happy about it.
One day, they asked him to run an errand at the bank! Robert felt terrified that he would be hurt or mugged, or get in trouble again! It was scary for him and he felt alone and overwhelmed.
While he was upset like this, the manager told him that it was cold outside and reminded him to dress warmly. The past and the present were getting all mixed up for Robert, and he thought the manager asked him to bring his friend Haad along for protection. But the manager couldn't know that Robert had a friend named Haad in because he had only known Robert a short time.
And his friendship with Haad will always be with him in his heart and his memories
Robert wisely recognized that this job was too much pressure for him, and he quit the job to keep himself healthy and safe.
He had been able to take care of himself all on his own, even with no father no mother, no brother and no Haad.
He had made a good decision and he felt proud that he was able to protect himself with out help from anybody else.
Robert behaved like an honest and responsible adult.
Robert's response to this story was a large grin:
M: What do you think of my story?
R: Its good. Its true too. I like your story better.
M: What is it that you like about my story?
R: Your story has all of my feelings in it.
He went on to say that this story of mine was a safe story, with nothing too bad happening in it, only bad feelings.
In the next few months Robert would take in several of my re-stories. The stories and re-stories constituted our entire process for a period of approximately twelve months. For the remainder of our work together - our relationship traveled well beyond these stories - but would occasionally revisit and review them when they asserted themselves during times of stress or when they had been triggered by external events.
It would be important in any discussion of Winnicott, but especially in this case, not to overlook the concepts of the transitional space and transitional objects. Robert's stories are explicit examples of transitional phenomena, comparable to an infant's babbling, or an older child's songs and nursery rhymes (Winnicott, 1971, p 2). They come from within Robert, but the same time they come from with out - he passively watches as they omnipotently play through his mind. This passivity reveals pathological use of the transitional object, which feels as though it has a dominating external vitality of its own.
Winnicott describes transitional phenomena as an attempt to bind fears and sorrows: “a word, or tune or a mannerism - that becomes vitally important to the infant at the time of going to sleep and is a defense against anxiety, especially anxiety of a depressive type” (Winnicott, 1971, p. 4).
Denial of loss and separation plays an important role in the pathological aspects of the transitional space (Winnicott, 1971, p. 5). The first story “came into” Robert after Haad’s death, a loss which was devastating to Robert in itself, but also reactivates much earlier, overwhelming losses: his father’s death and his mothers’ frequent long, mysterious absences. It is likely, that Robert began relying upon such fantasying far earlier in his life, perhaps at the time of his mother's first hospitalization, or following his father's death.
Perhaps Robert's stories served as a stand in for his father, and the safety Robert experienced as he fell asleep held in his father's stories. As Winnicott points out: “A need for a specific object or behavior pattern that started at a very early date may reappear at a later age when deprivation threatens (Winnicott, 1971, p. 4).
One day Robert reported that his stories were changing. My stories had been "mixed up good" with his, and he would remember both stories together. He said that his stories were safer now, not as angry. When Robert relived these old memories, a newer memory of telling them to me, of my listening, writing, and responding, had become a part of his story.
Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play (Winnicott, 1971, p. 38).
Re-storying served to promote relatedness in the transitional space, without challenging Robert's "neutral area of experience" through playing with the stories - passing them back and forth between us , allowing the story to change, and to change us as well. Ultimately, the stories allowed Robert to move from a place of hallucinatory omnipotence and merger to being in relation to myself and the group.
When Robert started at our program his only relationships were with Haad, and the other “story people” Eventually he formed several close friendships at the program. He says that stories and the voices are "no bother" now, although they remain in "the back of my brain." As instances of imaginative play and creativity emerged in Robert’s daily life - at first a giggle, then playing with riddles and funny stories, and eventually developing into full fledged mischief- became as breathtaking and moving as they had once been rare. In this light, Robert's stories can be seen not a symptoms, but as an emergence of the True Self, a spontaneous, creative gesture that was waiting to be met.
During our last week of work together Robert passed the US citizen examination, which he described as a commitment to “live life in the present, instead of the stories.” - an acknowledgment of his wish to maintain an attachment to external reality, rather than psychotic, post-traumatic fantasy.
Through the course of treatment, and this course of study, I have adjusted my expectations, my goals, and my understanding of the task at hand with regard to this and similar cases. The job is much simpler than I thought, but also much harder. It is I think; to wait patiently, to watch very closely, and to try not to miss an opportunity to celebrate the client’s capacity, however fragile, for creative living.
REFERENCES
Winnicott, D. W. (1965). The maturational processes and thefacilitating environment; studies in the theory of emotional development. Madison CT: International Universities Press,Inc.
_________ (1971). Playing and reality. New York: Tavistock Publications Ltd.
_________ (1972). Holding and interpretation; fragment of ananalysis. New York: Grove Press
_________ (1992). Through pediatrics to psycho-analysis: Collected papers.New York, NY: Brunner /Mazel Inc.