Together, We Can Find Your Voice. Love, Phoebe

Lynn Higgins

The treatment

With long blond unkempt hair that was cascading around and covering her face, Abby entered while steadfastly looking down and towards the floor. She was clutching onto her book for dear life as she shuffled ever so slowly into my office. She sat in the middle of the large couch looking as if she folded into the middle of it, not daring to look up from her lap. Sitting there, she looked as though the couch was both swallowing and consuming her. Phoebe immediately jumped up, without any hesitation and curled up next to her. Abby, saying nothing, was glued to the pages in front of her which she turned slowly, trying to manage whatever she was feeling and whatever might be going through her mind. A small, ten-pound Boston Terrier with big brown eyes and a loving and sensitive disposition, Phoebe remained curled up next to Abby on that couch. Phoebe was just not moving. As I tried to offer some conversation with her, where she was, and what we do here, Phoebe sighed and placed her head on Abby’s lap. As Abby was looking up at me, she placed her hand on Phoebe’s head and left it there.

Little did I know that this would be the beginning of something significant and special that would occur between the two of them and the three of us. For the next few months as we became accustomed to each other, this pattern of Phoebe gently but obviously placing her head on Abby’s lap as they settled in on the couch, would occur towards the beginning of each session. As time went on this beginning became a kind of ritual where Abby would wait for Phoebe to jump up next to her. At some point, the content of the sessions became secondary to what was developing on the couch.

As a seven-year-old girl Abby was not social—as opposed to anti-social. She wanted desperately to be included in groups during lunch, play, anything with the other kids at school. She would laugh awkwardly and say things the other kids clearly didn’t understand. She was so painfully inappropriate that she was consistently ignored or rejected and called weird by almost everyone she came in contact with. She was excluded from most activities and not chosen for groups or teams causing her to retreat further into her own world. She was lost for hours in this private place and became less meaningfully verbal.

She wasn’t eating or sleeping, so she would go to school tired and hungry, but unaware of her hunger. The fact that Abby was not eating, yet hungry for contact from others, left me almost aching for how starving she must have truly been. She was very thin and looked rather gangly and waif-like. Her attachment to others and her interest in life felt aloof, distant and cut off. She wanted everything to do with people, and nothing, protecting herself from persistent rejection by her own distancing. It was at this point, at the school’s recommendation, that her mother brought her in for treatment.

Abby has a twin brother who has severe autism. To this day, he is not toilet trained and is nonverbal. He spends much of his time with his maternal grandparents because their mother cannot manage both of them. For the first four years of Abby’s life, her mother suffered from severe post-partum depression and could not care for either Abby or her brother—at all. As a result, both Abby and her brother lived with their maternal grandparents exclusively for those first four years. Her father, drug-addicted, and also not involved, passed away when she was three years old. As her mother clawed her way out of her depression, she began medication, therapy and entered social work school to help her understand herself and her children. She wanted to become a better mother, a present mother. She subsequently met a man, David, who loves all of them dearly. He presents as rather naive with little insight and complains that he doesn’t earn respect in his endeavors, but he has a heart of gold and the best of intentions when it comes to both Abby’s mother and her children.

Mom, David and Abby would come to the weekly sessions and sit in the waiting room. Phoebe would greet them all, especially Abby. Abby would wait for Phoebe to trot into the treatment room ahead of her, follow her and they would resume their positions on the couch. Abby would draw, read her books, play with her Gameboy. She would, it seemed out of obligation, introduce me to what she was playing but remained so focused and engrossed in her play that my presence seemed inconsequential.

With Phoebe sitting between us on the couch, out of desperation one day, 1 began to ‘use’ Phoebe to communicate with Abby. 1 said, T did NOT hear Abby say that Phoebe!!’ And then—for Phoebe—in a rather loud and astonishing voice, ‘WHAT?’ 1 would continue in this manner until one day Abby looked up and responded with, ‘What did Phoebe just say I said?’ So, I playfully responded with, “‘Phoebe said you really want Lynn to sit right next to you’”. Or, ‘Phoebe said, “You really want Lynn to play with you.’” Abby would vehemently disagree with Phoebe that she said anything of the kind, but at least she was responding and talking. She began correcting Phoebe. 1 felt like I had struck gold. 1 would slightly exaggerate my responses until she would laugh and correct me to make sure I said whatever it was that she meant, exactly as she meant it. This initial commentary back and forth was playful, light, silly and a bit provocative. She then began to ask Phoebe to tell me something that felt to me like a feeling or something she was trying to communicate. We were beginning to use Phoebe as the medium to both communicate and to clarify what she was feeling. All the while, Phoebe would sit next to Abby with her head on her lap, seemingly unaware of what was playing out around her, but steadfast in her presence.

As this dynamic unfolded and developed, the atmosphere in the room became much more playful and spontaneous. Abby began to bring in a giant stuffed bear named Bear-y that she had had at home, which soon was accompanied by a plethora of additional stuffed animals. Each week she would lug multiple stuffed animals into the room, introduce them to me, set them up along the furniture and make them talk in the same way that I was talking to her through Phoebe. They spoke to each other, to Phoebe, to me, and back to her, about children at school, about her mother, about anything. Over time, not only did these conversations develop in their content, but they also became more thoughtful, contemplative, reflective and fluent. Phoebe always had a say about a situation. ‘She’ asked questions about families, games on the playground, and how children talk to each other. Abby insisted these conversations continue at home so we both taught her mom how to be part of the dynamic with her stuffed bears. Her mom was thus able to develop a real communication with Abby. As this continued over a period of about a year, Abby’s voice began to change as she would jump out of the role of talking like one of the bears or Phoebe and would use her own voice to correct them. She began to use her voice in such a way that I was then able to ask her questions and remark more directly.

Abby began to write story after story, both in session and out of session. She had so much to say. Her stories were about children on the playground, children not listening to each other and groups of children playing together happily, about music class that felt extremely uncomfortable, about having a sibling that was disliked and who was the character in her story of whom she felt painfully ashamed. These stories launched many conversations about social dynamics as well as her internal wishes and feelings. Conversations would happen either directly or through Phoebe, but importantly, they began to happen.

At home, Abby was becoming belligerent and angry. She wasn’t listening to her mother and they were fighting constantly. She refused to shower, eat, and do her homework. She was at risk of failing math, in particular. Index cards were used, games were played, but Abby refused to engage with anything to do with math. During this period, her mom would come in periodically for some sessions alone to discuss ways in which she could encourage Abby to express her anger verbally and modify how she was responding to Abby. This period was extremely challenging for both Abby and her mom, in different ways. Abby became so angry that she felt inaccessible both in session to me and to some extent at home to her mom. However, this was less the case with Phoebe; at some point, Phoebe sat so close to Abby that Abby had no choice but to respond to her. This went on for many weeks until Abby began talking to and through Phoebe again, in ways that were reminiscent of an earlier period. We went back to square one.

Again, slowly she became more responsive to me. ‘Phoebe’ began asking her about her feelings of rejection by kids at school. She had a lot to say about what was happening socially at this point. She told Phoebe about feeling weird, about not being like other kids and feeling like she had no friends, even though everybody else did. She told Phoebe everything that was happening in school. ‘Phoebe’ listened and I, like Phoebe, commented in ways that let Abby know she was seen and heard by her.

Abby also had a teacher who really cared about her, who helped her navigate everything from negotiating conflicts with other children to how to join games on the playground during recess. She had Abby come in for extra help with math and spoke to her mother about getting her some new clothes that were more appropriate and that would help her fit in—at least in terms of looking more like her peers. Abby began to care about her appearance and also to notice what she did to put other children off that had earned her the label, weird. She began to modify her behavior. She began to care about math as well as her other subjects. She also wanted to have clothes more like those the other children were wearing. This made a huge difference in other children’s reactions to her.

Abby began to like to sing in the chorus class. Her teacher encouraged her to try out for the school play, a musical. She got a part with a one-line solo and as a moderate lead. She worked hard to learn her lines and to develop her stage presence. She had to learn to use her voice loud enough so that she was able to project out toward the audience—so she could be heard. Although awkward, she began to fit in with the other children. Having to project her voice in this way helped her find the strength that had been already percolating within her. She excelled. Her grades improved. She began reaching out socially and writing her own stories, complex stories about real issues. She won an award for her stories, which helped her gain visibility and acknowledgment for something important to her. At the end of sixth grade, Abby was solidly on her way to experiencing herself differently in this world.

Theoretical considerations

When Abby walked into the treatment room as a young seven-year-old, it was clear she was severely depressed, cut off and hesitant. It seemed that she hardly existed. 1 felt as if I was sitting alone in the room—clearly an empathic experience of what Abby had been feeling. Altman et al. (2010) discuss the importance of the relational therapist’s countertransferential experiences as a mechanism for honing-in on the goings-on in the family through empathy towards both the child and the parent/family. Paying attention to the parent-child interaction, listening to descriptions of experiences at home and one’s own affective responses—all inform the direction a therapist will move.

Stern discusses the infant’s repeated and yet unsuccessful ‘attempts to invite and solicit the mother that fail to bring her to life [and] ... to be with her by way of identification and imitation’ (1995, p. 100). Abby had learned to survive by ‘suppressing her own perceptions and feelings [taking into herself] ... the parental badness in order to hold onto the security of believing [s]he has a good parent' (Altman et al., 2010, p. 84). Modell (in Kohon, 1999) refers to Andre Green’s concept of the dead mother syndrome as a fundamental and as a ‘traumatic disruption in maternal relatedness in infancy and early childhood’ (p. 76), which potentially serves as the seat of early trauma. The subsequent deadening becomes ‘clothing’ we wear and carry with us each day and throughout life. Abby desperately needed contact with her mother, so she ‘deadened’ herself in order to survive and to maintain an illusion of contact with her mother, connecting with the emotionally absent mother in order to find some way to feel some aliveness through the contact, even if it meant maintaining a chronic deadness. This ‘imitation may be the only way the infant can engage the mother. If 1 cannot be loved by mother, 1 will become her’ (Kohon, 1999, p. 78). Abby had ‘taken in’ and become an earlier, depressed version of her mother.

Stern describes a depressed mother as physically present and emotionally absent because ‘she can no longer or hasn’t been able to engage or remain engaged with or become emotionally invested in her child’ (1995, p. 99). It seemed that all Abby’s mother’s long-held fantasies about repairing, connecting or redoing her own childhood that she may once have felt, were stuck and thus transmitted to Abby. Stern suggests that when the mother relinquishes such fantasies they become replaced by the reality of the disappointments in her childhood. ‘The accompanying profound sense of loss that runs beneath the sense of worlds gained’ (Stern, 1995, p. 25). Therefore, the profound sense of loss and sadness that Abby’s mother has carried with her, which was then enacted and communicated to Abby, may have then contributed to her profound and lasting post-partum depression.

Altman et al. discuss the need for the parent to recognize the child’s inner world, without which s/he feels ‘alone and [with] a part of himself that he cannot make sense of. Recognition, then, allows the child to feel real and part of the world’ (2010, p. 85). Abby had not only become the badness she felt from her mother but had also been disappearing from any sense of aliveness.

Abby was thus extremely cautious and clear about not wanting to relate to me or anyone else for that matter. However, she tolerated Phoebe by allowing her to sidle up and sit next to her. That was curious to me.

Phoebe’s presence and attentiveness clearly offered Abby an alternative experience of relationship. Horowitz refers to dogs as ‘students of behavior’ (Horowitz, 2009, p. 163). They never stop looking at and studying us humans. Horowitz contends that dogs can identify characteristics of an individual through smell and nonverbal behavior and can recognize the physiological changes that accompany fear, anxiety and sadness. ‘As the perpetual student, the dog knows our most ordinary of behaviors and these behaviors are chock full of information the dog can then mine’ (Horowitz, 2009, pp. 166-167).

It would seem that Phoebe knew that Abby was disconnected and certainly sad. As a young dog that paid close attention to my comings and goings she, for some wonderful reason, took a particular interest in Abby. From day one, Phoebe would assume her position next to Abby on the couch, and remarkably, Abby didn’t push her away. It was out of a spontaneous, and a rather desperate moment that I began to talk to Abby through Phoebe, which allowed me to ‘mine’ her truth, her voice. She would hardly speak unless it was to tell me something about a computer game, which felt like a time filler, an avoidance, a well-rehearsed strategy. Phoebe allowed me to puncture Abby’s same-old-same-old responses.

Stern discusses Winnicott’s concept of the ‘transitional object’ as having both intrapsychic and interpersonal qualities. The idea that an object can both contain intrapsychically and possess external and tangible qualities allow the transitional object to safely ‘hold’ the child and provide an environment for growth to occur. Holmes, when discussing attachment, refers to the ability of an internalized object to profoundly alter the life cycle. ‘[W]e need someone to be there for us—and if not a person then an animal’ (1996, p. 66). Phoebe’s constant presence allowed Abby to have a different experience of attachment and provided the warm and safe holding environment unique to a transitional object.

Abby certainly became more animated, and so did I, when ‘Phoebe’ would talk to her about something. When she drew pictures, told stories or played any computer game, Phoebe would have questions for her, a comment about what she was doing or not doing. Her disagreements with Phoebe suggested to me that there was a shift in her ability to be present, and perhaps, attach in the treatment room.

The content of Abby’s statements and responses revealed a positive transference towards Phoebe. Additionally, the resulting use of Phoebe and through the nature of the play itself, Abby was able to move developmentally in her play towards being and feeling seen in the treatment room. Through imaginative play, suggest Brown and Vaughn, ‘a child stops thinking about thinking. The child can then become a different self’ (2009, p. 17). Additionally, they state that during play, the brain is making sense of itself. New connections and insights can form along with a shift in cognition helping to sculpt the young brain. ‘For humans, creating simulations of life may be play’s most valuable benefit’ (ibid, p. 34). Slade and Wolf (1999) further state that ‘during the first two years of life, the child undergoes a series of developmental transitions ... [T]he major cognitive achievement is the gradual emergence of the ability to represent experience symbolically, according to Piaget—into both play and language’ (p. 149).

Abby was thus able to safely attach and feel a sense of belonging to such an extent that she could find her ‘self’ and her voice with just enough distance, through Phoebe. Brown and Vaughan state that when ‘food and sleep are in peril, play will disappear’ (2009, p. 42). Though, in Abby’s case, lack of sleep and disinterest in eating may also have been a reflection of her disconnection and the absorption of her mother’s depression. Certainly, not eating is an effective way to not be alive, and to not feel oneself. By now Abby had begun to sleep, and she then began to feel more connected during the day at school. And, little by little, she began to eat at lunch with the other children.

In order for Abby’s attachment to develop into a healthier internal working model, ‘she needed to be seen and known, the primary mechanism by which an infant comes to know and be known by another’s mind’ (Beebe and Lachmann, 2014, p. 35). Being seen in the treatment by Phoebe, then myself, and then subsequently by her mother, gave Abby an internalized structure and a developing sense that she was becoming both seen and known. Phoebe, from the beginning, saw Abby. In school, Abby began to have friends. It wasn’t easy, and there were many bumps in the road, but she began to use her words without fear and spontaneously in a way that has demonstrated stunning insight.

The present

Finishing with the appointment before Abby, I heard the door to the waiting room open and a stream of giggling from her that 1 had never heard. It was startling because I had realized at that moment that I had never heard Abby laugh or giggle—ever. When I went out to greet Abby, with Phoebe in tow, she was laughing and giggling contagiously. She was smiling the biggest, most inviting smile I had ever seen on her face. She wanted to hurry up and come in to play. Abby has never initiated any play—other than the occasional board game. Abby’s play, on those infrequent occasions, consisted of her taking a board game down, and becoming impatient with me when trying to learn and follow the rules, or realizing that she would have to work to first learn and then potentially win. This was true for all the games she had ever attempted in the sessions prior to this.

Abby looked more grown-up during this session. She was behaving in a way I had never experienced from her. She felt more engaged, determined to pick what she wanted to play and insistent on staying with her choice. She had clearly shifted emotionally and physically during this past summer. Her facial structure seemed to be changing giving her the appearance of a strikingly beautiful budding young adolescent. I found myself looking at her as though she was a different child. Coming in she insisted she measure her height with my height so we could see who was taller in a very playful and rather taunting style. She was catching up to me, she insisted. (I am all of 5’3”). Abby’s measuring her height against mine felt like a statement about the internal developmental shift toward a more oedipal dynamic. Abby’s comparison to me in the context of the transference allows her to reach and to grow and have an alive mother, this time. She is beginning to insist by her words and with her actions that her mother become alive.

After some playful back and forth, Abby insisted we play Twister. Though rather easy with two people, we modified the rules: one of us would be in

Together, we can find your voice T1 charge of the spinner, having to label the colored circles one through six in a consistent manner and try to create a scenario where the other person would fall. Each of us had three tries, each turn. Though I could see Abby’s physical lack of strength, she held her own. In the end, she out-strategized me—fair and square. I lost. She flaunted her win with that big beautiful smile. Given Abby’s history around her lack of any ability to socialize, make eye contact and simply relate, this was a milestone and a moment that gave me great pause.

Discussion

Abby’s treatment is now into its fifth year. She is twelve years old, entering seventh grade as a wonderfully awkward pre-adolescent who is worried about her clothes, her schoolwork and her friends. She excels in every subject and wants to be a writer when she grows up.

When Abby came in those first months, 1 didn’t know how I could possibly gain a point of entry into this withdrawn young girl. As Phoebe relentlessly sat next to her and I sat next to Phoebe, Phoebe was then situated in the middle of the two of us. We would both pet Phoebe, but most of the time I was talking to myself until that desperate moment when I spoke to Abby through Phoebe. It was rather one-sided at first until it began to take shape as a playful kind of back and forth—the beginnings of a conversation. Every game in the room had felt off-limits to Abby. She was not interested in most things, other than the iPad or Gameboy games she brought in herself. I did not experience these games as shared play. She was expertly keeping me out of her world. Phoebe told her many things I could not have said to her. She answered Phoebe. She would get off the couch and look at Phoebe to make sure she got the message. I had no sense of hope that this was achieving anything meaningful until she began to bring in her stuffed animals from home—by the armful. When her mother was able to utilize this strategy we devised at home I felt that Abby could practice communicating in this manner, within the context of the relationship that mattered the most to her, her mother, as a true form of reparation. Her mom came in for her own sessions rather frequently as she was increasingly brought on board and taught about using the strategy of talking as if she were one of the stuffed animals, as an attempt to repair some of the damage that she felt so terribly guilty about having induced in her children. She began to get some real feedback from Abby in this process. While it was hard for her to hear the negative pushback from Abby, she worked to respond differently. When Abby became argumentative and angry, Abby’s mom really struggled with how to navigate her anger without taking it personally or lashing back at her. We worked tirelessly so she could see the big picture—which she ended up understanding in theory at first. Supporting her mom to employ at home a successful way for Abby to feel heard and seen in an authentic way was a real struggle for us all.

One day, Abby cut off most of her hair. When she entered the treatment room, next time, I noticed it immediately. From my perspective, this was a statement that Abby was ready to be seen—truly. Unbeknownst to me, a fight had occurred at home because Abby did not discuss cutting her hair with her mom and stepdad before she did so. They were enraged thinking that she should have asked them first. When we discussed this together, Abby remarked to her parents, ‘do you know why 1 didn’t ask you? Because you would have said “NO!”’. Remarkably, after some discussion, her mother agreed with her. This new haircut represented another shift in Abby wanting and needing to be seen and to individuate. Seen by her classmates, her parents, the world. Seen by all.

She went to school wearing her new clothes with her new haircut. This is when she tried out for the school play. Though very tentative and selfdoubting, she learned her lines and worked hard to be heard by the audience. Everyone was very proud of her. Though I could not attend the play, her mother sent me videos. Abby allowed me to watch them with her, and she narrated scene by scene what she was thinking during the performance. Her language was beginning to accurately reflect her internal world. Since Abby was an avid reader, her knowledge of the language was sitting inside of her waiting for an opportunity to be put to use—to express the luscious yet painfully lonely world that lived inside of her. As her words moved more fluently in her relationships with the other children at school, she became much more spontaneous in her actions, her play and in her interactions with human beings—adults and children alike. She was beginning to feel the warmth of connection and was devouring it like the most nourishing meal she has ever had. No wonder her entire physical structure is changing. And, that beautiful smile.

From the very beginning, on that very first day, Phoebe wanted you to know, Abby, that she has always believed in you.

References

Altman, N.. Briggs. R., Frankel, J., Gensler, D.. and Pantone, P. (2010) Relational child psychotherapy. New York: Other Press.

Beebe, B., and Lachmann, F.M. (2014) The origins of attachment: Infant research and adult treatment. New York: Routledge.

Brown, S.L. and Vaughan, C.C. (2009) Play: How it shapes the brain, opens the imagination and invigorates the Soul. New York: Avery.

Holmes, J. (1996) Attachment, intimacy, autonomy: Using attachment theory in adult psychotherapy. New York: Jason Aronson.

Horowitz, A. (2009) Inside ofa dog: What dogs see, smell and know. New York: Scribner. Kohon, G. (1999) The dead mother: The work of André Green. New York: Routledge. Slade, A. and Wolf, D. (1999) Children at play: Clinical and developmental approaches to meaning and representation. New York: Oxford University Press.

Stern, D.N. (1995) The motherhood constellation: A unified view of parent-infant psychotherapy. New York: Basic Books/Harper Collins Publishers.

16 Coimtertransferential?

Counter-therapeutic? Counter-intuitive?

 
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