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Winnicott's mindpsyche and its treatment

Winnicott's Mindpsyche
and Its Treatment
Joan Lavender
This paper presents Winnicott's concept of Mindpsyche and two clinical examples of how the concept is applied in two treatment modalities. First, a discussion among the members and leader of a dance therapy group is presented, in which participants attempt to understand why certain moments in the dance experience feel both frightening and exciting for them. They specify that these moments have to do with improvising in such a way as to generate a certain level of arousal which produces a momentary integration of feelings, thoughts and behavior, and with being seen at such moments. The author suggests that these experiences of embodiment suggest a solu· tion to the problem of Mindpsyche, which is a state in which the soma has been drawn into the mind, depriving the individual ofthe natural process of mutual interrelation between psyche and soma. Moments of embodiment can be perceived not only by the dancer, but 'by others who witness the dance. Yet it may be impossible to specify what is unique to the outward manifestations (the real actions) of these dances that demonstrates their embodiment. The fIrst ex.ample of embodiment is from Gendlin's Experiential Focusing. The dance ther-apist may be in a particularly advantageous position regarding work with problems of mindpsyche. In the second example, three moments of treatment are presented, in Which a bulimic patient who is "in her head" learns how to establish a mutual interrelation betweeIi certain movement cues and breathing to generate momentary states of em· bodiment. Joan lavender
oward the end of a session, the me~bers of the dance therapy group T reveal a secret. One says, "There is something terrifying about being seen (dancing) in this way. It's even worse than· .my regular (verbal) therapy session. rve never felt so exposed, but I don't want to stop." I inquire further, hoping to hear why the dancing is so scary, or why it is wonderful. The group is puzzled, even though even the most resistant member agrees that this mixture of terror and elation is what she feels too. Someone says, "It's something about being seen. You are watching me make dances and you delight in my attempts." Another member adds, "No, you don't love us for this, you laugh at us." The group agrees that it has something to do with being watched, and that it works best when they feel my concern and not criticism. They have established one aspect of the secret: it has something to do with being seen. ' They speculate further. It doesn't happen all the time, or in every dance. It only happens when the dancing comes from a certain level. What level? It comes when r notice my breathing and stay in touch with how my muscles feel. Finally, a member says quietly, "I know why this scares me. I think it's like being born. It feels like my mind is showing itself through my dances, and that is what you are seeing· .•• The group develops this theme, corroborating unknowingly with Win- One might ask what happens if the strain that is put on mental functioning organized in defense against a tantalizing early environ-ment is greater and greater? One would expect confusional states and (in the extreme) mental defect of the kind that is not dependent on brain-tissue deficiency. As a more common result of the lesser degrees of tantalizing infant care in the earliest stages we fmd mental functioning becoming a thing in itself . This is a most uncomfortable state of affairs, especially because the soma of the individual gets seduced away into this mind (and away from its natural relation with the soma. <Winnicott, 1958, p. 246). A member of the group stated, '1 never felt like my body belonged to me anyway . You can beat it up and it doesn't matter to me. The problem is that it's palpable. Now, my mind is something else. That's where r live. n The group members nod in unanimous agreement. People with severe eating disorders, self-mutilators and prone to accidents of all kinds, they frustrate staff with the tenaciousness of their se!fCbody-) destructiveness. They play with death. In this session, they are uneasy letting me know where they "live" because I will demand embodiment from them, and leave them no escape. r suggest that what these people are experiencing during their scariest moments in dance are momentary episodes of integration of psyche and soma, which Winnicott defined in the folloWing way: Winnicott's Mindpsyche
the imaginative elaboration of somatic parts, feelings and functions of physical aliveness . The psyche and soma mutual interrelation, and with an inside and an outside is felt by the individual to form the core for the imaginative self . the is not, however, felt by the individual to be localized in the brain, or indeed to be localized anywhere. <Winnicott, 1958, p. These moments of "embodiment" are indeed felt by each dancer creating a certain kind of dance; they are also witnessed by the rest of the group who are observing, not casually but intensely. The members of the group are often moved precisely by the same moments in .the dance that excite the dancer: and it is these moments about which the dancer has much to say. The talking is about something new that has occurred to the dancer while dancing, or it is about something already known that now What are the observable features of a dance that is "embodied"? How . can one determine that the dancer is indeed "behind" her dance? There is no way that I know to describe the particular qualities of such a dance. AB Winnicott said-it is not localizeable. However, it is possible to speak of a kind of balance or integration of various movement qualities that is so subtle, yet present. One dance therapist refers to the "implicate order" revealed in such dances. CR. Wiener, 1983, personal communica- tion.) This phenomenon has also been described as a kind of "tracking of experience" producing a result which is simultaneously unique and uni- versal. The particular movement qualities of the dancer are idiosyncratic, but the moments of balance and search for balance itself, Le. the dance, has the aesthetic appeal of an artistic experience. As far as the setting and the patient population, I am writing here from treatment experiences involving severely-personality-disordered individ- uals in a group therapy using dance movement as the modality of treat- ment. Mindpsyche is the problem. I start with dance because it precedes the verbal realm, thus simplifying the task of establishing integration between various domains of development. Movement integration (between various systems of outer behavior and psychic life) ~1l precede integration of movement with verbal life. In other words, meaningful movement The first clinical example is of an internal psychic movement process which can also serve to generate actual movement. I offer it to prepare the reader for the second clinical example, which has both an internal movement process and an externalized dance experience. Based on Eu- gene Gendlin's Experiential Focusing, this approach asks the patient to carefully choose words that fit the felt-meaning of his bodily experience. Although there are no gross body movements involved in this approach, Joan Lavender
there are significant shifts of breathing and posture that signify shifts in the inner process of the patient . ~ G. is a 30 year old man, severely-disturbed, depressed and pained- looking. Once able to attend a fme graduate school in English literature, he has spent the last few years unable to use his talents and requiring repeated hospitalization. Whatever the details of Go's past, one look at him and it is clear that he has undergone a loss of his sense of physicality and is in the grip of a mind gone desperate. His voice is flat,his chest concaved and inert-looking. He describes himself as a dead body, yet on the brink of desperation. G. says flatly that he is in a state of anguish, but is unable to relate this to inner or external events. This paradoxical presentation is quite unusual. The only liveliness in G.'s presentation is terse pulling action in his fingers, which he applies to the tuft of hair he is preparing to yank out of his scalp. G. does not appear to notice that he is tearing his hair out. Perhaps he is in a heightened state of mindpsyche where feelings are ~ought" but not felt . ' T: Can you go inside for a while, finding the place right underneath your breathing, where you feel your feelings? G: I don't feel anything . T: Ok. Is there a place where you don't feel the anything? G: . I think there is something . it's in my heart . yes, there is something in, near my heart . like rve been stabbed. An image goes with this . of a huge knife. (minutes pass, G. is breathing more easily and visibly now.) This heart needs comfort . (hesitating) I need comfort . the worst part of this is the feeling of not being able to communicate . T: How is it now? G: It's lighter in there now . some energy . but the stabbing is more intense at the same time. (He looks as ifhe will cry, does but he does not.) It feels like I should go on . but that is just what I always do. I always go on. Now I can feel this. My head is talking now, my mind is telling me to go on. I am always pushing my body against this mind. I didn't notice this before. My body wants to rest, then it will be able to go on . this is the piece I have missed . this "pushing against" feeling. rm tired now, but I feel eased up too. G. has been working this way for about ten minutes. The group has been watching him, and they seem to reflect the change in his manner throug4 their breathing and steady gaze. G. returns the following day cleanshaven, without pulling his hair, and says that he has less pressure in his head. He speaks about personal losses suffered during t'he last two years and wonders if he had not paid sufficient attention to his feelings about them. Maybe he never took the time to mourn. G.'s momentary experience of psychosomatic integration left its effect. It remained in an understated way over the next week, and was remem- The dance becomes the search for and evidence of a certain level of reciprocity between psyche and soma. By temporarily tuning out the complex channel of spoken language, which::carries within the capacity for double entendre and innuendo, the patient has" a Bimpler but still complex task. An automatic checking back process between external movement and sensation, cognition and affect forms itself into D;lovement patterns. The patterns relate to other patterns which have a felt-meaning for the dancer. A dancer without mindpsyche will not have',an internal bodily reference point with which to improvise. She will either not be able to move at all, will get stuck in stereotype and movement ruminations, or will complete a dance without any sense of ownership or satisfaction. Someone watching such a dance will have a similar sense of dissatisfaction or boredom. Kinaesthetic empathy will be not evoked, although SYmpathy for the detached dancer might be. Three Critical Incidents from the Case of"J.:
A Search for Mindpsyche
J. is diagnosed as having a borderline level of personality organization and a severe anorexia and bulimia. Once a child prodigy, she has not been able to work or to socialize for many years, having destroyed professional and personal relationships under the tyranny of her severe eating disorder. Her binges were daily, and included one incident in which she swallowed a metal spoon. J. is a small woman, thin but not emaciated, with a pallor and swollen glands from vomiting. Her face has a forced frozen smile that evokes a "mugging for the audience." J. is ingratiated and grandiose, mixing stories of her unusual childhood with confabulation. She complains of being misunderstood, and of not knowing what she feels. She is a liar. J. describes her problem as "trying to get my sense of who I am to come down from my mind into my body," J. offers to do the fIrst solo dance in a group, by improvising to the theme of "finding herself." Exhibiting none of the natural shyness often seen in solo work, she leaves the group behind and strides out in the dance space. She stands in the center of the floor. Her breath is held, her chest is puffed out and looks immobile. J. stretches her arms out to their fullest, and acts out the gesture of searching for an embrace. She fInds none, and •••••••• ~V' •••••• ' •••• ' ••• t"~f •• I •••
wraps her arms around herself in a hug. This dance is mimed. The group watches respectfully, but they are not moved~:They are learning to identify authenticity through their own responses: and J. is ~n need of some. One member asks her why she is looking "out there" to ·find herself "in here." J. is puzzled, caught off guard, and appears vulnerable. She had used the only way she knows to find approval-looking "out there." I ask J. to try again, in a brief improvisation. This time she will sit among us. There is no need to move away so soon or so far; her geographic separation from us is not accompanied by psychic individuation. I suggest that J. spend a full minute simply noticing her breathing and its movement. J. puffs herself up and forces a hollowing exhalation. She is afraid that her own respiration is not adequate, and that we, the audience, won't see anything happening. Even so, a feeling begins to form arpund her as she sits in stillness. She moves without the abrupt announcement offfnow I am going to start." Her transition into movement flows from breath and she follows this subtle change in her torso. She seems to fi,ll with substance. J. follows the line of gravity, and finds her head rolling down to the floor. Her grin has dissolved, revealing the face of a frightened child. J: I don't know what that was. I felt something in my arms and stomach. I wanted to roll more, with my head going all the way, but there was such pressure in my head. rve been lowering my head of a toilet bowl for so long now, I forgot to notice that moment . you have no idea what it is like, to spend your life with your head over the toilet. Group Member: I never saw you be so simple before. I feel like I J: (Confused but interested) What do you mean? What was different? (pausing, she checks her inner state.) I am so hungry now. I don't think In the following weeks, J. begins to identify a variety of mixed feeling states that are lodged psychically and somatically in her stomach. These feelings produce physical pain and a sense of starvation. Then, they become psychological hunger. J. lies curled up on the floor, crying that her anger is bigger than she is, and that she is too small and young to contain it. She curls herself near the other group members, and peeps out to watch them dance. She states that she is hungry, and her eyes are hungry to take in our bodies. She remains in contact with the reality of the sessions, and also takes these reactions J. has made a trial attempt to stop binging. She is growing long hair, has started to experiment with makeup, and has given up·tomboyish overalls. In dance sessions, she is often doubled over with emotion that registers as physical pain. She is finding that her eating disorder hurts, and she can feel it. J. insists on dancing in sessions despite the pain, and we discuss how much her body can sustain. During this phase she must dance a bit and then watch. She must take bite-size amounts, although her impulse is to gulp down the dance improvisation. In one session she pulls herself free from the group, and stands at the sidelines. She recalls having been a wallflower. She asks us to let her lead a group improvisation. She wants us to lift her. J. is pleased and embarrassed by this urg~. J. has become less verbose, more expressive and her dances are eloquent. Today is the last session offour months. Her dance is a mixture of sadness and pride. She is able to move from floor to leaping in the· air without losing a sense of physical transition. She is subtle in gesture, and her tension is modulated. The significant gesture occurs when J. begins to grab for her sinking sweatpants. Is this a little girl losing her pants, or a woman disrobing? J. is no longer cute. She is intrigued that her dance both contains and communicates her sense of female sexuality. She finishes the dance with a duet, dancing with another woman whom she has previously avoided. The dance partner is a remote woman, known for her sexiness. She starts to cry as J. displays her conflict of woman vs. child. J.'s body continued to feel more responsive, and her movement became truer to itself. One could say that she had developed a sense of integrity. This change affected every area of her life. She recognized hunger in her stomach, and began to modulate her need for real food. She differentiated real hunger from her legitimate need for human contact. She could sense when her movement was false, and felt more reliable. J.'s progress in the treatment of her problem with mindpsyche included the following achievements: 1. The establishment of an improved relationship between J. and her breathing process. I asked J. to keep her awareness partly on her breathing while she danced. Doing so produced associations. These related to her fear of breathing, and her belief that she could stop her own breath. Slowly, she had developed a psychological reliance on the continuity of that physical process. As she solved movement problems in order to improvise, she began to feel a sense of continuity throughout her life. Winnicott's Mindpsyche
2. Awareness of muscular sensations as distinct from inner organ perception. J. had identified her body's need for a c~rtain level of stimulation and rest. A co- mingling of breath and muscular awareness produced J.'s ability to sense 3. With the establishment of the above, J. began to feel safer. Memories and associations occurred during her dances. She could contain these and 4. The majority of interpretations made during J.'s dances were self- interpretations. These understandings remained with her, and seemed to have J. had the beginning of mindpsyche. Her particular movement attributes included the use of very large expanses of space around her body (she moved as if she were still large), many reaching gestures, and lots of leaping. These choices lend themselves to interpretation. But my point here is merely to say that they began to work in an adaptive integration for her. Careful attention paid to breath, muscle and inner state enabled J. to treat her mindpsyche, and a simpler verbal style ensued. I suggest that J. learned to soothe herself, and to simultaneously contain and express herself through movement precisely because she· worked directly with her body. In a sense, a moving body can be thought of as our original holding environment, in which the satisfactory and mutual interrelation of psyche and soma, under optimal circumstances, produces a sense of aliveness. When J. could develop this function, even in moments, the group could confirm her achievement through their sensitive observations. It is in this sense that I came to appreciate the group's secret, when they shared the excitement and terror of References
Gendlin. E. (1971) A Theory of Personality Change. In A. Mahrer and L. Pearson (Eds.) Creative Developments in Psychotherapy. Cleveland, London: Case Western Reserve. Gendlin. E. (1973) Experiential Phenomenology. In Phenomenology and the Social Sciences, M. Natanson. (Ed,) Evanston: Northwestern University Press. Lavender. J. (1983) "Stepping Out and Acting Up," unpublished manuscript. Weiner. H. (1983) personal communication . Winnicott. D. (1958) Mind and its Relation to the Psyche.Soma, in Collected Papers; Through Pediatrics to Psychoanalysis. London: Tavistock: New York: Basic Books.

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Psychological Medicine , 2001, 31 , 1331–1345. DOI : 10.1017\S0033291701004664 Printed in the United KingdomThe neuroendocrinology of chronic fatigue syndrome andA. J. R. P A R K E R , S. W E S S E L Y  A. J. CLEARE" From the Department of Psychological Medicine , Guy ’ s , King ’ s and St Thomas ’ School of Medicine and the Institute of Psychiatry , London ABSTR

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