Early attachement and dramatherapy, Athen's conference 2012

Attaching with Anna

Kathleen OLIVIER

 

I am going to tell the story of a girl I have met at my workplace where I am employed as a clinical psychologist, but where, as a dramatherapist, I propose props, cloths, puppets, mirror, and myself for play.

Anna is around ten years old when we meet and she has been received by the medico-psychological services for some years already. She came from Algeria when she was one year old under the Kaffalah law because her biological family had given her to another family who had more financial means and could not have her own child. In fact she was raised for some years by the mother of her adoptive mum and it is only when her “grand-mother” got dementia that the adoptive mother had to take care of her. She however did not invest her motherly role and when she separated from her partner, the child was let to be grown by the adoptive mother’s sister and other members of the family. Finally the social care got informed of this unreliable system and Anna was removed from this adoptive family to be taken to a foster family at the age of five.

When we meet, it is at a point when the foster mother is also ready to stop the relationship because she feels that despite the effort she is giving to raise Anna, the same way she has been doing with her own kids, the girl doesn’t accept the rules. The most difficult behaviors for the foster mum are the “lies” and “stealing”. She feels she cannot trust the child and therefore she cannot go on living with her.

During our first encounter, while telling me about her life story, Anna decides to reveal events when she has been very scared by the partner of her adoptive mother while he was on drugs and made a closet fall on her. She felt she might have died and cried a lot while telling. It was the only time she cried; the foster mother was in the office, listening with some surprise to the events the girl had gone through. Maybe Anna had not had a life so similar to her own kids even if she was displaying behaviors telling about her strengths, resiliency, and defenses. She needed therapy.

 

We started meeting on a weekly basis. At first, Anna showed the need to check if she could trust me, asking details about my personal life and also looking for clear boundaries, often displaying inappropriate physical distance. She was quite confused between her own self and mine, having a hard time differentiating her own desires. She proved to be quite ambivalent about the relationship, refusing what I would propose even when she had at first suggested the idea or checking if I was “angry” when she had acted in a way she knew was not accepted in her foster home or at school. At the mean time she was saying how unimportant she might be to me because ‘it was only my job’. I felt she was testing if the relationship I was proposing was secure enough to go further. 

Anna was quite disorganized in her thoughts and actions, going from one activity to another, talking quickly, at times almost shouting, and changing topics of talk many times. Her story describes how she had not received enough attention by the first caregiver whose role is to give meaning to the sensations and emotions through words. Her intentions, which are the meaning associated to our actions, had been poorly given direction and her impulses not very contained by an adult. She had poorly been thought by a constant adult mind and therefore could poorly think about herself and about the other – one could refer to a deficit in the metacognitive process of theory of mind.

For many weeks, she was particularly attracted to all the sticky and humid material I had on my desk like glue, white corrector or child-clay. She was actually putting in her mouth most of the material I had, because she needed to go through these experiences and also checking what limits I would give her. We had to clean my office, desk and ground, her hands and face many times, but I prohibited she ate the glue for safety reasons and I guess she needed to have me repeat I would not let her injure herself. I relate this first phase of the therapy to the “embodiment' phase coined by Sue Jennings (Embodiment-projection-role, E.P.R model) when the child encounters the world through touching, smelling, tasting and all sensory experiences. Anna may not have had the opportunity to experience this phase in her adoptive family and her foster family may not propose her such activities unrelated to her biological age. It is sometimes easy to forget that kids who have such history can display much younger emotional abilities than cognitive skills.

After that phase, she became interested in painting self-portraits with black ink. She seemed to be satisfied in the process but at the end, she almost always decided to tear the drawing apart or throw it to the garbage. It was as if the creation was never good enough and she couldn't consider positively something that had come out of herself – her self being still so fragile. One day, I proposed she could create a mask with two faces: one showing her hidden side and the other the side she showed to the world. She made a crying face for the hidden side, while the other had a big smile. Some sessions later, she asked to see it and started to destroy it saying it was not her but me who wanted her to do this. She had such hard time feeling what were her own desires and needs. In a parallel way, she broke some creations others had made, then being very sorry. This “projection stage”, second phase in Sue Jennings’s E.P.R. model appeared to be quite painful. She gave it an end when I came with the clay she had been asking for, for which I had received a special permission, and recognised she would say “no” because I had accepted. Her need for control was a way to verify I didn’t want to decided for her and, as an individuation process, this was therapeutic in itself. A little before terminating, she asked to use child-clay again, and mixed all colors to create a very small objet looking like a nest. She said she would leave it on my shelf and I shouldn’t remove it. Something of a bound and a safe place between her and I was symbolized and remained. We may have found the right balance between a safe container and a space for freedom: a nest from which a bird could start flying.

I had to leave for pregnancy and, during that time I proposed she could be in the therapeutic group working through playback theater with two of my colleagues who had co-constructed that space. When I came back, I met her again on the group for two sessions before we had to change the time and she could not attend anymore. She was displaying a great need to be seen and heard in the group, but the most memorable moment I recall is the day one of the girls told a story about her own birth and said that she, as a baby, had decided to be born a little after the due date: making herself expected by her mother. Anna was chosen to play the baby and I believe she asked for that role. I remember how she took the role of the baby coming out of the womb of the mother : “third stage” in Sue Jennings’model. I felt she was experiencing this moment as a possibility for the child to decide on her own life which was a very empowering scene. It was a real process of “be-coming”, of “creating herself”. She could then allow herself to play the little baby needing to be taken care of, expressing the healthy duality of the relationship between control and letting go, between oneself and the other.

Meanwhile, the relationship between her foster mother and herself had changed a lot and Anna came one dame quite angry telling me that the foster mother behaved to her as if ‘she thought she was her real mum’...We both laughed with the implicit understanding that it was actually what Anna was looking for while her adoptive family had still very unsecure bounding qualities and her natural family had still not responded to the calls of the social care and justice. I felt that Anna could now trust this foster mother to keep the rules clear and therefore hold safety. Trust is a mutual relationship.

She had become older than the kids we usually work with at my service, but since she had told me she wouldn’t want to meet a new team and wanted to pursue our work together, I had asked and obtained a special medical authorization. However, knowing she could pursue this relationship, she started saying she wanted to stop the therapy because she didn’t want to miss her social life at school. This social life was quite chaotic and her interest for school almost inexistent, but I knew she needed to take some control over the decisions in her life. For the two ending sessions, she spontaneously asked we role reverse and that she played the therapist and I the teenage girl. When I asked how the girl was, she described a girl who didn’t want to talk because she was too sad missing her mum. She played a quite terrifying therapist very upset the girl didn’t want to be active and threw the girl out after calling to the director explaining the girl was misbehaving. I felt she was reproducing the role of the adult she had been confronted too: frightening and with a behavior not adapted to the situation. Next session, she reproduced the scene and then, while the teenage girl tended to rebel a little more, she, as a therapist, reminded the girl she had to respect her personal boundaries and couldn’t accept such aggressive behavior. I understand she was introjecting the frame of a healthy relationship with interpersonal limits clarifying the spaces for the two individuals. Anna had to voice to me that she knew it was “as if” and check if it was alright the way she had acted toward me playing the child. I answered it was alright. She could experience ‘for real’ going over the limit and then create her own delimitation for action. When we last met for closure, she asked again if I was not angry with her because she was leaving. I wasn’t angry, but I felt it was a goodbye to a real relationship and that I would miss our encounters. However, I felt she was not going alone, as the relationship with the foster mother was better, the mother had let go of her expectations and seemed to just enjoy her relationship to Anna. Anna was still complaining about the rules but the thread of trust and safety seemed to be strengthened.

 

Some analysis on the dramatherapy processes underlying changes in attachement: neuropsychological hypotheses.

My encounter with Anna was very teachful in terms of attachment issues because this kind of client comes to work hard with our own way to enter into relationship, try the strengh of our self, our limits and our capacity to give the other a space to experience freedom of being. It is when trust and safety appears in the therapeutic space that the level of stress reaches the good level for learning and creativity to occur. Mediated through the cortisol hormones, the brain can be reorganised , new synapses and even new neurons can appear. Cozolino has been working on the effect of the emotional environment to enhance new learning: psychotherapy is a “corrective emotional experience when new emotional memory recorded”. However the non direct approach that dramatherapy permits helps to not overwhelm the client with too many emotions or direct memories of difficult situations: too much stress inhibits learning.

Many client may have experienced repeated distressing events (like separations, pathological relationships, situations of negative valence) or some ponctual events overwhelming their capaciyy to withstand (trauma). When the event cannot be treated by the emotional and cognitive systems at the time it happens (to young or too fragile in terms of psychological abilities; or an event that cannot be accepted by a human conscious), the information cannot be treated by the hippocampal memory system that usually records this event in its context. It therefore becomes a free floating memory that can be reactivated by many unrelevant triggers. Clients like Anna are living in a state of hypervigilance and constantly reacting as if the danger was near: agitation, defenses, high emotional state. Our work as a therapist is to help the client create new and more positive associations and memories on events that the client is going through (being in a relationship, being under the eye of another, going outside). Mooli Lahad has been working on assessing the different ways a person is able to respond to a traumatic event (coping modes) so that we, as therapists, rely on functional areas. The purpose is for the client to be secure in the type of interaction and communication we propose . Anna needed me to be physically and emotionally interacting with her (playing together in clay ). Our flexibility of mind, imagination and body is a necessary ability to be able to follow the client on the theme he wants to work on but also through the medium he feels good with. The dramatherapist needs to feel at ease with the dramatic material he proposes so that a real relationship can be emerge. This is a “right brain to right brain connection, implicit non verbal affect laden communication while at the same time a left brain to left brain connection to co-create a coherent narrative” (Allan Shore). Therapy is allowing integration of all aspects of the person (reassociation)

With these clients that have experienced previous relationships where their own feelings and thoughts were poorly respected and therefore had trouble developing, attunement is a basic factor for healing. Siegel explains that attunement to the patient alters the self-regulatory integrative fibers of the brain. It is through the close attention the therapist gives the patient, that the patient can start give attention to himself, his own feelings, behaviours, and thoughts. Attunement is a participating to the attachement process “The therapist feels the feeling, not merely understands them conceptually, the whole self vibrated like a tuning force to every quiver in the client's being without, however, losing the basic emotional stability that the client needed to help regulate his or her runaway emotions”. Anna, from the vey beginning of our encounters was asking “why I was looking at her like that?”, and “what was I writing about her?”, asking “why I should come to see her when I had my own kids”, then when we were playing together she was not asking anymore...!

While the client is mainly displaying impulsive behaviours and doesn’t seem to be aware of his action; through the eyes, body responses and attention the therapist is giving him, the client can get new levels of perception of his own processes and get metacognitive abilities. Bion calls the role of the therapist “préoccupation” which helps bind the thoughts that can otherwise be quite dissociated in the patient. Through the resonance system that includes mirror neurons and other areas (insula for emotional and physiological resonance; temporo-superior areas for sensory integration of motor actions, Ramachandran) and gets stimulated in the observer's brain when there is a goal in the actor's actions, the child perceives that his behaviors have meaning in the care-giver’s representation. Little by little he integrates these intentions for himself. Anna had been asking for her life history where many parts remained unknown. When in role, she became the baby who decides to be born, she created through this process a new representation of the relationship between her inner child and inner mother. For the last sessions, inthe role of the therapist, Anna made were very conscious comments on what was happening . When the person starts becoming mindful and attuned to himself, therapy starts ending: “when you can make sense of your life story, you can change it (Siegel).

Anna who was going from one activity to another, or constantly changing the topic of her talk became conscious of her own process and remained longer on one subject. She could also start planifying actions she would play and create the fictional space: “I am doing as if...”This cognitive process is creating a distance between the impulse, the idea and the action, which is necessary for more symbolization and less acting out to occur. While her own self is growing, she is also differenciating with the other’s ideas, emotions and actions (Jung and process of indivuation of the self)). Landy talks about the aesthetic distance as one of the main therapeutic aspect in dramatherapy when one can create a “change in the relation between self and role and self and other”.; and integrate a social existence. In pretend play, what I do is temporary say, “I am going to be this superhero”, and to do role play, that requires a theory of mind, starting point for empathy (Ramachandran), but also for self-love. When Anna felt the therapeutic relationship was sure enough, the attachment could allow her to have enough trust to start taking care of herself and try new experiences in other places (the “real world”); I believe this is when she asked to stop coming . The therapeutic process for Anna may not be over and entering her teenage, she will experience many new relationships that will help go on building her self and identity. In the dramatherapeutic space where we met I feel it was not child therapy but a therapy for the inner mother-child relationship necessary to enter any further relationship. As for myself, I have to thank Anna for how she made me grow through this thin interplay where which both had our roles.

 

References.

 

Cozolino (2002). The neuroscience of psychotherapy: healing the social brain. Norton.

Jennings, S. (2011). Healthy attachment and neurodramatic play. J Kingsley

Lahad, M (2010). Protocol for treatment of post traumatic stress disorder: see far cbt model: beyond cognitive behavior therapy. Published in cooperation with NATO Public Diplomacy Division

Landy, R (1996). Persona and performance; the meaning of role in drama, therapy and everyday life. Guilford Press.

Ramachandran, V. (January 4^th, 2010). The neurons that shape civilization..TedTalks. (web communication)

Siegel, D. (2012). The developing mind: how relationships and the brain interact to shape who we are . Guilford Press.