ZERO TO THREE Corner
To fully grieve a parent’s death, a young child needs to come to terms internally with the loss. In this article (Zero to Three, Vol.31, No.6), the author describes this process in a toddler whose mother committed suicide. In therapy, the child formed a relationship with a stone statue and communicated her need to be found and protected. Drawing on the notion of “potential space,” an intermediate area of experiencing between reality and fantasy, the article underscores how creating potential space in therapy can help a young child tap into a wellspring of imagination and subjectivity where personal meanings about loss can be explored in ways that are uniquely helpful to the child.
Stewart and Virginia came to the clinic in late February. Snow still lay on the grounds outside of the clinic. Exhausted and cold, Stewart hung up his winter jacket before sinking into a chair in the therapy room. I knew something from the intake notes about why Stewart had come. The notes mentioned that Stewart was anxious. He was seeing a therapist to help him, but needed help with Virginia, his 2½-yearold daughter. The intake worker wrote down the following words to describe the problems: temper tantrums, screaming fits, and fears of separation. Virginia also stared into space. She often did not want to hear what was being said.
Stewart, age 30, told me that he knew anxiety all too well. It paralyzed him. He felt it when he woke up, when he left for his part-time job, when he dropped Virginia off at preschool, when he tried to fall asleep at night. It rarely left, dwelling in his stomach, his bones, his very movements. Stewart revealed that he experienced his first symptoms of anxiety when he was a teenager, right after his father passed away. At that time, his symptoms were so severe that he developed panic attacks, attacks during which he felt he couldn’t breathe or move. At that time, his anxiety was paralyzing, so paralyzing that he struggled to finish high school. Stewart was helped by a psychiatrist, but continued to have anxiety in the ensuing years. Stewart also talked about his wife, Anna. He had met her 4 years prior in the library. They dated and married about a year later.
Parental mental illness
“Anna had bipolar mood disorder,” Stewart noted a bit later. This is a mental illness characterized by bouts of depression and mania. When she was depressed, Anna was despondent, indecisive, and slept for long periods of time. When manic, she talked incessantly, her thoughts raced and became grandiose. At times she showed rapid cycling, going from depression to mania in short periods of time. The mood swings worsened after Virginia was born.
The story continued in starts and stops. Stewart didn’t understand why Anna refused to hold Virginia after they returned home from the hospital. One day she said she “couldn’t stand all the fussing” but on other days Anna didn’t hear Virginia’s cries. Stewart became alarmed and contacted mental health professionals when Anna typed strange notes on the computer talking about how her baby was gone. Anna refused medication, he said, claiming that it was poison. Remembering those days, Stewart also recalled that he couldn’t reach Anna. Nothing was right.
Stewart took Anna to an inpatient psychiatric unit where she stayed for 2 weeks. There he learned that she had postpartum psychosis, a condition that begins abruptly, usually 3 to 14 days after giving birth (Attia, Downey, & Oberman, 1999). Women with postpartum psychosis evidence severe and often dramatic symptoms, including insomnia, hallucinations, delirium, and confusion (Attia, et al.). Postpartum psychosis is a rare condition that affects 0.1 to 0.2% of all women experiencing childbirth, and women with bipolar disorder are at higher risk than women without a psychiatric disorder for developing it(Altshuler & Kiriakos, 2006).
On the unit, Anna was treated with antipsychotic medication. In the meantime, Stewart became Virginia’s caretaker. He learned how to prepare bottles and to change Virginia’s diaper. He began to swaddle and rock Virginia when she cried. He cared for Anna too when she returned home from the hospital. Over time and with antipsychotic medication, Anna seemed to improve, but Stewart remained anxious. “I took care of Virginia as much as I could,” he told me. “But I was working too so I couldn’t always be there.” One day Stewart found that Anna had tossed her medication away. In the next weeks, Stewart noted that often Virginia was hungry or her diapers had not been changed when he came home.
Stewart’s voice grew strained as he told me about a painful memory. One day, shortly after Virginia’s first birthday, he trusted Anna to take Virginia for a walk. Later that day, the police came to the house. He learned that Anna was holding Virginia in her arms as she tried to run in front of a passing car. A man grabbed Anna, holding her and the child and saving both. I asked Stewart where Anna was now. Stewart paused for awhile. He then said she was gone. I asked if he could tell me more. “Soon after,” Stewart said, “Anna committed suicide.”
Coping with loss
Stewart told me that he had been seeing a therapist to better cope both with his loss and his own anxiety. I learned too that Virginia knew very little about her mother’s death. Stewart didn’t think she could handle or even understand what had happened. “She’s too little, too fragile,” he insisted. Stewart shared other worries: he had met someone new. He wanted to start a new relationship with. Janet. “I don’t think Virginia wants me to see her,” he added, “she says she has her own mom, even though I never talk about her.” Stewart did want help with Virginia and, for this reason, he had sought me out.
When I observed Stewart and Virginia together, strengths were also evident: Stewart had cared for Virginia since birth and the two could show genuine pleasure when they played with each other. Virginia herself was curious and articulate. A bundle of contradictions, she was also petulant, fragile, easily frustrated, and had a strong need to control. If Stewart didn’t go along with her wishes, Virginia would tell him to “go away.”
As I showed Stewart and Virginia the way to the bus stop, we walked through an inner courtyard in the back of the clinic, passing by a stone statue of a woman that stood half hidden by a copse of trees. With one arm, the woman fought off a dragon; in her other arm she held her baby up high to protect it from harm. Virginia stopped as we passed. I can still see her now—a darkheaded child looking with intent interest at the statue. It was only after Stewart called her name that Virginia came out of her daze.
Where to begin?
As I jotted down notes from my initial assessment, I began to synthesize in my mind what I knew about the family. This helped me to formulate steps that could be taken in therapy to promote healing. Throughout my account, I have modified details to protect confidentiality.
Two themes stood out in my notes: mental illness and suicide. Neither had been talked about or shared. Stewart and Anna both had a mental illness. Stewart was in treatment and therapy. Anna had received treatment, but had stopped. Her illness was also chronic and severe. These illnesses affected both Stewart and Virginia and their relationship. Stewart worried constantly that Virginia would develop bipolar disorder like her mother. His concerns about this made it hard for him to set healthy boundaries that might make Virginia feel safe. He caved in easily to her outbursts and let her make many decisions on her own. Anna’s mental illness had also greatly affected how Virginia was cared for in her first year of life. Anna’s illness had made it hard for her to recognize and meet Virginia’s needs. On many occasions she had not responded to Virginia’s cries. Virginia had likely experienced many lapses in caregiving. At one point, Anna had tried to kill both herself and Virginia.
Loss was another prominent theme. Anna was gone. She had taken her own life when she was severely depressed. Although Virginia was young when her mother died, Anna was still immensely important to her. For instance, when Stewart mentioned Anna’s name, Virginia became all eyes and ears, clinging to any words that her father might mention. Virginia was also terrified of separations, something that was likely linked to her mother’s death. Stewart too had been devastated by Anna’s suicide.
Approach to therapy
How did I approach therapy? I started by laying the foundations for a relationship of trust to develop: I listened, supported, and tried to give Stewart and Virginia the safety to marshal their energies to articulate, express, and actively make sense of what happened. The format was flexible. Stewart and Virginia saw me separately, but we also had joint sessions (Lieberman, Compton, Van Horn, & Ghosh Ippen, 2003). When the two were together, I helped to bolster their own relationship and to further a sense of security in each other’s presence. A secure attachment relationship to a parent is a powerful and positive force in a child’s development (Bowlby, 1988). In a secure relationship, a parent helps a child to tolerate and make sense of painful situations and to feel confident and safe in exploring the world. I reasoned that furthering a sense of security in the relationship between the two was Virginia’s best hope for long-term mental health.
Bolstering security comes about in many ways: through reassurances to a parent that they can give a child the love and support they need, through a parent’s reassurances to a child that the child is loved, by a parent providing open, honest communication about experiences, including death. I reasoned that Stewart was the person best able to reassure Virginia that he was there. He was also the person best able to help Virginia understand what had happened. He needed to tell her more about her mother and why she had left. He needed to tell her about her mother’s mental illness. Virginia also needed the space and freedom to ask her own questions and she needed time to take in information in. Virginia was a toddler, however. How much could she understand loss or mental illness? How much did she even remember her mother?
To talk with Virginia about her mother, I reasoned that Stewart needed to feel comfortable himself about what he was going to tell Virginia. He also needed to tailor what he said so that she could understand. Stewart also needed help in how he told Virginia about Anna. Children listen both to the content of a message and to its emotional tone, how it is said. Stewart needed to talk with Virginia in a way that led to understanding, not to more anxiety, avoidance, or fear.
We talked about mental illness and parenting. In this context, Stewart shared his fear that Virginia would develop bipolar mood disorder. Parenting is an important life role, including for individuals with mental illness (Apfel & Handel, 1993). Stewart came to learn that when mental illness is treated and monitored, it does not necessarily need to eclipse good enough parenting (Goepfert, Webster, & Seeman, 2004). We also talked about how parenting can be supported for an individual with mental illness who is struggling to raise young children (Henry & Nicholson, 2005). These discussions alleviated some of Stewart’s worries.There are many barometers of progress in therapy. Some indicators are unexpected and surprising as it was with Virginia. Her behavior with the statue, as described in the next section, became my barometer for change.
What was therapy like?
Whether Stewart and Virginia invested trust in me would depend on them, I knew, but also on me: whether I could be perceived as available and responsive; whether they felt that they could share with me through words or play what they were feeling inside; whether they felt that I could tolerate and understand what they shared.
Relief that the truth could be spoken
A first priority was to understand more about Anna, Virginia’s mother. I knew little about why Stewart kept information about Anna and her abandonment from Virginia. In the next sessions I therefore worked alone with Stewart. Together, we explored together how Stewart met Anna, what he had felt about her, their decision to have Virginia, the times she was hospitalized, and when she left.
It soon became clear that Stewart had done much grieving work already in individual therapy. But he had never talked with Virginia about the loss so I asked him why. Stewart said he felt he should have kept Virginia safe. He also worried about how Virginia would take the information: what she didn’t know wouldn’t hurt her.
Talking with Stewart directly about Anna’s death helped built trust. He felt relieved that the truth could be spoken and shared. I understood too why Stewart had not told Virginia about Anna: He wanted to protect her from devastating information. But in so doing he had also cut off the possibility for Virginia to heal.
I had a dual message in mind when I spoke. I conveyed genuine understanding for his decision to remain silent. However, I also considered the potential damage that the silence was inflicting on her and on their relationship. She trusted him. She believed in what he told her. What if she heard from someone else?
“Can she remember?” was an early query of Stewart’s. “Can she understand death, let alone suicide?” What he said was true. Virginia was very young when Anna died. She was still very young. Yet, Anna was Virginia’s mother and even very young children can remember experiences long before they learn to speak (Lieberman et al., 2003). I spoke about the intense interest that Virginia had shown when Stewart mentioned Anna’s name. I explained that if children are not given the facts about death, they may persist in believing that the parent will return. The best reason I understood for sharing had to do with trust. If their relationship was to be viable, it had to be built on being accountable. Virginia had to know that Stewart would tell her what happened. She needed to experience that he could tolerate the pain of loss and help Virginia tolerate it too.
Over time, Stewart came to see that talking made sense. We agreed that it was best to give Virginia a simple explanation of what had happened: He would say to Virginia that he had something to tell her that was sad. She had a mother. Her name was Anna. She wasn’t with them any more. She had died. She died because she had an illness of the mind. He wanted Virginia to know that Anna had loved Virginia. Stewart also wanted to reassure Virginia that he loved her and was there for her. He did not go into the exact details of Anna’s suicide or her attempt to kill them both. With time, he would fill in these gaps too.
The larger message was conveyed over many sessions, often in small bits and parts, allowing Virginia space to absorb what he said. When Stewart first broke the ice, the emotions in the room were intense. “Do you remember your mother, Virginia? You had a mommy once. Her name was Anna.”
Virginia stared at Stewart with seriousness and intent beyond her age. “Anna’s my Mommy,” she said. Stewart told her more. He told her that Anna was gone and would never come back. She had died. Virginia looked at Stewart for a long time before saying “I know.” He told her that he wanted to tell her other things too. Some of the things he wanted to say were sad. Virginia said “OK,” but then abruptly turned to play.
In other sessions, Stewart shared more about Anna. He brought in photos of Anna and showed them to Virginia. He told Virginia that Anna was sick in her mind and that she had hurt herself. He told Virginia that she had not made her mother go. Later, he told Virginia that her mother was buried and that she would never return. In the sessions, Stewart gave Virginia space to process what he had said. He answered her questions and listened, giving Virginia time to take in what he said in her own way. He also assured her that he was there for her. He was her parent. He loved her, was accountable, and would stay with her. He would be available to answer questions that she might ask.
Close your eyes and count to ten
The stone statue stood in the clinic courtyard, half-hidden in the shadow of the clinic and surrounding trees. Sculpted in the 1930s by Edouard and Olga Chassaing, the statue was created to symbolize “the powerful figure of Medicine clutching the infant Humanity high on her right shoulder while calmly but strenuously warding of the Dragon of Disease with her taut left arm” (Scheinman, 1995, p. 155). Each week, Virginia asked to see the lifesized statue of the woman safely holding her baby to keep it from the dragon. We went outside and she stood there, lost in thought, mesmerized for a short period of time. Then she ran off and hid. I was the finder, but also the one left behind, the abandoned one.
This is what a typical session was like: Virginia asks me to stay near a bench and “not” to watch. She runs. I count to 10. I search for her near bushes, behind the statue, calling her name. She is delighted. She grows flustered and angry if I don’t find her soon enough. She perceives my difficulties in finding her as painful misattunements. In describing the urgency of Virginia’s hide and seek games, words from Tom Waits song, Georgia Lee, come to mind:
Close your eyes and count to ten, I will go and hide but then
Be sure to find me, I want you to find me
And we’ll play all over, we’ll play all over, we’ll play all over again.
What Virginia might have been communicating dawned on me first slowly, then more forcibly: Would she be protected? Did someone care enough to find her? Was her mother gone? Could she be found?
With time, Virginia’s hide-and-seek game included the statue. She hid near the statue, as if seeking safety in its shadow. Sometimes the game of hide-and-seek stopped as she stood to look at the statue or to touch the woman’s hand. At times she placed small piles of stones, acorns, or leaves near the statue, often humming as she did. Sometimes she ran up and touched the dragon’s face. In her games, Virginia expressed longings for her mother. In her mind, the statue who was not her mother became her mother, a safe and protecting mother.
Later on, she began to share fragmented pieces of herself through questions that were laden with meaning. She asked questions about the woman, the child, the dragon. She asked whether mothers love children and why they go away. She also asked about graves. Fathers, at first almost absent in her stories, became more prominent in her storytelling.
One day Virginia found a purple coneflower. She plucked it and asked me to wait. I saw her slight figure running to the statue. She placed the flower at the woman’s feet. She looked at the woman for a long time before skipping back to me.
Virginia and Stewart came to therapy for 9 months. We finished in November, when leaves were still changing colors. There were strong indications that both were moving on. Stewart was dating Janet. Virginia too was changing in subtle, but significant ways. She was less clingy, more able to laugh, less prone to go into dazes, more herself.
A parent protects a child in many ways, by words, by holding the child, by thinking of the child, and by being attuned to a child’s feeling states (Bowlby, 1988). I tried to hold Virginia in mind when we told stories about the statue. I held her hand too when we returned to the clinic. Stewart held her in his arms during some sessions and he learned to hold her with words. He told her the truth about her mother. He told her that Anna had loved her. He told her that Anna had a mental illness. He told her that Anna was now dead. He told her Anna would never return. He also told Virginia that he loved her and was there for her. The words became a powerful bond. They helped Virginia to grasp and tolerate what had happened with Anna. They helped her to trust that she could believe in what her father said, that he could tolerate pain and help her to tolerate it too. The words calmed her in ways that were at times almost imperceptible.
Young children think concretely. They take explanations literally. But they are also learning symbols, words, or thoughts that stand for things (Piaget, 1951). Toddlers also develop play and an imagination— sticks become horses, statues become mothers. With symbols, children move from acting on to contemplating. With symbols toddlers begin to create and make internal sense of their own feelings and experiences. Words are shared symbols. Through words, children can remember and can talk about people that are gone, things that are past, experiences that are too painful to understand without help.
Death is one of the most painful experiences we know. It is painful to grasp, painful to talk about, painful to come to terms with. Mental illness too is hard to grasp in its entirety. Facilitating open communication between Stewart and Virginia about Anna’s death and mental illness was a first critical step in promoting healing. Virginia took in what Stewart told her, but she also needed to make internal sense of what this meant to her. She came to terms with the death in a transitional space where she played hide-and-seek and created a relationship with a statue.
Hide-and-seek, the perpetual game played by young children, helped repair Virginia’s fears of being lost, fears that had been fueled the suicide and by early and painful gaps in mothering. In our games, Virginia enacted her fears of abandonment in play. I called Virginia’s name and found her. In the space of the hidden courtyard, I let her know, again and again, that she could be found.
Potential space (Ogden, 1990; Winnicott, 1971) is an intermediate and protective area of experiencing, an experiencing that lies somewhere between outside and inside, between fantasy and reality. In potential space, a toddler develops the capacity for symbols and selfhood through a dialectical process of oneness and of separateness. In this space, a subjective internal world emerges as the toddler comes to distinguish between what is “me” and what is “not me” and between symbol and symbolized.
The hidden courtyard where our therapy sessions took place likely helped to spark Virginia’s entry into potential space. In this transitional space, she could begin to make sense of fragmented, frightening, and painful events that she had experienced but had not understood. The concrete nature of the statue and its likeness to a mother, especially a mother who was struggling to protect, may have also facilitated Virginia’s entry into potential space in our sessions. In a safe place in the courtyard and in her mind, Virginia established a dialectical relationship with this stone mother who at the same time “was” and “was not” her mother. This dialectic afforded some safety for Virginia to explore and share feelings about a mother who had, at times, been dangerous. It also helped her to better grasp in mind what she had experienced.
Potential space can also be created in therapy, especially if meanings are played with, considered, shared, and understood (Ogden, 1990), but it is not inevitable. If a therapist intrudes “too much” on the child’s imaginative play, potential space will not emerge. Similarly, steering away from imaginative play will reduce the likelihood of its emergence. The security of the relationship that Virginia established with me likely helped her to explore in her mind and to enter into her own potential space, a space she also shared with me. She trusted that she could play, imagine, and dream without getting lost. She could also ask me questions and share her meaningmaking with me.
Coming to terms with loss is both arduous and painful. Being told promptly about what happened (Bowlby, 1980) and being able to share in the family grieving process and to ask questions in the aftermath are central to health grieving (Lieberman, et al., 2003; Ostler, 2010). Facilitating a young child’s ability to enter into potential space in therapy sessions can help further the grieving process even more, as it allows a child to tap into a wellspring of imagination and subjectivity as the child makes internal sense of the loss. Entering into potential space appeared to facilitate a child’s ability to “work through” the meaning of a parent’s mother’s death in a way that was uniquely helpful to the child.
Teresa Ostler, PhD, is an associate professor in the School of Social Work at the University of Illinois at Urbana-Champaign. Trained as a developmental and clinical psychologist, her research and clinical work focus on attachment, child development, and parental mental illness.
Copyright 2011, ZERO TO THREE. All rights reserved. For permission to reprint, go to www.zerotothree.org/reprints.
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