Internal Landscapes and Foreign Bodies

Eating Disorders and Other Pathologies

Gianna Williams

• Editorial: Routledge
• Año: 2018
• ISBN:
  9780429915086
• Edición: 1
• Categoría: Psychology
• Categoría: History & Theory in Psychology

Klein's model of projective and introjective processes and Bion's theory of the relationship between container and contained have become increasingly significant in much clinical work. in a highly imaginative development of these models of thought, the distinguished clinician gianna williams, one of the leading figures in the field, elucidates the psychodynamics of these processes in the context of impairment of dependent relationships and of eating disorders in both men and women. This is a timely and brilliant account of an area of psychopathology that is rapidly growing in significance.

1
The Inner World of the Child

In attempting to describe the model I have in mind when I refer to the Inner World of the Child, I will not start with a definition, but with a vivid recollection of an exhibition of children’s paintings which was for me a significant experience. The paintings had a common theme, since the village where the children lived had recently been flooded by a river running through it. The flood had not been great, and no human lives were lost. The very perceptive head teacher of the village school suggested that the children make a picture of what had happened on the day of the flood. It was striking that although the children had shared the same experience - no part of the village had been more affected by the flood than another - the paintings varied enormously.

I remember that one of them showed the village completely covered with water so that only the bell-tower could be seen; a number of people were portrayed on top of the bell-tower, which had a flat roof, and some had a very frightened expression. The picture also showed a shark and a sword-fish floating in the water, both of them highly unlikely creatures to inhabit a river. I also vividly remember another picture - a little boy and a man, who I guessed was his father, were carrying sacks up the half-flooded stairs from a flooded cellar, and the sacks were realistically marked as containing food provisions. Other paintings were extremely vivid in colour, and I remember an abundance of red Wellington boots. Probably the most cheerful pictures made me feel uncomfortable because I doubted that this experience could have been a purely amusing one, like a good opportunity for a paddle. But I was certainly struck by the variety of the paintings, and it gave me an opportunity to see how varied children’s reactions to the same external experience can be.

In terms of the internal world, I would like to suggest that at least one of the reasons why the same experience was portrayed in such different ways by different children was that it was filtered through an internal frame of reference: I would take the varied representations of the flood to be a reflection of differences in the children’s inner reality. When we attempt to understand the origin of such differences it is difficult to make a clear-cut separation of the elements deriving from nature, and the elements deriving from nurture, in the making of the inner world.

The aspect of the inner world, then, that I would particularly like to focus on in this chapter is the subjective element that influences and colours the perception of external events. I am going to describe aspects of my work with a patient that may help to illustrate more clearly what I refer to when talking about the inner world. I have deliberately chosen a case whose external circumstances were not particularly traumatic, as this might help one to focus on the subjective component of the inner world, rather than look for external causes. In the case of my patient, a girl chronologically in her teens but emotionally in her early childhood, the reason for disturbance could not be very clearly pinpointed in terms of her history. Yet, though the cause was uncertain, its effects were undeniable.

The Cheshire Cat

Louise was referred to the clinic by her school, where she was described as being switched-off and out of touch. She had no friends, and the teachers found it difficult to establish contact with her. Her actual school work did not seem to be greatly affected. Louise was very imaginative in her essays, but they were said to be at times ‘a little weird’. She was able to learn, but related much better to books than to people. There were some aloof features in her which engendered concern about the possibility of a deterioration, and of her drifting even further away from relationships as she got further into adolescence. Nobody knew of any traumatic experiences in Louise’s childhood except for a separation of two weeks from her parents when she was three and a half. A year later, a little brother was born and Louise found it hard to adjust to the birth of this child. Her father had taken time off from work and looked after her while Mother was in hospital.

When I first saw Louise, I was struck by her very young appearance. Although she was tall for her age, she really looked much more like a twelve year old than a fourteen year old - very thin, rather lanky - and her large dark eyes didn’t focus on me when I first met her. In fact, the difficulty in meeting her eyes was one of the aspects that most struck me on that occasion.

I will start by describing some instances from my early work with her. On occasions when Louise was sitting in an armchair facing me, talking and apparently in touch, a cloud would form between us. She could no longer be reached, and it seemed that her mind had wandered away. This happened a number of times. At first, I thought she might have switched off as a defence, in order to avoid something painful that had emerged at that moment; but her attention seemed to fade away just as easily and suddenly at other times, when it seemed unlikely that this could be the case. I was often taken by surprise by her.

I then began to think that her behaviour might have a different meaning and unconscious purpose. Perhaps what really mattered was Louise’s need for me to experience the feelings evoked by her sudden ‘disappearances’. Indeed, I often did feel very lost: I did not know where she was, whether she could actually hear what I was saying. In addition to that, I was at times puzzled by a strange smile, and a sort of grin that came over Louise’s face and contrasted with her blank expression. I wondered whether Louise might not have a need to evoke in me a painful feeling that she herself could not bear - perhaps the only way she could tell me about it.

Sometimes, she scribbled during her sessions. On one occasion, she got engrossed in drawing, producing a picture very similar to the face of the Cheshire Cat. She said it looked like an illustration in her copy of Alice in Wonderland (a book she was particularly fond of). It was a picture of the cat’s face with a very wide grin on it amidst the foliage of a tree. At first, she talked about the cat’s features as if they were something attractive: she liked the cat’s elusiveness and its mockery, features to which I had to some extent been exposed in my relationship with her. I tried to put this to Louise as simply as I could, saying that at times she had behaved with me in a very elusive and slippery ‘Cheshire Cat’ sort of way, and that there was even sometimes a sort of smile on her face which seemed to fit in with that picture. Perhaps, I said, she wished me to have an experience like Alice’s with the cat: we could try to understand together what this might be about.

I shall not describe in detail the process involved in sharing with Louise the perception of the slippery, elusive quality she sometimes put across. I often told her that she wished me to feel something I knew she could not as yet convey verbally: she wished me to know how it felt to be with someone and not really know how long that person was going to be available, present and giving of attention. I thought - and still think - that Louise needed me to feel this uncertainty and the anxiety that went with it, in order to convey the quality of a crucial aspect of her inner world, one crucial to her feeling so adrift in life. If the central character of her inner world was a Cheshire Cat type of object, elusive and extremely unreliable with an element of mockery or cruelty, it was not surprising that she had very little to hold on to in order to cope with anxiety. Indeed, such an object would not protect her from anxiety, but engender it.

An important part of my work with Louise consisted in providing her with an experience of attention and consistency, which gradually began to counterbalance the elusive quality of the Cheshire Cat, there one minute and gone the next. It is hard to know how this image developed within Louise’s mind. From what we know of her mother, we might wonder if she had been able to devote enough attention to her child, but I do not think there is any basis for thinking that Louise was ever treated with deliberate cruelty. On the other hand, she probably felt treated with cruelty, most of all when her younger sibling was born.

As I have said, there was a period of months during treatment when Louise herself was the Cheshire Cat, and I was confronted with the ‘disappearances’ and the ‘grin’, together with the feelings that they evoked in me. Some changes then started to take place. Louise became much less elusive and very gradually more able to confront the pain she had avoided by being the Cheshire Cat. The less she herself was the Cheshire Cat with me, the more she began to perceive me as elusive and unpredictable. I remember her insisting on one occasion, for example, that I had stopped in mid-sentence, as if my mind had wandered off. In fact, I had ended a sentence with a question mark that Louise had not heard in the tone of my voice. There were instances of distortion that we could observe together during the sessions, but mostly I became the Cheshire Cat for her when the sessions ended. Any ‘good-bye’, even that at the end of a session, was perceived as a cruel disappearance, almost as if I were laughing at a small child for making such a fuss about being abandoned. The way she experienced me appeared to be filtered through the image of an internal Cheshire Cat-like mother.

It was important to prepare Louise very carefully for holidays, and even to talk about the approaching end of a particular session, letting her know that there were only five minutes to go. She could not tolerate abrupt ‘disappearances’. On one occasion, when there was good contact between us, Louise referred to Alice’s plea to the Cheshire Cat, please, to disappear more slowly. Consistent drawing of Louise’s attention to this aspect of her inner world, and comparing it with outer reality, brought about further gradual modifications; she came to relate to an inner image that was a little more reliable and less cruel than the Cheshire Cat. It was a long process, and I am now going to try and describe some of its stages in more detail.

Teddy-Bear Parents

The gradual modifications were, I think, more the consequence of the texture of the relationship that developed between us than related to the content of my interpretations. As I said earlier, an important part of my work with Louise consisted in providing her with an experience of attention and consistency. Louise needed to feel sufficiently contained to be able to relinquish the protection of harmful defences and face the psychic pain that had previously been intolerable. In her case, the intolerable pain was the perception of a slippery, elusive, unreliable quality, most probably derived from her perception of her mother. Her harmful defence was to reverse the situation and become elusive, unreachable and out of touch herself.

A great deal of anxiety was in store for her once she began to be more in touch with her feelings and phantasies about my not being constantly available.¹ Gradually Louise began to trust me to be there at the expected time, and not to suddenly disappear. A differentiation slowly developed between the teenager who could make do with some degree of uncertainty and the younger child in her, who expected me to be available on demand. For the younger child, my freedom to come and go was quite intolerable. I was also supposed to be quite unchangeable in my appearance: Louise could be very disturbed by my wearing a dress she had never seen before, and even more by a change of hairstyle.

She had memories of her teddy bears, a collection of them, when she was a little girl, and she still kept two of them. It became evident that she would have preferred me to be like her teddy bears: teddy-bear parents remain where you leave them, they don’t have a life of their own. This image can be seen to represent a change in Louise’s inner world, from an elusive and unpredictable Cheshire Cat to a deadly teddy-bear type of couple. But neither the cat nor the teddy-bear parents could provide her with much help or firm holding.

A rather extreme example of deadening control over parent figures comes to mind from another treatment. A little boy, who used to bring a robot with a battery to his sessions, clutched the battery with one hand and the robot with the other. It was extremely important that the battery be left outside the robot so that it wouldn’t move. At times, he brought the robot and left the battery at home. One might say that a robot with a battery is not the most caring of parent images anyhow, but a robot without a battery is deprived of all movement and life. At this stage, the patient was himself a very lifeless little boy. There was no battery or heart in his inner world.

The teddy-bear parents couldn’t provide much life for Louise either. Certainly, they could not be of much avail in helping her to use her potentialities. For instance, they could not provide an inspiring identification for her sexual development.

It must be evident by now how far Louise was from her chronological age, and how little she had touched on adolescence. However, a change had taken place in her external relationships, for by this time she was much less withdrawn. She had made some friends in school: they were girl friends only, although the school was mixed, but this was a step forward. She was no longer relating exclusively to books. She might also have had some helpful friends, but I never heard about them at this point. I heard only about the anti-treatment ‘friends’.

‘Proper Assistance’

It may well be understandable why Louise so much needed to find within herself and externally allies who would protect her from missing and valuing me. It was probably just because the relationship with me was becoming more important to her, and hence my absences more painful, that she became very sensitive to the opinions of her ‘friends’. Apparently, news of where she was going when she left lessons to come for treatment had spread, and she reported that in school ‘they’ were ‘making fun’ of her. This may have been true, but knowing how easily Louise could find a Cheshire Cat sort of mockery when there wasn’t any, I was not quite certain. I did not know whether the school friends were really helping her in her anti-treatment campaign. It appeared to me that, whatever her friends said, she was very welcoming of a voice that told her ‘Don’t go there - it is really no good for you’. This was probably an internal voice saying that change could be less painful - and what about no change at all?

After a period of uphill sessions, in which I tried to draw Louise’s attention to this internal voice that matched the reported external voices, on one occasion she made a co-operative response. She said I had reminded her of a dialogue in Alice in Wonderland - no, it was in Through the Looking-Glass - and she paraphrased the dialogue. As, unlike Louise, I do not know the book by heart, I shall quote from the actual text. What follows is the exchange between Humpty Dumpty and Alice on the subject of her age:

So here’s a question for you. How old did you say you were?’

Alice made a short calculation and said ‘Seven years and six months’.

‘Wrong!’ Humpty Dumpty exclaimed triumphantly. ‘You never said a word like it.’

‘I thought you meant “How old are you?” ’ Alice explained.

‘If I’d meant that, I’d have said it,’ said Humpty Dumpty.

Alice didn’t want to begin another argument, so she said nothing.

‘Seven years and six months!’ Humpty Dumpty repeated thoughtfully.

‘An uncomfortable sort of age. Now if you’d asked my advice, I’d have said “Leave it off at seven” - but it’s too late now/

‘I never ask advice about growing,’ Alice said indignantly.

Too proud?’ the other enquired.

Alice felt even more indignant at this suggestion. ‘I mean,’ she said, ‘that one can’t help growing older.’

‘One [my italics] can’t, perhaps,’ said Humpty Dumpty, ‘but two [my italics] can. With proper assistance, you might have left off at seven.’

(1872, pp. 271-2)

This association to the dialogue between Alice and Humpty Dumpty was, I felt, a turning-point in my work with Louise. She appeared to be saying that the anti-treatment voices came from a somewhat doubtful source - the source of ‘proper assistance’ that can bring growth and development to a standstill.

At this stage, Louise appeared to be more open to work with me in identifying the internal obstacle, the (actually) improper assistance that had stunted her development. She could begin to see that perhaps it wasn’t solely the responsibility of an elusive, unpredictable mother. (Certainly, by this time, I was not perceived as so unreliable.) Nor was it perhaps the fault of parents who would not settle for a teddy-bear status, for being controlled, and who reserved for themselves the freedom to come and go, to have other children. Louise was very aware of not being my one and only patient. This had been a great source of grievance during the most controlling phase of her treatment. But now that the grievances were beginning to lessen, she was becoming increasingly interested in understanding what Humpty Dumpty could stand for within herself.

Some of Louise’s as...