Wilton, A., 2001. The impact of illness on the therapist's self and the handling and use of this in therapy. Reformulation, ACAT News Autumn, p.x.
The theme of our conference this year is the self: the self in psychological theory, the self in CAT, the self that we try to strengthen and free in the individuals with whom we work. In my paper I look at the self of the therapist under threat from illness. This is necessarily a very subjective picture of one individual, one psychotherapist namely myself suddenly facing this situation.
I intend to explore the following areas:
My own subjective experience of myself under threat.
The repercussions my illness caused within my work and how I rightly or wrongly, having to think on my feet, managed these.
The responses of my patients to my illness looking particularly at the sudden inevitable change in the balance of the therapeutic relationship.
The ways in which at times the new patterns of reciprocal roles could be used therapeutically.
Before beginning to write this paper, I tried to find my own definition of the self. I found the following extracts from Winnicott’s Through Paediatrics to Psychoanalysis insightful:
There is certainly before birth the beginning of an emotional development and it is likely that there is before birth a capacity for false and unhealthy forward movement in emotional development. In health environmental disturbances of a certain degree are valuable stimuli, but beyond a certain degree these disturbances are unhelpful in that they bring about a reaction. At this very early stage of development there is not sufficient ego strength for there to be a reaction without loss of identity. (1)
Already according to Winnicott there is in the womb a fledgling sense of self born of the baby’s interaction with the environment. He goes on to quote a patient’s individual experience of her very earliest self:
This patient said: "At the beginning the individual is like a bubble. If the pressure from outside actively adapts to the pressure within, then the bubble is the significant thing, that is to say the infant’s self. If, however, the environmental pressure is greater or less than the pressure within the bubble, then it is not the bubble that is important but the environment. The bubble adapts to the outside pressure"(2)
Later he writes:
Let us attempt therefore, to think of the developing individual, starting at the beginning. Here is a body and the psyche and the soma are not to distinguished except according to the direction from which one is looking. One can look at the developing body or at the developing psyche. I suppose the word psyche here means the imaginative elaboration of somatic parts, feelings and functions, that is of physical aliveness. We know that this imaginative elaboration is dependent on the existence and the healthy functioning of the brain, especially certain parts of it. The psyche is not, however, felt by the individual to be localised in the brain, or indeed to be localised anywhere.
Gradually the psyche and soma aspects of the growing person become involved in a process of mutual interrelation. This interrelating of the psyche and soma constitutes an early phase of individual development (See chapter X11). At a later stage the live body, with its limits, and with an inside and an outside, is felt by the individual to form the core for the imaginative self. (3)
These descriptions enable us to catch a glimpse of the development of our sense of self from before birth. The process involves both the individual’s subjective experience of interaction with the environment and with his or her own body and psyche in Winnicott’s sense. These lead to the individual’s internal interactions. It is a process of development that can be compromised by environmental or internal pressures stronger than the individual is able to healthily integrate, what Winnicott calls impingement. This is of course the process which gives rise to the development of maladaptive reciprocal roles and procedures.
I see our sense of self as born from the unique experience of each one of us, similar maybe in some ways to the experience of others but essentially different from that of any other individual. A patient brought this home to me when she asked me: "How can you ever understand me or where my thoughts and feelings go when we all think and feel every minute of the day and night. How can I ever explore with you and make sense of the complexity of mine in one hour a week?"
In order to work as a psychotherapist it is the responsibility of each of us to make sure we are in a fit state to do so. We must be sound enough physically and emotionally, grounded enough to be able to meet whatever our patients need to bring to us, throw at us, engage us in disentangling. One of my patients said to me recently rather ruefully, "I never treated you with velvet gloves". This was in response to a sense that she was now unsure how gale force she could be, given my perceived vulnerability.
One of the first threats to my sense of self when I found myself suddenly ill, was an uncertainty that I could continue to fulfil the above prerequisite, one that I had prided myself on being able to resolutely meet over many years.
I would like to now turn to my own experience of threat to the self through illness. Over the period of a year I noticed a small knocking pain and consulted my GP who is French a number of times about this and he would shrug his shoulders in characteristic fashion and say, "We all have the leettle pains", leaving me wondering if I were being hysterical. Just before his departure for his summer holiday in France I broached the matter again and he was about to write me another prescription for a pain killer when something in me rose up. "No, I want an X-ray and an ultra sound immediately. I insist on knowing what this is. Two days later post ultra sound I found myself sitting opposite a surgical oncologist who, in as kindly a way as he could, broke the news to me that I had ovarian cancer and suggested as he put it, that I clear the decks for surgery in four days time. "The good thing is," he said, "while being serious it is still operable". The summer day suddenly turned cold.
Here was impingement, a threat to the self that was full force. Initially denial and perhaps a healthy narcissism surfaced. How could healthy energetic, stairs two at a time me have cancer? Was this some kind of mistake, had I been given the results of someone else? Sickeningly the reality of my situation bit. Fear in the pit of my stomach followed the denial: fear of loss in a variety of ways: loss of my dear family, our plans for the future, my work, and my healthy body, life itself in all its forms.
Many feelings welled up in me over the following weeks and months and provoked me to reflect. I immediately started to keep a diary. The cancer seemed at times like an invader, an enemy to be fought off by the united efforts of my mind body and spirit. I struggled to make meaning of what had happened to me. This making of meaning is both an essential task in the development of the self and is part of the function of the self as I see it. I found it important to be kind and encouraging to myself, trying to use meditation, positive imagery, and many other ways to attend to myself. Doubts and fears inevitably welled up. Was this experience some form of punishment for something I had done or not done? Had I allowed or provoked it in some unconscious way to happen to myself. I even asked myself if I in some way needed this to happen in order to make my spiritual way. I am still working on these questions in a variety of ways.
A certain defiance I think took me successfully through the surgery surprising doctors at how quickly I recovered. The news that I would need to have chemotherapy came as another blow. The idea that the only medically proven treatment for this kind of cancer involved poisoning the patient with some highly toxic substances appalled me and I began searching for other ways. After reading quite a volume of research on methods of treatment complementary to current medical practice, I, however, decided to accept chemotherapy. The Keats line, ‘As though of hemlock I had drunk or emptied some dull opiate to the drains and Lethe-wards had sunk,’ comes to mind. Chemotherapy was like being repeatedly bitten by a poisonous snake. After the first couple of times, however, I did find that I could to some extent control my bodily and emotional reactions. This sense of having some control contributed to my being able to maintain my sense of self.
Management of my Practice
After the initial diagnosis much had to be done in the 4 days given me to deal with my work. I first talked the matter through with my supervisor who was very supportive. Interestingly, I had already asked him some months before I became ill if he would take on the task of being in touch with my patients should I become suddenly too ill to work or should die unexpectedly. Perhaps at some level I knew what was going to happen to me? I decided that I would simply tell each patient that I had to have emergency surgery and time for recuperation and that if they needed to be in touch with me they could write or leave a telephone message and I would respond as soon as I could. I would in any case be back in touch with each one of them by the end of August, this being the end of July. This message was given in person where possible otherwise by letter. I saw one or two individuals face to face where this seemed important. I had not completely decided how I would respond if patients asked me the nature of my illness.To the best of my memory and to my relief none did.
At the end of August I had to make further and difficult decisions about my practice. I again discussed things with my supervisor. I decided that I would be able and chose to continue doing some work although with a greatly reduced number of patients. By this time I had also decided to bring my practice in London to an end by the summer of the year 2001 and so there was a finite time limit on the continuing work offered.
I want to now explain the criteria upon which I based my decisions as to with whom I would continue working and those with whom I had of necessity to either end or refer:
I decided that where a patient had suddenly lost an important other in childhood I would try not to cause them to have a repeat of this experience but rather use the situation to work through the fears of loss naturally resonated by my illness.
I also tried where possible to continue working with those patients where the nub of the work was in full swing.
I chose to continue with those individuals who were more severely disturbed whom I felt would benefit from an ample time in which to negotiate ending.
The Effects of my illness on Patients
I would now like to explore the variety of effects that my illness had upon the relationships between my patients and me. Of necessity, I had to reveal more about myself than I normally would. I had to let people know that I was ill with cancer and that my on-going treatment might at times affect my capacity to work with each one on a regular basis. I also had to tell them that my immune system would be affected by treatment and therefore I would not be able to see anyone who had an infection of any kind. These necessitous revelations contributed to a shift in the pivotal reciprocal roles described earlier of physically and emotionally sound enough therapist to patient seeking a more sound equilibrium.
The following change occurred in many cases.
A questioning arose in patients ranging from discomfort through to panic and guilt as to whether I was strong enough to have his or her weight put upon me. The reciprocal role could be expressed as fragile easily damaged to needy weighty. A common reaction was as follows: My situation seems trivial in comparison to yours. I feel badly sitting here putting further weight on you.
One individual found herself in a painful dilemma over this. How could she deal with her feelings over the cancer issue? It was important to her to know how I was but how much was she allowed to know and if she did not ask to know, would I see her as an uncaring person. This situation brought us to a very useful discussion about reciprocity. How much may one person say about himself or herself before he or she should cede to the other. This proved very fruitful and my patient was able to push past the block and have the space of our sessions for herself.
In another case where a patient from earliest childhood had had the task of looking after his mother, being able to express his fear and anger at perceiving me as weak avoided us becoming locked again in the early pact with his mother that went as follows: You are weak and powerless and I must look after you but then you must be just for me. At the point at which I became ill he had been just beginning to be able to have his full range of feelings for me from the savage to the passionate and loving. His silent fury at my perceived weakness brought us powerfully back to his early experience of his mother having a breakdown, going mad and being hospitalised. Love for this individual had always meant being locked in with the other with no boundaries. It also meant having to completely look after the other in order to be loved and being tantalised. For the first time the possibility and the sadness of two being separate not enmeshed but able to see and appreciate one another became a possibility. The powerful reexperiencing of these early feelings in the here and now allowed us an opportunity to work them through in the room. Incidentally, this led to a discussion within myself of whether in fact ill had to be synonymous with powerless and weak.
There was a fairly general sense amongst my patients of holding back on anger and gale force feelings for fear of damaging me. These blocks were often discovered circuitously. My illness temporarily came in the way of our work for one individual as he felt he had to be in a caring role and found himself not wanting to talk about certain things to do with death that he needed to explore. He expressed himself in a round about way as we discovered later by advising me to watch a film called the Green Mile in which a woman dying of a brain tumour is breathed into and healed.
Another patient finding it difficult to express to me how she felt about my illness brought instead her feelings about her friend dying of cancer. (This was quite difficult for me to hear) She felt she could not express to her friend how much she would miss her in case she hurt her. She dare not lead in the relationship but had to wait passively within the other person’s cues and responses. We managed to change this RR with both her friend and with me.
I caught on several occasions the fear in patients that I would not be able to give the sustenance they needed from me. This was powerfully brought home to me when one individual repeated a remark made by someone in her circle about his partner namely I see her breasts as two empty baskets. We used this to enable her to express her feelings to me in relation to my illness and also those towards her mother from her earliest days.
I caught a sense, with several patients, of a lurking fear that they had in some magical way caused my illness through their anger or hatred. One patient disappeared without trace when she heard that I was ill and my guess would be that this was the case with her. Letters and phone calls failed to bring her back to explore the situation. Another person, with whom I had worked over a long period and where we were in the process of bringing the work to an ending, meeting only intermittently, was thrown into a frightening sense of panic when she heard about my illness. Her fear was that that she had in some way been too much, unbearable and had caused my illness and that I might die, just as had happened with her friend. She was in a seriously disturbed state and it was difficult to get her to come and see me to work this through face to face as she was afraid of how she would find me. This was the most frightening reaction to my illness that I came upon but we did meet and work it through.
It was important with each individual to discover and explore each of these reactions to work them through as fully as possible and to give the person the opportunity to be as gale force as he or she needed. I was left feeling sad that I could not give this opportunity to those patients with whom I had to end or to refer on. These individuals were however, patients with whom I had just begun to work or those for whom I judged premature ending would not be too difficult.
Ways found in which new reciprocal roles could be used therapeutically
In conclusion I would like to explore two of the ways in which I think the shifts in reciprocal roles following my illness could be used therapeutically.
I want to first look first at the reciprocal roles of healthy strong powerful therapist to unhealthy weak powerless patient that can occur in therapy and have to be wrestled with. This is particularly likely to happen in psychodynamic psychotherapy where regression is tolerated and used rather than in CAT where it is discouraged but occurs at times all the same and has to be resisted. I think the fact of my evidently not being the healthy, invulnerable strong one as was put upon me sometimes before I became ill helped to equalise the power balance between my patient and myself in some cases and at times I used my vulnerability to bring this about. What I am saying is that my sensed powerlessness as a result of illness enabled the other in some cases to more easily have his or her power.
This has been the case with one individual with whom I have been working long term. The subject of psychiatric labelling and the negative effects of this upon the person concerned was a very central issue when we began our work. My patient felt she had been put in a category of sick, useless, mad, worthless one in face of normal healthy successful powerful medical professionals. She felt she had had the madness of her family and society dumped upon her and that there was no way that she could ever throw this off and feel healthy and normal (A very Laingian view with which I agreed).
We set out to try and change this negative perception. There was also a sense of wanting together to change the practice of labelling more widely. Of course the above RRs came to be played out between us. I became the powerful professional unassailable one and she the weak, unacknowledged, crazy worthless one. These RRs recurred repeatedly through our work and I felt at my wit’s end as to how we could change them. This theme became a subject of her great anger with me as she felt I was holding her in this position and I was repeatedly called upon to survive her rage.
Although I do not have the exact quotation, Jung once started a session by saying something like, "So we are both in the soup". I tried this way with my patient to good effect. In my acknowledging my weakness, my own pain at being labelled and not trying to hold on so bravely, she became able to voice and have her sense of her own strength and power to give. This leads me to think that our strict rule of never revealing anything about ourselves could be usefully relaxed at times. I could quote other examples but do not have space.
The second set of RRs that I want to look at are abandoning to abandoned. The very fact of the possibility of my abandonment through illness resonated early fears and anger particularly in those of my patients who had suffered early loss of an important other. As explained above one of my criteria in deciding with whom I would continue working when I became ill, was early loss of an important other, the likelihood being that the present situation would resonate these early feelings that could then be usefully worked through.
Although the sense of abandoning to abandoned came up with most of my patients it was particularly evident and there to be used with the following individual. The mother of this young man had died of asthma when he was three. He had been sitting on her lap at the moment of her death. His experience prior to and after this happening was of being picked up and then dropped as if he were of no value and someone or something else had caught the other’s attention. After the death of his mother he was forcibly placed in one setting after another often with little match to his needs. When we started our work, he was in a relationship with a young woman who was playing out with him the old picking up and then dropping pattern and he was suffering much unhappiness although he could see with me the origins of the procedure. Our situation gave ample opportunity for him to re-experience and to express both his fears and rage about being dropped and his guilt that it must be he who in some way caused the situation with his mother his girlfriend and with me by being too much or unbearable. On one occasion he arrived for his session having driven all the way from the North only to remember on the doorstep that he had flu and should not see me. As we come to ending we are still working on his main procedure of longing for a perfect closeness with the other but always expecting to be dropped found not good enough and so in his anxiety and rage drawing rejection from he other.
I would like to finish by saying that I feel full of admiration at the way both of the above individuals have taken on their self-destructiveness.
It occurs to me as I finish writing this paper that in so doing I am perhaps engaged in the task of defending my sense of self. I hope however that my experience will be helpful to other therapists particularly those who find themselves in a situation similar to mine.
In writing this paper and presenting it at the CAT conference I was given the opportunity to give voice to the self and be heard and met. This proved to be an important experience for me. I would like to thank my colleagues and friends within ACAT who helped encouraged and supported me in doing so. I want to highlight that in my experience ACAT has a precious and remarkable attribute, one that we all need to recognise and nurture i.e. its capacity to provide a community within which we can each give voice to the self and be warmly met. It is a challenge to and opportunity for each one of us to find our own particular way to make our contribution to the ethos of ACAT.
Winnicott, D. (1975) ‘Through Paediatrics to Psychoanalysis collected papers’. London: Karnak Press. P.182
Winnicott, D. (1975) ‘Through Paediatrics to Psychoanalysis collected papers&rqsuo;. London: Karnak Press. P182-3
Becker, E. (1973), The Denial of Death, New York, Free Press.
Burkitt, I. (1991), Social Selves, theories of the social formation of personality, London, Sage.
Angela Wilton died in 2002 and you can find a A tribute to Angela Wilton online.
A Study of Birth Stories and Their Relevance for CAT
Wilton, A., 1995. A Study of Birth Stories and Their Relevance for CAT. Reformulation, ACAT News Spring, p.x.
What's it like to have Cognitive Analytic Therapy?
Sloper, J., 2002. What's it like to have Cognitive Analytic Therapy?. Reformulation, ACAT News Spring, p.x.
A Randomised Controlled Trial of the Efficacy of CAT for the Treatment of Personality Disorder
Clarke, S., 2001. A Randomised Controlled Trial of the Efficacy of CAT for the Treatment of Personality Disorder. Reformulation, ACAT News Autumn, p.x.
Borderline Traits and Dissociated States in Later Life
Hepple, J., 2001. Borderline Traits and Dissociated States in Later Life. Reformulation, ACAT News Autumn, p.x.
Reconstructing the Infant : Review of 'The Interpersonal World of The Infant' by Daniel Stern
Scott Stewart, M., 2001. Reconstructing the Infant : Review of 'The Interpersonal World of The Infant' by Daniel Stern. Reformulation, ACAT News Autumn, p.x.
Research and Cognitive Analytic Therapy: What do we need to know?
Pollard, R., 2001. Research and Cognitive Analytic Therapy: What do we need to know?. Reformulation, ACAT News Autumn, p.x.
Some of the Historical and Cultural Background to the Self
Pollard, R., 2001. Some of the Historical and Cultural Background to the Self. Reformulation, ACAT News Autumn, p.x.
The Development of Self in Early Experience: Borderline Mothers and Their Infants
Danon, G., Rosenblum, O. and LeNestour, A., 2001. The Development of Self in Early Experience: Borderline Mothers and Their Infants. Reformulation, ACAT News Autumn, p.x.
The impact of illness on the therapist's self and the handling and use of this in therapy
Wilton, A., 2001. The impact of illness on the therapist's self and the handling and use of this in therapy. Reformulation, ACAT News Autumn, p.x.
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