Hiding in Plain Sight: Working with the Child Experience of the Adult Client

1. Hiding in Plain Sight: Working with the Child Experience of the Adult Client UMHCA Annual Conference March 15, 2019 Diane Bachman, CMHC Mara Ashby Callister, LCSW

2. PLEASE DO NOT DUPLICATE THIS POWERPOINT PRESENTATION WITHOUT WRITTEN PERMISSION FROM THE AUTHORS…THANK YOU In regards to today’s presentation, Diane Bachman, CMHC and Mara Callister, LCSW have no relevant financial relationship with commercial interests to disclose.

3. Outline • I. Diane • Story: The Little Prince • Integrating split off child parts through Mentalizing • A therapist stance of “Play” • 2. Mara • Winnicott’s idea: the false self • Fairbairn’s model of the mind • Summary and closing

4. The Little Prince: a story about a pilot who finds healing by connecting with a “Little Prince.”

6. Drawing #1

7. Drawing #2

9. A Common Developmental Pathway • Stage 1) Childhood. • Stage 2) Woundedness. • Stage 3) Breakdown. • Stage 4) Integration; reconnection

10. Peter Fonagy • — Developed MBT • —Evidence based • —Originally developed for BPD • —MH problems due to • unstable attachment • difficulties mentalizing — The “p” factor

11. What is Mentalizing? • “Interpreting the actions of oneself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs, and reasons.” • Understanding behavior in terms of the mental states underlying interpersonal interactions • Bateman and Fonagy, (2016)

12. What is Mentalizing? • Attending to emotions, thoughts, desires, & beliefs • Secure attachment • Seeing others from the inside and ourselves from the outside • The ability to think and feel at the same time

13. What is Mentalizing? • Humility derived from not knowing • Focus is on the process • Playfulness • Moderation • The false belief test: theory of mind • Bateman & Fonagy, (2016, pp. 118) • https://www.youtube.com/watch?v=8hLubgpY2_w

14. Mentalizing in the Self • Able to express oneself appropriately and listen patiently • Autobiographical continuity • Rich internal life • Allows for emotion regulation • Moderation • More creative and flexible • Bateman & Fonagy, (2016, pp. 118)

15. Mentalizing in Relationships • Acknowledge Opaqueness • Absence of paranoia • Contemplation and reflection • Perspective-taking • Genuine interest • Openness to discovery • Forgiveness • Predictability • Trust • adapted from Bateman & Fonagy, (2016), pp. 117

16. Mentalizing as a Counselor • “Why is this patient telling me this right now?” • Awareness of how we handle the intensity of therapy • EG Do we step in to educate or instruct • EG Do we get into problem-solving mode • EG Do we get defensive and try to prove our point • Eg Do we become passive and more compliant with them • Use mentalizing to be more thoughtful about our technique • Great way to manage resistance

17. How Does the Capacity to Mentalize Develop? — Mirroring • Lack of mirroring • Incongruent Mirroring (it’s a hat!) • Contingent mirroring: the caregiver accurately matches the infant’s mental state (it’s a boa!) • Marked mirroring: the caregiver mirrors while indicating that she is not expressing her own feelings

18. How Does the Capacity to Mentalize Develop? • Child internalizes the idea that disruption is followed by repair • Caregiver infers what is going on and responds. The infant senses that his caregiver is actively trying to understand him (not projecting into him)

19. Intense emotions of any kind falling in love sadness rejection Attachment system is threatened Triggers for the loss of Mentalizing

20. Might I be feeling something? Have I felt this way before? Why might I be feeling that way? How might I respond? How will I decide how to respond? What Mentalizing Looks Like

21. Verbal Interventions to Facilitate Mentalizing • Focus on their state of mind • “When he said that, what did it do to you?” • “How do you make sense of that?” • “What was that like for you?” • “What sort of frame of mind were you in?” • Try to understand; refrain from giving the clever interpretation; stay in the not knowing

22. The Importance of Trusting the Patient • "...it is only in recent years that I have become able to wait and wait for the natural evolution of the transference arising out of the patient's growing trust in the psychoanalytic technique and setting, and to avoid breaking up this natural process by making interpretations. It will be noticed that I am talking about the making of interpretations and not about interpretations as such. It appals me to think how much deep change I have prevented or delayed in patients in a certain classification category by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of having been clever. I think I interpret mainly to let the patient know the limits of my understanding. The principle is that it is the patient and only the patient who has the answers." • D. W. Winnicott, (1969)

23. Mentalizing Polarities

24. “It is in playing and only in playing that the individual child or adult is able to be creative and to use the whole personality, and it is only in being creative that the individual discovers the self.” D. W. Winnicott, (1971) What Do We Mean by Play?

25. What Do We Mean by Play? • Beginner’s Mind Try to be mindful, and let things take their natural course. Then your mind will become still in any surroundings, like a clear forest pool. All kinds of wonderful, rare animals will come to drink at the pool, and you will clearly see the nature of all things. You will see many strange and wonderful things come and go, but you will be still. • Achaan Chah (in Chah, Kornfield, & Breiter, 1985, p. vi)

26. It is really a question of discovering the real artistry in a person (everyone has it but often deeply buried) and then liberating this—it is, I suppose, enabling someone (or indeed oneself) to become more fully alive. Ben Nicholson (in Waddell, 1998, p.4). What Do We Mean by Play?

27. What Do We Mean by Play? 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)

28. “There is no such thing as an infant. Whenever one finds an infant one finds maternal care, and without maternal care there would be no infant.” —D.W. Winicott

29. Winnicott’s idea: a true self and a false self • British pediatrician-turned-psychoanalyst • Studied all ages but mostly wrote about infants • Infants develop a “false self” and a “true self” • True self develops as caregiver accurately identifies and responds to infant • True self includes needs and “givens” • Consistent, responsive care leads to coherent selfhood and identity

30. Winnicott’s ideas: a true self and a false self • False self develops as environmental demands supercede infant needs • False self is not bad, but can be overdeveloped • Everyone has a false self (i.e. defenses are necessary) • winicott’s false self in the story of the Little Prince?

31. Winnicott’s idea: a true self and a false self • Treatment offers a relationship and opportunity to foster the true self: • 1. Identification and acknowledgment of core needs and emotional/relational experience • 2. Grieving the false self

32. Winnicott’s idea: a true self and a false self • What clients or clinical experiences come to mind? • Keep this question in mind as we look at a case example.

33. Winnicott’s idea: a true self and a false self • Case Example: Scott • 30-year-old male • Therapist formulates client hobby as reactivity to marriage conflict. • Therapist encourages client to talk about marital conflict. Client connects to childhood experience.

34. Winnicott’s idea: a true self and a false self • What clients or clinical experience comes to mind? • Share with a neighbor

35. Fairbairn’s model of the mind • Scottish philosopher, WWI officer, doctor • Studied infants and all ages • From birth, we are biologically wired for relationships • Model of the mind describes healthy & pathological mental functioning

36. Fairbairn’s model of the mind • The infant’s mind takes form as she internalizes her relational experience

37. relating to Other Self relating to Fairbairn’s model of the mind: an object relationship • Infant takes in the experience of her “self” and the “other.” • Infant carries around both “people” and the feelings connected to their interactions.

38. Fairbairn’s model of the mind • https://www.youtube.com/watch?v=QeHyBYPjJJ8 • What’s happening between mom and daughter in the video?

39. Fairbairn’s model of the mind • Some relational experience is “too much,” too overwhelming • Overwhelming experience is repressed into the unconscious • Repressed experience “disappears”: out of sight, out of mind • But WHY? • overwhelming need • too much aggression

40. Just Right Other Self Other Self Other Self Other Self Other Self Repression Repression Too Much Longing (non-mentalized) Fairbairn’s model of the mind Too Aggressive (non-mentalized)

41. Fairbairn’s model of the mind • Early relational experience stays with us throughout our lives. • Internal experience is relational experience. • Good mental health requires: • Wide range of feelings • Flexible relating to self and others • Treatment can modify internal object relations.

42. Fairbairn’s model of the mind • What clients or clinical experience come to mind? • Keep this question in mind as we look at another case example.

43. Fairbairn’s model of the mind • Case example: May • Female client, mid-30s, late phase treatment • Client shares intrusive, recurring thought about hating the therapist. • Therapist treats thought as meaningful. Client explores and makes links to childhood.

44. Fairbairn’s model of the mind • What clients or clinical experience comes to mind? • Share with a neighbor.

45. Summary and Closing • We need a broad repertoire of ideas and methods with which to think, work and play in clinical practice. • A conceptualization of the child experience in the adult client can be a powerful treatment tool.

46. Summary and closing • From the cover of Antoine de Saint-Exupery’s Little Prince: • “A pilot stranded in the desert awakes one morning to see, standing before him, the most extraordinary little fellow. ‘Please,’ asks the stranger, ‘draw me a sheep.’ And the pilot realizes that when life’s events are too difficult to understand, there is no choice but to succumb to their mysteries. He pulls out pencil and paper…”

47. References Bateman, Anthony & Fonagy, Peter. (2016) Mentalization-based treatment for Personality Disorders, 2nd Ed. Oxford University Press. Bateman, A., Campbell, C., Luyten, P. and Fonagy, P. (2018) A mentalization-based approach to common factors in the treatment of borderline personality disorder. Current Opinion in Psychology 2018, 21:44–49 Chah, A., Kornfield, J., & Breiter, P. (1985) A still forest pool: The insight meditation of Achaan Chah. Wheaton, IL: Theosophical Publishing House. Daehnert, Christal. (1998). The False Self as a Means of Disidentification: A Psychoanalytic Case Study. Contemporary Psychoanalysis, 34:251-271 Saint-Exupery, Antoine de. (1995) The Little Prince. Thorndike, Me. : G.K. Hall. Scharff, David E. (2005). Object Relations Theory and Practice: An Introduction. Rowman & Littlefield Edition. Stadter, Michael. (1996). Object Relations Brief Therapy: the therapeutic relationship in short-term work. Jason Aronson, Inc. Waddell, Margot. (1998) Inside Lives. Karnac LTD. Winnicott, D. W. (1971) Playing and Reality. New York: Basic Books Winnicott, D. W. (1969) The Use of an Object. Int. J. Psycho-Analysis: 50:711-716