God of the gap. Some thoughts about allowing room.
I’ve always liked tis image. I find the space between God and Adam astonishing. I think Michelangelo had real courage to leave this gap. A less brave painter would have been unable to allow this much tension and uncertainty-particularly since it is painted on the ceiling of the Sistine chapel where there might have been a wish for certainty.Whenever i see this picture I’m reminded of the idea of Transitional Objects mooted by the psychoanalyst Winnicott. In his theory he speaks of the nipple and the feeding child. He asks who owns this space? Does the baby “own” the breast or vice versa. He writes that “Psychologically the infant takes from a breast that is part of the infant, and the mother gives milk to an infant that is part of herself.” (Playing and Reality) He goes on to suggest that this space is where “… the intense experiencing that belongs to the arts and to religion and to imaginative living, and to creative scientific work.” (Playing and Reality)
In other words it is the area where play takes place.I have occasionally had an experience of creative play in my work as a therapist. A patient will tell me a story of something that happened to them. We will talk about it and come to an understanding of it. But often there is a sense of incompleteness. So we go back to the story and read it again. Suddenly the missing piece falls into place and the story’s unconscious meaning is understood. These are moments of great satisfaction for both the therapist and his patient. The beauty of these moments is that they belong to the gap. Nobody owns the meaning. It has been created in the potential zone that is both and neither baby and / or breast. It is a magical place.
But it can only exist if both therapist and patient allow space between them .As a psychodynamic counsellor I spend a lot of time trying not to say too much! (Some of my patients find this frustrating not to say persecutory!) Yet it is only by allowing space and silence that we create a gap that allows for play. It takes a certain amount of courage to remain silent- particularly when a patient is pushing me to give them an answer. It means that as a therapist I have to trust the process. To believe that the framework within which | work is one that maximises creativity and discovery.
So it seems to be a good picture for my Facebook page which is one way in which I offer people a space in which to play. People can simply Like or Unlike. They can choose to follow me or not. At best they can write something. I can only provide the breast. What is done with it is the gap- where all manner of possibilities exist.
This is a story about a Blackberry. When I joined my current Community Mental Health team I was given a Blackberry. I don’t like Blackberrys, finding them too small and fiddly. Nonetheless I took it. On trying to open it I found that it was password protected. Irritating but not a huge problem. I asked my manager if she had the password. Apparently not since the previous owner has now left the Trust. perhaps I.T. would have the password .”I’ll ring them” I said. “”No. You have to fill in a form.” This I duly did. Three weeks later I’m still waiting. I then discovered that I can have any phone. So I looked at the menu and chose an i-phone.Partly because I’m used to them and because they work well for me. I have some hearing loss and some loss of eyesight. I filled in the form and reached the final box which asked for a cost code. Having no idea what this was I asked my manager. “Oh.I don’t authorise that. You have to ask A .at W. base. I dutifully rang A. to be told that she was on duty today and couldn’t take phone calls etc. But if I emailed the form she would look at it tomorrow. This I did. The reply came back that I couldn’t have an i-phone because I hadn’t told my current manager that I had sight problems .If i wanted an i-phone on these grounds I must have an Occupational Health assessment. Was this alright? “Of course” I replied. I have yet to hear from Occupational Health. Meanwhile I am using my own phone to make calls. It’s just quicker.
I’m not complaining about phones per se.I don’t really mind what phone I get. What bothers me is the way in which it becomes increasingly difficult to get even the smallest thing done quickly. This story can be replicated in dozens of organisations, I don’t doubt. But what I find so difficult is that after a time this attitude becomes too much. One simply gives up trying to change anything. Yet if the Trust had simply said “Yes.That’s fine. You may have an i-phone.” I would have felt wanted. The organisation would have given me a sense of being appreciated. I am expected to go and work with patients who are vulnerable, damaged, difficult, demanding and more. I bring 30 years of knowledge and experience to my daily work .Yet my reasons for wanting a particular mobile phone are not taken at face value.I am treated like Oliver Twist who had the temerity to ask for More. This is my central point. There is a fear of Need. It is not wise to be needy in the current NHS. Certainly not if one is a staff member.(Nor a patient.) Need threatens to overwhelm the system. One sees pictures of emaciated babies sucking hopelessly at an empty breast .The despair of both mother and baby is obvious.The causes of this picture are often so complex that one needs is a Marvin with “a brain the size of a planet” to unravel them. Global warming is doubtless part of the problem. My right to drive a car has consequences for a mother in Africa .Politics, International, National and local play a part. As does Power. The interactions between all these variables would tax even Marvin. These are of no direct interest to a mother who wants to have enough milk to feed her baby. But their impact is deadly.
I was at a conference recently where the question was asked “If the NHS was a patient, what would be the diagnosis?” Answers ranged from Depressed to Dead! The most telling one was “It would be a person who has suffered years of systematic abuse.” I have worked with women who have been systematically abused over years. Their ability to care for their children is frequently compromised. Each new baby stands for another chance. Yet this same child represents another demand on a mother who is already overwhelmed by her own neediness.So the child becomes hated because it is experienced as yet another demand. Small wonder that we have all the sad tales of Baby P. and others. My request for an i-phone feels like this.I am asking an already overwhelmed service for yet another resource. It is obliged to respond in some way because it has been told it must. But it will not make life easy for me.The longer it puts off my request, the longer it can survive. Eventually I’ll either die or give up. In any event the service has an outcome. Albeit one reminiscent of my third world mother who is trying to do a simple job. Nourish her child. But somehow she is a victim of forces way beyond her. All she knows is that it is unlikely to end well.
The link is, once more, to Van Morrison http://youtu.be/R7Ls6KyP2-8
The psychoanalyst Donald Winnicott had many things to say about mothers and babies. One is that there is no such thing as a baby. Only a mother and a baby. He also spoke of maternal holding. The idea that the mother “holds” the baby both physically and emotionally. She provides an environment in which the baby can grow and thrive. (Being an old fashioned chap he also assumed that a mother had a husband who could in his turn support the mother. Thus forming a triangle of forces, which I gather is about the strongest and most stable shape one can create.) This blog is one more in a series about Organisations. In this piece I want to compare two environments with which I am familiar. A university and a Community Mental Health team. I shall look at how these two environments manage the task of holding and containing. And their impact on staff.
The original sense of the word “contain” had a sense of how one behaved. Or that one should behave in a certain way. Which still allows for something to be contained in a physical way. If water is in a bowl, then it has to behave in a certain way. If it is held in a pipe, it then has to behave differently. The shape of the container alters the way in which the contained behaves.There are many ways to contain. At one extreme are prisons, secure units and the like. These include cells, seclusion rooms etc. A physical space that offers a holding environment- albeit a very primitive one. Then come organisations like the armed forces, religious orders and similar. They also offer a security along with a sense of safety. Then comes family life. At best this gives security and safety with flexibility. (At best.) Somewhere along this continuum comes school, university, sports, clubs and the like. All give a sense of belonging and security. Allowing their members room to grow and play whilst still having rules and a structure. As with any group all these set ups will be more or less liberal. More or less rigid, depending on who manages them. And their function. (One expects a military unit to be much more rigidly managed than a folk club.)
Until recently I was a university lecturer. The faculty erred toward the rigid end. Module content was strictly defined. The ideal was a pre-set lesson plan setting out learning aims and objectives. Ideally delivered via Power Point with a lecturer sitting serenely at the front of the class. It was a university equivalent of an old Nightingale ward presided over by a Sister who was governed by a Matron with all parties knowing their place and deferring to the Doctor.The comment was often heard from colleagues on another campus that coming to us was like leaving a university and coming into a school of nursing.
Compare this to the Community Mental Health Team to which I have recently returned. The team seems to consist of an uncertain number of staff, which is remarkably permanent! It is only an uncertain to me, I’m sure! Partly because I am only part-time. It also reflects the patients with whom we work. We work with people whose lives are fragmented. People for whom there has not been a good enough holding environment. We are managed but not lead. Our managers used to share office space with the rest of the team. Recently they have moved to their own office-away from the rest of the team .(Logistically this is perfectly reasonable. Managers need a safe space. Emotionally its impact is to leave the team feeling more fragmented. Our parents have moved out, leaving us to manage as best we can.)
To return to the original idea of containment as behaving in a certain way. Both organisations face uncertainty. Anything to do with the NHS is uncertain, whether one is teaching or working on the front line. In the university the unforgivable sin was to not fill in our Outlook diary at least a fortnight in advance. In the Mental Health term the grave error is to not fill in RIO-a system that records clinical data. In both cases the needs of the organisation trump the needs of the individual. In both cases it felt that we, the children, had to contain our parents. Not vice versa. This was because our parents felt uncontained. Nobody held them so they respond out of their experience of being parented.
If we were making biscuits it wouldn’t matter took much how we were managed. The process would be highly mechanised. But in both cases we worked with people. With all their anxieties, questions and uncertainties. As a lecturer and as a clinician my task is to hold these anxieties until they can managed by their owners. In both cases the structure around me does not facilitate this holding. In the university I felt myself to be wrapped in a strait jacket. In the Mental Health team I feel like the famous “motherless child”. Or a child of a mother who is so overwhelmed that she has no time to care for her children. We are left to fend for ourselves.
To return to Winnicott’s statement that there is no such thing as a baby. Only a mother and baby, I wonder how things will work out in the future. Will the university “mother” be able to relax and learn to let her child play? Will the Mental Health team mother get some help with her depression-and be able to care for her “team Child”? If not, then I fear for the health of both mothers and their children.
The link is to Van Morrison’s version of “Motherless Child” http://youtu.be/R7Ls6KyP2-8
I am in the interesting position of having left a university faculty where we taught nursing and now working in nursing’s front line. Both organisations have to manage chaos. Or defend against their fear of chaos. It is barely worth noting that my creativity is your chaos. What i find liberating and exciting, you may find terrifying and anarchic. The skill is to find some way of allowing my creativity to live alongside your order-And to allow us both avoid killing each other! In the university there was a terror of anything that smacked of chaos. The faculty was closely managed and tightly controlled. Learning outcomes were set out. Aims and objectives clearly stated – for both staff and students.We could have stopped delivering education and moved to selling car tyres and very little would have needed to change. Instead of teaching our students how to take Blood Pressure we would teach them how to change a tyre. Instead of learning how to manage a disturbed patient, students would have been taught how to manage a difficult customer. The system was designed to take almost any content and deliver it. Thus as a lecturer one was expected to be able to teach almost anything – regardless of one’s specialist knowledge and training.This is akin to the early problems of student nurse training and retention-and is still expressed in the shift system.One is not expected to care what one teaches. No more than nurses are expected to care which patients we see.The aim is to teach a subject, not a group of students. Similarly the shift pattern in nursing means that my patient may not see me for three days or three weeks, depending on my off duty. All that matters is that are seen by someone..Both the university and nursing practice set out to control anything that is feared to be uncontrollable-or uncontrolled. Such as attachment.
Th word chaos has its roots in ideas of chasms and empty spaces; of sponginess, looseness and emptiness. (Going back further the image is of gums. Of a space waiting for teeth to fill them.) From this there is a sense that chaos is a potential space, waiting for something to occupy it. If we stay with the image of gums waiting for teeth to emerge, we have a picture of a baby moving away from the Breast and approaching more autonomy. Once I have teeth, the range of things I can eat expands hugely. It also signals a different relationship with the Breast. One that involves learning about my separateness from the Breast.If the university discouraged separateness and autonomy, psychiatric services seem to have become overwhelmed by Need. After a very short time back in front line nursing, I’m struck by how nearly psychotic the service has become. The chasm seems to have become so al consuming that staff and patients have give up trying to find ways out of it. We all now live in its depths.Health is no longer defined by autonomy but by how far down in the chasmic depths one is.
If the university defended against a fear of chaos by rigid control, clinical work seems to have all but given up any hope of managing the chaos. (Hence the image of psychosis where the boundaries between fantasy and reality become utterly blurred. Am I spying for a secret agency or being spied on? Am I responsible for that tsunami or is it about to overwhelm me?) I recently attended a staff meeting in my clinical area.It lasted for about 30 minutes. 20 minutes was taken up by our manager telling us about our progress in filling in RIO,our data base .We had made progress here, had overtaken Team C there but were lagging behind in these areas.(This review had been conveyed to her by her managers.) I was taken aback .No mention had been made of the number of patients staff were supporting.That each team member does about eight hours unpaid overtime each week. That caseloads are dangerously high. No.All that mattered was that a data base was correctly completed.
There are many lessons here. My central point this time is how we manage chaos-or our fear of it. The university and the NHS management deal with it by trying to control the smallest details. The patents and staff manage it by psychosis .Neither seems a good solution. I will end this blog with quote form Winnicott,a psychoanalyst who understood many things. He writes
“It could be said that with human beings there can be no separation, only a threat of separation; and the threat is maximally or minimally traumatic according to the experience of the first separatings”.(Playing and Reality 1971)
I have recently left the world of academia to return to front line nursing. After seven years teaching in a university I’ve decided it’s time to move on. I’ve spent much of this week wondering how I feel about this move. I was sad to leave friends and colleagues behind .I was sad to leave classroom work behind. I am a good teacher and enjoy the buzz of classroom work. But…as I carried on thinking about my reaction to leaving, it dawned on me that I was rather numb. I wasn’t clear about my feelings. As this week has gone on the numbness has given way to relief. From this comes a feeling of freedom. I can breathe! (This was apparent in my singing lesson. I had breath to hit the high notes. To be able to move from a low note to a high one and back down again. Without too much effort. I could breath.My lungs had room to expand.)
As I was musing about these feelings it dawned on me that this was what is described by women who come out of an abusive relationship. Many of my patients describe a pattern. At first their partner is very loving and attentive towards them. They feel loved and wanted. As the relationship develops things change. Slowly and imperceptibly. He becomes more controlling .He wants to know where she has been. Who she has been seeing. He goes through her mobile and looks at her text messages. (But gets very angry if she does the same thing.) Little by little the power is taken from the weaker one who continually adapts herself to her partner’s demands. There seems to be no end to her compliance and his dominance. At the end there is a truly MAD relationship- Mutually Assured Destruction.
My relationship with my university fits this pattern .When I first got the job I was delighted and excited. Oh! The wonderful conversations I was going to have! The heady atmosphere of living and working with academics! (Yes. I know! But one has to dream a little!) In truth, the early days of our relationship were fun. We laughed a lot. We enjoyed each other’s company. Slowly, however, things began to change. My dream partner became more demanding and less helpful. I was left to write and run a course by myself. (I had no idea how to do this. I’d spent 20 years as a clinician.) The person given me to help simply returned my poor attempts with red lines everywhere. “Wrong! Wrong! Wrong!” No proper help was given.I was left, literally, in the cold. (My office was a small, cold, damp room in what had been the servant’s quarters.An apt image.)
As with any abusive relationship, there were good times. Friends who supported me and shared their experiences. Both good and bad. Once or twice I complained about my treatment to “the authorities” .Support was mixed. I had to follow appropriate procedures. Fill in the proper forms. Go through the right channels. So I carried on because I had invested a lot in this relationship. I was proud of my status as their partner.
There is a story told about frogs. Put one in a pan of boiling water and it will do its best to jump out. Take the same frog. Put it in a pan of cold water. Slowly increase the temperature of the water. The frog will adjust to each increase in temperature. Eventually it will boil. But never have tried to escape, not realising its danger. The end result is the same.Death.
My turning point came after one particularly painful episode where I felt bullied, humiliated and threatened one time too many. There was, as always, a power imbalance. I was, structurally, the more vulnerable partner. Following a bout of depression I handed in my notice.I left this week. Hopefully I will be missed. Friends are sad that I’m going.My students will miss me and my funny ideas! The university has lost a gifted teacher. But nothing much will change. It rarely does…
There are many more things I want to explore in future blogs.General issues about power and abuse. Bullying and victimhood. Where and how we should train future nurses, therapists and counsellors. About the ways in which an organisation chooses to ignore its shadow side. But seven hundred words is enough for today.
I have been thinking about boredom. I thought I might need to engage with my readers in a more dynamic way, lest sitting reading a blog be too boring. So, here is a clip from a piece by Stop Motion Orchestra which I hope will grab your attention. (It is called “Instant Everything”) Continue reading