Paper given to the Westminster Pastoral Foundation on 11th June 2011.
An extended version of this paper was published in 2004: Reference: ‘The capacity
for self-care’, International Journal of Infant Observation, 7.1: 108-125.
THE CAPACITY FOR SELF-CARE:
Maggie Turp
1. INTRODUCTION
This paper focuses on the first year of a long period of transition, stretching from the
physical dependence of early infancy to independent self-care in adult life. I shall
draw on infant observation extracts illuminate some of the ways in which a sense of
being deserving of care might be communicated by an infant’s primary carers and
internalised by an infant. The themes I will be highlighting include parental sensitivity
and respect, recognition of infant achievements and, on the part of the infant, early
intimations of concern for others. Klein’s concept of the prototypical good internal
object is identified as centrally relevant to self-worth and thus to self-care.
These matters are discussed with reference to the adequate or inadequate
development of a permeable and resilient psychic skin (Bick 1968). The concept of
‘narrative skin’ (Turp 2003) is introduced and discussed. (In the published paper, I
also draw on Winnicott’s writing on the establishment of ‘indwelling’ of the psyche in
the soma, but I am leaving that aside this morning). The paper includes a brief
discussion of connections between the establishment or non-establishment of a
capacity for self-care on the one hand and self-harming behaviour in later life on the
other.
The growth of psychoanalytic infant observation as a tool for teaching and, more
recently, as a research method (Reid 1997, M. J. Rustin 1997, 2001, S. Briggs 1997,
A. Briggs (ed) 2003) has gone hand in hand with an increased interest within
psychoanalysis in health and normal development. The subject of self-care, an
individual’s active concern for his or her physical safety, comfort and well-being, has
not often been directly addressed in the psychoanalytic literature. My starting point is
an assumption, one which I believe will be generally shared by the audience here,
that a capacity for self-care evolves in a context of object relations and that
internalisation of parental care plays an important part in the process.
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Rustin (2001) discusses our reliance in our thinking and our work on the concept of
internalisation and the absence, at the same time, of a clear and detailed picture of
what is actually involved. He suggests that one research potential of infant
observation is the possibility of shedding light on the specifics of the internalisation
process. This paper contributes to research in this area. Some of the elements
involved in one specific example of internalisation, the internalisation by the infant
‘Esther’ of particular aspects of the parental care she receives, come into view via the
presentation and discussion of the selected infant observation extracts.
2. PHYSICAL DEPENDENCY IN INFANCY
The first and most obvious statement to be made is that we are endowed at the
beginning with a very limited capacity for self-care. We have a will to survive and a
potential for self-care, but for some years we will be dependent on others for physical
as well as emotional care. At the beginning, this dependency is absolute. If we are
not fed, we will starve. If we are not cleaned and changed, we will lie in our urine and
faeces. If we are not wrapped and dressed, unwrapped and undressed, then we will
be too cold or too hot. If we are not watched over, then any accident may befall us,
since we are equipped neither to appreciate the difference between what is safe and
what is dangerous nor to take evasive action. We are dependent also on experiences
of responsive holding and handling, in the absence of which we are vulnerable to the
well-documented effects of touch deprivation (Spitz 1945, Hopkins 1990, Turp
1999b), including failure to thrive and, in extreme cases, failure to physically survive.
In the early weeks of life, our capacity to regulate levels of arousal, to soothe
ourselves when we need soothing and to enliven ourselves when we need to be
enlivened is very limited. Research has shown that premature infants are unable to
regulate their basic physiological functions, such as body temperature and heart rate.
A number of studies, including Field (1995) and Ludinton-Hoe, Nguyen, Swinth and
Satyshur (2000), have described the progress of premature infants who receive
'kangaroo care', spending their early weeks in almost continuous skin-to-skin contact
with the mother, living chest-to-chest inside her T-shirt instead of inside an incubator.
It has been found that the mother’s body temperature and heart-rate continually
adjusts in order to keep the infant’s temperature and heart-rate within the ideal range.
Full-term infants also benefit from maternal regulation of physiological functioning,
although they are obviously less dependent upon it than premature babies.
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(Pause here and talk about the contact from the medical anthropologist researching
self-neglect: grooming and social status in primates; involvement in ‘
Dirt’ exhibition.)
From this position of absolute dependency, most of us eventually achieve an
adequate level of self-care.
3. MATERNAL CARE, SELF-WORTH AND SELF-CARE
Object relations theory revolves around the interaction between infant desire and
phantasy, maternal response and the consequent shaping of the internal world of the
infant. An underlying and widely accepted premise is that internal objects colour our
every encounter with the external world. Good internal objects are the source of
resourcefulness, authenticity and self-worth. They underpin resilience in the face of
life’s challenges and the capacity to recover from life’s disappointments.
Klein described the good internal object as deriving on the one hand from the
nourishing and comforting qualities of the breast and on the other from the
contribution made by the infant’s own capacity for love and gratitude.
The establishment of the good internal object is immediately relevant to self-care, for
self-care must surely be grounded in a sense of self-worth, in the understanding,
conscious or unconscious, that one is deserving of care, that it is right that one
should be treated with proper care and respect. Many of us will have encountered
patients who have achieved a great deal in the external world but are nevertheless
plagued by feelings of worthlessness and inadequacy. While many factors, including
academic and work achievements, contribute to self-worth, the feeling that one is
deserving of care and should be treated well simply on the basis of being oneself
remains the most significant. The following observation extracts relate particularly to
the building of an internal object capable of generating and supporting self-care.
I first met the observed infant in question, ‘Esther’, a week after she entered the
world. She arrived via a planned Caesarean section, which took place five days
before her due date. When her mother, ‘Helen’, returned from hospital, I visited to
make my first observation and enquired about Helen’s health. ‘Oh, it’s a bit
uncomfortable’, she said, ‘but nothing compared to what you get’. She and her
husband Rob gazed lovingly down at Esther, asleep on her mother’s lap. To this
couple, as to many parents, their baby is a source of wonder, inherently loveable and
deserving of the best possible care.
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Parental sensitivity
From the start of life, Esther’s parents do their best to ‘read’ how she is and to
respond to her (imagined) internal state and to her preferences. In this way, they
indicate to Esther that she is deserving of their attention, interest, concern and
respect.
Observation at 3 months
Helen puts Esther is in her rocker chair and gives her a toy doll (‘Katy’). Esther cries.
‘Don’t you want to go in there?’ says Helen and lifts her out. They sit at the kitchen
table together and Helen makes Katy sing and dance.
Observation at 4 months
Rob is looking after Esther. She has just started eating solid food and he is about to
prepare her lunch. He tells me seriously ‘She likes a little pureed carrot and apple,
but she doesn’t like courgette’.
Observation at 7 months
Rob is telling me about last Friday when Esther ‘cried and cried’. He says ‘I wonder
what it’s like for her, not to be able to tell us what’s wrong’. He turns to Esther and
continues ‘You definitely had a pain, though, didn’t you? Maybe it was a sore throat?
You felt better when you’d had some Calpol, though, didn’t you?’.
Observation at 7 months
Esther is in the kitchen in her high chair. She is banging plastic cups together noisily,
then banging down on the tray of the chair so that the cups dance around and
eventually fall on the floor. When they have gone, she sits quietly for a minute then
rubs her right eye and begins to play with her left ear. Helen says to me ‘She’s tired.
She hasn’t had a sleep this morning’. She adds, ‘It’s funny. My Dad pulls his ears as
well when he’s tired’.
Because her needs are well intuited and responded to, Esther soon becomes adept
at indicating them more clearly.
Observation at 8 months
We are upstairs. Esther has been crawling around and playing happily but now each
book and toy is discarded after only a few seconds and her face wears an expression
of discontent. She points at her cot and says ‘Uh! Uh!’ Helen says ‘She does that
now when she’s tired’ then to Esther ‘You want to go for a little sleep, don’t you?’
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Observation at 8 months
Rob is looking after Esther. We are in the kitchen catching up on Esther’s progress
and drinking a cup of coffee. Esther is crawling around taking toys out of her big
basket near the window and playing with them. Suddenly she begins to cry. We look
towards her and Rob says ‘What happened? Did you bang your head?’ In response,
Esther crawls to window and mimes bumping her head on the window ledge. Then
she puts her hand to her head. Rob says to me, ‘Hey, look at that. She showed me
what happened’, and then to Esther ‘That was very clever, you know.’ He picks her
up and gives her head a rub and a kiss. Emma seems to forget the bump on her
head and perks up. She rubs her nose into Rob’s face in a cheeky kind of way and
smiles broadly.
Recognition of achievements
Like many parents, Helen and Rob take delight in their daughter’s achievements. For
the most part, these ‘achievements’ involve her simply being who she is and doing
the things she likes to do. We can see the process of internalisation taking place as
Esther’s facial expression and body language reflect the pleasure she takes in her
parents’ pleasure in her. She feels buoyed up by their responses, which are evidence
of their prizing of her. We can imagine that these experiences serve as a building
blocks for her sense of self-worth and thus for her future capacity for self-care.
Observation at 5 months
Esther is held by Helen with her legs astride, one each side of her thigh. She is
kicking her legs and waving her arms up and down. Helen rocks her from side to
side. ‘Are we going bicycling? Is it the Tour de France?’ Esther says Aah! Aah! with
great animation. Helen takes her over to the mirror. ‘Who’s that big girl? It’s a kicking
girl. Look at those strong kicking legs!’ Esther kicks and cycles some more, watching
herself in the mirror and panting a little.
Observation at 6 months
Rob is giving Esther her lunch. ‘Show Maggie how you can drink from your cup, even
though you’re very little.’ Esther clasps the cup with both hands and chews the spout
noisily, not in fact drinking. With the spout still in her mouth, Esther looks up at Rob in
a questioning way. He responds with a smile and a proud expression.
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Observation at 13 months
Esther is sitting on the floor playing with a soft toy lion. Rob says. ‘It’s really exciting,
you know. She can walk!’ He turns to Esther. ‘Let’s show Maggie your walking skills.’
He picks her up and sets her on her feet about a metre away from him. ‘Walk to
Daddy’. Esther looks across at me and gives a shy smile, then takes two steps to
Rob, who scoops her up. She points to her dog-on-wheels and shouts. Rob gets it for
her and she walks up and down the kitchen with great elan, pushing the dog by the
handle. Each time she passes me, she turns and gives me a huge self-satisfied
smile, looking thoroughly pleased with herself.
Concern for others
Where self-worth develops in a satisfactory manner, we may expect to begin to see
the concerned and respectful behaviour towards others that is also evidence of the
establishment of a good internal object and an associated capacity for gratitude and
generosity (Klein 1957).
The following observation speaks of the role of good care, including the infant’s
gratitude in relation to that care, in the establishment of a good internal object and
hence in the shaping of relationships with others. As Esther learns to talk, her selfconfidence grows. She is a sociable and chatty toddler who knows that she will be
listened to and that what she has to say will be received, considered and responded
to with due care and attention. By the age of 18 months, she is showing considerable
evidence of an internal resource that finds expression in a generosity towards others
and a genuine concern for their pleasure, comfort and well-being.
Observation at 22 months
The family has visitors. Esther is keen to see everybody seated and says to me in a
solicitous tone, patting a particular chair, ‘Maggie, You sit here’. Rob says ‘Where
shall I sit, Esther?’ ‘Here’ she says, pointing to another chair. Esther brings me a
crisp, then a biscuit then takes these items around to other people, saying in a
questioning voice ‘You like a crisp?’ ‘You like a biscuit?’
4. BODILY INTEGRITY AND PSYCHIC SKIN
One area of post-Kleinian theory, which is probably familiar to you, revolves around
the nature and function of skin, both physical and metaphorical. Psychoanalytic
literature in this area, including seminal contributions from Bick (1968) and Anzieu
(1989), is extensive and relatively well known. A theme that runs through much of the
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work is the role of the psychic skin in mediating the relationship between inner and
outer worlds.
According to Bick’s account, repeated failures of maternal care force an infant into
excessive reliance on inanimate objects for a sense of being held together and this in
turn leads to a distortion of psychic skin functioning. Such distortion is described by
Bick in terms of a toughened ‘second skin’ formation. This ‘rhinoceros hide’ protects
the infant against the threat of disintegration but impairs his capacity for relationship.
Some examples of self-harm encountered in clinical work, particularly those involving
attacks on an already scarred skin through cutting, burning or bruising, often in
conjunction with a tough and confrontational self-presentation, seem to exemplify this
state of affairs. Inadequate psychic skin functioning may also emerge in the form of
avoidance of relating or in ‘adhesive’ relating (Meltzer 1974). Stephen Briggs (1997)
has developed Bick’s work, exploring the complementary possibility of ‘porous’ skin,
skin that is slack and not fit for purpose, skin that is, metaphorically speaking, falling
into holes. This situation can find expression in a number of ways, including
psychosomatic illness, unadventurousness and an air of drifting and incomplete
presence.
I have come to believe that porous skin phenomena connect to a different kind of
self-harm, which I have called ‘self-harm by omission’ (Turp 2003). Self-harm by
omission is exemplified by behaviour involving significant injury or damage to health
which arises from lapses in self-care rather than from acts of self-directed violence.
Examples include self-inflicted sleep deprivation or poor nutrition, failure to seek
necessary medical attention, continuing overwork in the face of illness or disturbing
symptoms and accidental injury arising from states of distraction and inattention.
(Pause – I’m sure you must come across examples of this kind, where people don’t
directly self-harm but put themselves in the way of harm. Sexual risk-taking is
another common example).
In my experience, self-harm of all kinds is often associated with a sense of extreme
internal chaos and fragmentation. ‘Toughened skin’ and ‘porous skin’ are relevant
concepts here, since it is the skin, both literal and metaphorical, that holds the
individual together and safeguards coherence. A well-functioning psychic skin
militates against chaos, against the spilling out of what belongs inside (for example
blood) and the taking in of what belongs outside (for example poisonous
substances).
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The following observations of Esther testify to her fascination with her own skin and
the skin of others and perhaps an emergent sense of what it means to be embodied
within a skin.
Touching and being touched
From the start, Esther is carried a great deal, especially by her mother. Usually Helen
comes to the door when I arrive with Esther on her hip or shoulder. When she is
picked up, put down and has her nappy changed, I am aware of a respect for her as
a whole person who deserves to be treated with care and consideration. This respect
is characteristic of both parents in their interactions with Esther. The following
sequence of observations shows Esther beginning to learn about touching other
people (and cats) with care, that is without hurting them.
Observation at 4 months
Helen comes to the door carrying Esther. She says ‘Look. It’s Maggie’. Esther gazes
at me long and hard. Then she turns back to Helen and very gently fingers her face
and neck. She catches a strand of Helen’s hair and holds on to it. ‘I hope you’re not
going to pull that hair hard’ says Helen, half-joking.
The builder arrives and Helen stays at the front door, talking to him and to Esther.
Helen needs to select a new front door and we go out into the street to look at other
people’s front doors. ‘Yes, I think that’s the door we want, isn’t it Mouse?’, says
Helen. Esther holds on to the strand of hair, not pulling it, her face calm and alert.
Observation at 5 months
The builder is again in residence and Helen is carrying Esther so that Esther looks
out over her shoulder. She takes a strand of Helen’s hair, fingers it and pulls it gently.
She lets go and takes hold of Helen’s hand and tries to put it in her mouth, sucking
noisily on her knuckles. Then she does the same with Helen’s cheek, opening her
mouth wide but not hurting or biting. Helen says ‘That is a big kiss!’.
Observation at 7 months
Rob is carrying Esther. He speaks to me and, as he does so, Esther fingers his chin
gently. The cat comes into the kitchen. Esther spots it immediately, makes small
excited sounds and reaches her hands out towards it. Rob holds her where she can
touch the cat and she takes hold of its tail. ‘Gently’ says Rob and Esther is quite
gentle but nevertheless attempts to put the cat’s tail in her mouth. ‘No, not in the
mouth’ says Rob. The cat escapes and runs out of the room.
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Physical enjoyment and physical hazards
The mother’s capacity to respond to her baby’s experience seems to be felt
by the baby at first as a gathering together of his bodily sensations,
engendering the beginnings of a sense of bodily integrity (Shuttleworth in ed.
Miller et al. 1999: 32)
We experience ourselves in health as both the skin and as that which is contained
within the skin, moving flexibly between these two modes of awareness.
Returning to Esther, I notice that over time, as she is repeatedly ‘gathered together’
by her parents, her movements become smoother and better co-ordinated and that
they span a full range, from energetic and exuberant to finely tuned and painstaking.
Most of all, she looks increasingly ‘all of a piece’ or in the French phrase ‘bien dans
sa peau’ – ‘at home in her skin’. One reflection of a what Winnicott calls a good
quality of ‘indwelling’ of the psyche in the soma is the active enjoyment of physical
self-expression:
In health, the use of the body and all its functions is one of the enjoyable
things, and this applies especially to children and to adolescence (Winnicott
1986: 29)
Such enjoyment is readily observable in Esther’s vigorous kicking as a small infant. It
develops further as she extends her range of motor skills to include sitting, crawling
and walking. As with all infants, the possibility of accidental injury increases once she
becomes mobile. When Esther starts to crawl, I notice that her parents are very
protective towards her. I often see one of them insert a hand between her vulnerable
head and the wooden leg of the kitchen table that she might otherwise bump into. As
she gains confidence, Esther expresses her determination to be allowed to
experiment. Her enthusiasm for using her new skills outpaces her competence but
she remains undaunted. Soon she is running with gay abandon up and down the hall,
clearly in a high mood and omnipotent state of mind.
Observation at 16 months
We are in the kitchen. Rob pulls out Esther’s big ‘dog on wheels’ that she can pull
around by the handle. She pulls it up and down the kitchen with great enthusiasm,
emitting high squeaking sounds and occasionally looking over at me to see if I am
watching. She is absolutely pleased with herself and ‘full of herself’. Rob says. She’s
running now and it gets scary. She’s had some real spills. Last week she surfed
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down the stairs on a suitcase by accident. And last Sunday when we were walking in
the cemetery, she ran and ran and then of course she fell and grazed her knee.
His voice suggests that he is partly anxious and partly admiring of his plucky and
adventurous daughter. The need to manage a tendency towards recklessness and/or
a tendency towards timidity and excessive caution is an aspect of self-care that will
be a lifelong concern. It is one of the things that Esther, as yet, has little capacity to
manage for herself. Instead, it is manifested here in the Rob and Helen’s efforts to
ensure their daughter’s safety and at the same time to respect and support her
healthy sense of adventure.
5. IMPINGEMENTS AND NARRATIVES OF CONTINUITY
A major area of concern in Winnicott’s work is the preservation of ‘going-on-being’,
dependent from the outset on maternal protection from ‘impingements’. He writes:
In the ordinary course of events the mother tries not to introduce
complications beyond those which the infant can understand and allow for; in
particular she tries to insulate her baby from coincidences and from other
phenomena that must be beyond the infant's ability to comprehend (Winnicott
1949:245).
If the infant is properly protected early on, he will gradually learn to manage
impingements. However, if impingements come too early or are too intense, they are
traumatic for the infant and he can do nothing but react. The experiences do not
become thinkable. Reactive responses to impingements over a period of time cause
damage to the personality and result in fragmentation.
Management of a potential impingement
The following observation shows a potential impingement being managed in a way
that protects the infant’s experience of going-on-being.
Observation of Esther at 7 months
When I arrive, Helen tells me ‘I’m going to wake her up. She’s been asleep too long.
She’s been sleeping so badly at night ever since she had that cold. (Looks at me and
laughs) She’s had to come back into the big bed!’
We go upstairs and I see that Esther is fast asleep on her back in her cot with a
cover over her. Helen gently removes the cover and begins to stroke Esther’s
forehead. ‘Are you going to wake up?’ After a minute or two, Esther stretches,
extending her left leg and pointing the toe. She opens her eyes, sees Helen and
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smiles. She turns her head and spots me and gives me a long serious gaze. Then
she looks back at Helen and smiles again and begins to coo gently.
Helen speaks in a slightly more animated way. ‘You had a croissant for breakfast and
then a long, long sleep. It’s not a bad life, is it? Are you ready to wake up now?’
Esther smiles more widely and kicks her legs. Helen laughs and gives Esther a little
tickle in the chest. Esther becomes more enlivened and drums her legs up and down
on the cot. ‘Do those legs still work?’, says Helen. ‘Yes!! They work very well’.
Esther becomes still again and Helen passes her a knitted rabbit. Esther puts its leg
in her mouth and chews with an expression of great thoughtfulness. Rob comes in
and says ‘Are you chewing Minty’s foot?’ Looking at Rob, Esther becomes very
animated and kicks and drums her legs vigorously on the mattress. Helen and Rob
both laugh. Helen says ‘Do you get very far on that bicycle? How fast can that baby
go?’
Now Esther is fully awake. She reaches her arms out to Helen, who picks her up out
of the cot.
Esther is disturbed from her sleep in a very gentle way and allowed to wake up
gradually, at her own pace. Her parents respond to the ebb and flow of her energy
and activity, closely matching their own level of liveliness to that of their daughter.
Their sensitivity and respect for Esther’s timing ensure that a potential impingement –
being forcibly woken from a sleep – does not become an actual impingement.
One of the elements involved is the maternal provision of a ‘narrative of continuity’,
which links various parts of the day, in particular providing a bridge from the time
before the sleep to the time after the sleep. My experience as an observer and infant
observation seminar leader suggests that such narratives of continuity are a
ubiquitous feature of ‘good enough’ maternal provision. Mothers very frequently
describe to their infants (who are far too young to understand the content of what is
being said) what has happened, what is happening and what is going to happen
later.
6. NARRATIVE SKIN
I have wondered whether it would be helpful to view the subjective experience of
continuity of self - ‘going-on-being’ - as an additional psychic skin phenomenon, one
involving a significant temporal element. We know that going-on-being depends at
the start on regular and reliable protection from impingements, characteristic of the
phase of primary maternal pre-occupation (Winnicott 1956). Part of that provision is
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what we might think of as a maternally created ‘narrative skin’, a narrative of
continuity that protects and sustains a felt continuity of experience and helps to
ensure going-on-being from birth onwards.
Holding-in mind and maternal support for an evolving psychic skin, through physical
touch and narratives of continuity are, in my view, the warp and weft of skin
containment.
With regard to Esther, my general feeling during the observation is that, although
there are the inevitable disruptions that affect every family, these are kept within
tolerable limits. Rob and Helen manage on the whole to conserve the orderly and
familiar rituals of the day. From very early on, sequences of events are accompanied
and supported by verbal narratives. In the extract presented above, Helen offers
Esther a ‘news update’ on the day so far, including a summary of events yet to come.
Her narrative speaks of an unconscious recognition of the importance of conveying a
sense of continuity and of an orderly sequence of events. ‘You had a croissant for
breakfast and then a long, long sleep. It’s not a bad life, is it? Are you ready to wake
up now?’ Sorensen refers to this type of narrative as ‘a linguistic mode relative to the
sequence of events’ (2000: 49). The less technical phrase ‘narrative skin’ seems to
me to convey the sense of what is meant in a straightforward manner.
The final observation extract shows Rob ‘pacing’ actions and narrating them,
organising them in a time sequence, as he changes Esther’s nappy.
Observation at 3 months
Rob takes Esther upstairs to change her nappy and I follow behind. He lays her down
on the changing mat very carefully, talking to her as he does so. ‘That’s a bit cold,
isn’t it? Is it OK for you?’ He takes off her fabric shoes. Esther lies with her hand half
in her mouth and gurgles at Rob. She reaches with her other hand to take hold of
one the shoes lying next to her, brings it to her mouth and chews it. Rob talks her
through the nappy change, ‘Trousers off. One leg. Two legs. Now comes the
nappy...’. Esther is very relaxed and co-operative.
Rob picks Esther up when he has finished and walks around with her. She sits in the
crook of his arm, looks over at me and smiles perkily.
The overall feeling of this observation is that great care is being taken to ensure that
Esther’s continuity of going-on-being is not unduly disturbed. In respecting Esther’s
right not to be unduly disrupted, her parents lay the foundations for adult self-care
that includes the capacity for ‘Saying No’ (Phillips 1999) to demands that are
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excessive or that require the sudden and unreasonable interruption of the activity in
which the individual is already engaged. Through maintaining appropriate
sequencing and pacing of events, accompanied by a narrative of continuity, parents
offer their children opportunities to develop an internal resource, a capacity to
conserve order, including an orderly sense of time and time boundaries. Esther’s
valuing of order is increasingly in evidence as the observation proceeds, for example
in the observation presented earlier where she enjoys organising who is sitting where
at the table.
The contribution made by narrative skin functioning to self-care is particularly evident
when such functioning is not available, as if often the case with patients who harm
themselves, whether actively or by omission. These patients usually describe a
history involving considerable disruption. In extreme cases, they may refer to periods
spent in care and numerous moves from one foster parent or children’s home to
another. Their self-descriptions reveal them as individuals pulled hither and thither by
both external and internal pressures. They jump to respond to demands that seem to
the practitioner excessive and untimely and their life lacks order and coherence.
These external indicators of chaos seem to match and express the chaos that reigns
in the internal world.
Many practitioners will have encountered situations where this dynamic is re-staged
in the transference-countertransference, with the patient attending spasmodically and
the practitioner finding herself invaded by experiences of disruption and confusion. At
such times, it may be helpful to bear in mind the possibility that such difficulties have
their origins in distortions of skin functioning and especially of narrative skin
functioning. Sometimes I have found it necessary to focus on providing a narrative
skin in the early stages of the work, by helping the patient to put events into some
kind of order and describe them coherently. Although splitting and projective
identification are fully in evidence, interpretations cannot find a resting place within
the internal world of the patient and be made use of while the skin container is
hopelessly leaky. When the work progresses well, the internalisation of the
practitioner’s care, including her reliability and ability to provide a thread of continuity,
will be reflected in the patient’s improved time management and regular attendance
for sessions. At this point, one can begin to feel more hopeful about the patient’s
eventual capacity to engage in interpretive work.
Later developments then testify to a developing capacity for self-care, for example a
patient who has not gone away on holiday for over 7 years plans to do so; a patient
who has been very driven by work and putting in an excessive number of hours, to
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the detriment of his health, finds a better way of managing his workload. Sometimes
these low-key improvements in a capacity for self-care predate the disappearance of
the primary self-harming symptom. I have learned from experience that noting them,
explicitly acknowledging them for what they are – improvements in a capacity for selfcare – is fruitful and motivating for both patient and psychotherapist.
Maggie Turp, June 2011
maggieturp@googlemail.com
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