Ghosts in the Nursery: The Secret Thoughts of a Sick Child’s Parents

Introduction

Coming to terms with a child’s illness is one of the most difficult challenges a parent can face. Thoughts about the sick child arouse unbearable pain and fear. In many cases, parents feel isolated and sorely miss their old daily routine. Medical tests, doctors, and the entire health system, intrude on the family. They lose the freedom to live normal lives, and often, the freedom to think disturbing thoughts about themselves and their children. At times, such thoughts join unprocessed traumas from the parent’s past and undergo a process of toxification. In these situations, such thoughts become deep personal secrets: thoughts of rejection, disgrace, disappointment and hostility toward and even hatred of the sick child. Such thoughts produce profound feelings of shame and guilt. In this article, I shall try to expose these secrets, give them legitimacy, and propose how to work with the parents and assist them in processing the secrets they carry. A clinical example of a mother struggling to cope with her sick child is used to illustrate the work with parental secrets of guilt, shame and hostility toward the sick child.

Mourning and Melancholia

According to Hagman (1995, 2001), few of the clinical constructs of psychoanalysis have been as influential as the work of mourning. The model of mourning as a painful process of identification, decathexis and recathexis in reaction to the loss of a loved one is the cornerstone of the contemporary western understanding of bereavement, and has been used by psychoanalysts since 1917 (Abraham, 1927; Arango, 2003; Bonwitt, 2008; Fenichel, 1945; Freud, 1917; Hagman, 1995, 2001; Pollock, 1961; Kohut, 1972; Loewald, 1980; Volkan, 1981; Meissner, 1981; Frosch, 1990; McWilliams, 1994). This model has had a significant effect on how we view “normal” or “healthy” mourning, and has been used to define when and how mourning becomes pathological (Hagman, 1995, 2001).

Mourning is understood as a complex, multidimensional, and multidetermined process, reviving prior losses and separations, and necessitating a fully differentiated psychic structure and considerable ego strength for its optimal completion. Thus, the experiences that accompany each stage of mourning are different from one parent to another. Far from a severing or decathecting of the bond with the deceased, the painful travail of mourning consists of redrawing the boundaries of a libidinal boundary that was expanded to include a relationship in sensory reality and then reconfiguring the relationship symbolically onto an inner plane, thereby simultaneously transforming and preserving the cherished dialogue within the relationship (Arango, 2003).

In a brief overview of the considerable literature on the subject of mourning three major ideas are revealed in the era beyond Freud’s Mourning and Melancholia (1917; Arango, 2003): the transcendence of loss through meaning reconstruction (Neimeyer, 1988, 2001), continuity of self-experience (Gaines, 1997), and the internalization of relationship (Baker, 2001).

An ontogenetic review emphasizes the various factors that affect the grief process. Factors such as biological age and stage of development, availability of support, ability to express and process affect, intrapsychic structure and individual capacities for symbolization, all play key roles in determining the course and type of bereavement process. Normal adjustment, from this perspective, will vary in different sociocultural situations and different types of losses; it will be of longer or shorter duration, varying according to temperament and particular circumstance, but above all, according to the depth and quality of the object tie, and the significance of the deceased to the survivor (Arango, 2003).

When we go back to Mourning and Melancholia (1917), we see that Freud distinguishes between normal and pathological mourning. Freud claims that melancholia is created from narcissistic expressions of anger and ambivalence toward the dead person, and these are turned inward, preventing separation from the deceased and returning to life. According to Freud, melancholia splits the ego in two—one part identifies with the dead object, and the other part attacks it. In this way, the object is kept alive and becomes itself, but the object’s shadow rests on the ego. This process, which combines identification and projection, creates a melancholia that does not allow the individual, using Freud’s term, “to kill the dead”. If so, separation is the condition for returning to life. In cases of the loss of a child, “killing the dead” is tantamount to killing the self, especially because identification is formed between the two (Bonwitt, 2008).

In a 2002 article, Ogden explained mourning and melancholia. Using the terminology of object-relation theory, he wrote that in a denial of separateness, in the sense that “the object is me and I am the object,” there is a denial of the loss (Ogden, 2002, p. 773). The conclusion he then reached was that melancholy is the disease of those suffering narcissistic injuries, especially due to the great difficulty of carrying the pain involved in accepting the death of the beloved object. According to Bonwitt (2008), grieving the death of a beloved child is essentially different from mourning the death of a parent, if only because the death of a child contradicts biological logic that parents die before children. Grief about the death of a child never ends and becomes an emotional center from which the parent’s meaning of existence is derived. Therefore, Bonwitt (2008) posits that this type of mourning, even if it lasts for many years, can be seen as having pathological qualities resembling Freud’s distinction between mourning and melancholia.

However, we could also say that a narcissistic unity between parent and child is created within the bereaved parents. This may be the only emotional possibility open to them for bearing the pain and preserving their living child within them, perhaps in much the same way that a mother carries her fetus in her womb. This is an existential act that has no pathological qualities but, instead, is an attempt to continue existing in a life that carries infinite pain (Bonwitt, 2008).

Klein’s (1940) description of the manic defense, which characterizes the depressive position, may shed light upon the grieving process when it is infinite and intensive, as with a parent grieving a child. The manic defense is a denial of the depressive anxiety the parent feels, and marks the beginning of depressive recognition. This defense temporarily enables the individual to overcome the depressive pain and protects the ego from the complete despair that accompanies acknowledging the reality. Winnicott (1975, p. 42) called this manic defense “the notorious holiday of depression”. When this defense is in use, one can observe partial recognition of the internal and external reality (in other words, part of the reality is unknown/kept secret from the person) and denial of certain aspects of depression, emotion or content associated with the depression, it is an experience of suspended animation (Winnicott, 1975).

In this paper I will attempt to describe the manic defense channel as part of a parent’s grieving process. I propose this as an additional stage or way in which a parent attempts to deal with the pain of losing a healthy child.

Bereavement for a Healthy Child

In introducing her article in The Psychoanalytic Review, Dr Barbara Fajardo wrote about Solnit and Stark, who, in 1961, published their now classic paper, “Mourning and the Birth of a Defective Child.” In that paper, they described and theorized a range of experiences that might occur when parenting a developmentally impaired child, based on the works of Bibring, Benedek, A. Freud, and others.

The idea on which that study was based is that parents are faced with their child’s imperfection at birth and during various stages of development. This is true when a healthy child is born, and even more so in the case of a sick child. Parents are bound to grieve for the ideal fantasy child. However, when the gap between the fantasy-child and the real child is too great for the parent to bear, chronic mourning may develop. Solnit and Stark (1962) introduce the notion of “chronic mourning” (p. 534) to describe the sometimes lifelong depression experienced by these parents. Within their explanatory framework of mourning (as the libidinal detachment from the lost object–the fantasized perfect child), the parents’ psychic task is to decathect the lost object and then cathect the new, real child. As parents never have time to mourn without experiencing simultaneous demands from the real new child, this task may be hindered. Solnit and Stark explain that parental ambivalence is created by the simultaneous demands of decathecting the lost child and recathecting the new, real but damaged, child; because the ambivalence is often unbearable, it is repressed. The ambivalence and its repression contribute to further difficulties in completing the mourning and recathecting process. The ambivalence cannot be worked through, as it can in normal mourning, because the daily encounters with the damaged child do not permit a real “losing” of the object (Fajardo, 1987).

For the parent the ambivalence that is left motionless and frozen may be transformed into an inner secret in an attempt to preserve the ego’s use of the manic defense. The child’s illness may reawaken the mother’s identifications with her ill infant and her own mother, as well as attendant omnipotent wishes to protect her child from danger and damage and cure him if he is ill. Like the seriously sick analyst who cannot cure himself, the mother who cannot cure or protect her child feels narcissistically wounded on the one hand, and revisits infantile omnipotent fantasies of invulnerability and curative power on the other (Bemesderfer, 2000).

When she is confronted with her child’s illness, the mother may be tossed between her disturbing feelings and thoughts about her child and unresolved conflicts of her past. When confronted with trauma, the secrets that have been passed between generations, from mother to daughter, cause an internal flare-up. The mother’s inner secret may become multilayered, and draw into it unresolved childhood traumas and disturbing thoughts from the present struggle with the child’s illness. Unraveling the secret in therapy requires work on all the different levels to gradually release the secret. At the outset, one must work on the here and now, dealing with the mourning for the damaged child and the loss of the perfect one. Then, when space has been created in the parent’s external and internal reality, one can attempt to work through past conflicts that have surfaced in the wake of the child’s illness. When the parent is ready to confront the loss that has been denied so far, then he or she can begin to cry for his sick child.

In crying, a person gives expression to emotions, thereby reducing the tension and the grief (Klein, 1940). Since tears are identified with secretions, they become a means for the parent to expel bad feelings and objects. When a person cries or grieves, his internal objects grieve as well. In every loss in the present individuals are confronted by previous losses they have known (Klein, 1940). The parent of a sick child cries for his child’s loss of good health, as well as for the internalized objects of his childhood. In the best scenario, he recruits the objects of his past to grieve with him, because the thought of a sick child is an unbearable burden to bear alone. Yet, in contrast to the bereaved parent whose primary task is coming to terms with the loss of a child, the parent of a sick child is at the eye of the storm. He must marshal all his strength to fight for his child, and at the same time endure the dread, the pain and the unendurable emotions.

For the parent coming to terms with a child’s illness includes numerous stages. One of the options proposed in this paper is that, with the initial diagnosis, the parent’s reaction may be one of manic denial. To the extent that the parent is able to grasp the diagnosis, he becomes melancholic; and from that moment on, there may be an irregular swing between melancholy and manic denial (Klein, 1940). The use of the manic defense is necessary, at times, to enable the parent’s ego time to recover, and to provide a safe haven from the pain and despair that accompany the depressive position where the parent acknowledges his difficult reality. The danger in this process, however, is that one may get stuck in this position and there may be an internalization of the hostility toward and hatred of the child. Sometimes this hatred relates to the parent’s unprocessed feelings that are like ghosts from the past. It is hard to contemplate the hatred, the guilt and the shame that come with the thought of an ill child but a healthy parent. The fear of survival, and of being punished for it, is great. At times, the illness may exact such an enormous price from the whole family that the parent becomes exhausted and seeks relief from the fight for the child’s life. There may even be moments when the parent entertains the notion of forfeiting the life of the child altogether. It such times, the parent cries not only for the child but for himself as well.

It is inconceivable, unnatural, and unthinkable that a mother should outlive her child. The illness of a child is beyond comprehension. It arouses pain, fear and a sense of dread. It is as unnatural as the situation in which a mother tends to her adult offspring. It may be said, albeit tentatively, that the thought of our own mortality—that our children will bury us sooner or later (preferably later)—is far more bearable than the opposite: that we will bury our children.

There are unthinkable thoughts (Bion, 1962) that the mind buries in an attempt to protect and spare us pain and turmoil. This paper addresses the buried secrets hidden from the thinker himself.

In a well-known Hebrew children’s song, a child describes his father as a mighty hero whose ladder reaches the heavens. Who among us cannot relive the pain of discovering that daddy does not have a ladder that reaches all the way to heaven? And, in the same vein, who can deny the painful awareness that we cannot bring heaven down for our children either? And that sometimes children go to heaven without the benefit of daddy’s ladder? How great is the pain of a parent wandering the halls outside his child’s hospital bed?

I shall begin with a description of the secrets in our lives, making the distinction between conscious secrets (of which the possessor is aware) and unconscious or repressed secrets. I will suggest that some secrets can be simultaneously conscious and unconscious for their possessor.

The Secret

1. A Conscious Secret

A conscious secret is one that is known to its possessor, and it is something that the person does not want to share with others. The Latin root of the word secret is secretus, meaning “to separate” or “put aside by itself.” Its derivative, secretion, refers to a matter that is separated or differentiated, with the suggestion of something unclean and unnecessary that needs to be disposed. The French word secretaire means both “desk,” a place where private (read: “separate”) things might be kept, and “a secretary”, a person in possession of confidential (again: “separate”) information. The idea of “separation” is central to the etymology of each of these words. A secret marks the boundaries between insiders and outsiders (Landau, 2004), which is why it is so significant to the development of the self from the very earliest stages of life.

According to Landau (2004), a conscious secret is one for which the possessor can find no one with whom to share it. Buried deep below is the primary, unconscious material that has not been well assimilated. In her view, the private is conscious emotional content that lies fairly undisturbed in a closed drawer of the emotional secretaire. This conscious part is the exposed tip of a deep central core in which the “incommunicado element” (Winnicott, 1965, p. 186) is found: it is the essence of the soul, which is hidden quietly and privately and contains the uniqueness of the self. Winnicott claims that this basis does not, by its nature, communicate; it is unknown and has to be left undiscovered. It is agonizing only if it is penetrated or attacked (Winnicott, 1965).

2. An Unconscious Secret

Freud (1919) described the secret as unconscious, and in his thoughts about the uncanny, he made a connection between the repressed and the secret. The uncanny is at the same time familiar and homely, and secret and hidden. Its repression has turned it into something alien and forgotten, and its return is a source of dread. According to Freud, “the uncanny is the name for everything that ought to have remained hidden and secret and has become visible’ (1919, p. 220). Khan (1989) spoke about the secret as a potential space. In his opinion, in situations of emotional trauma, a person may take refuge in symptoms or disappear into a secret. What is hidden within him or repressed is subject to reprocessing, but what has disappeared into the secret is cannot be reprocessed, or, in other words, is unconscious. When the development is disrupted, however, the potential space of the secret is transformed into “secrecy” (Khan, 1989). In Khan’s view, it becomes unconscious. Nevertheless, it is possible that what is made to disappear within a secret becomes hidden from the eye (to paraphrase Steiner), or impossible to contemplate, but not repressed; it is then ignored, though it is in plain sight. I suggest, therefore, that the secret can be simultaneously conscious and unconscious to its possessors.

3. A Secret Hidden from View

Steiner (1985) described situations of psychic retreat in the case of extreme anxiety. In certain situations, the patient turns a blind eye to the truth to avoid the fear surrounding an encounter with others and with reality. He has access to all the facts, but the conclusions are denied him. The retreat thus provides an area in which there is no need to confront reality, and is a place governed by fantasies of omnipotence that do not require close examination. This situation is described as one in which the patient is disconnected, distanced, and turns a blind eye. I would argue there are secrets hidden from view and detached from the possessor, but simultaneously conscious and unconscious. In other words, for a person to turn a blind eye, he would have to recognize the secrets at some level. It would then be possible to say that the person hides a secret from himself.

I suggest that some parents of sick children carry within them family secrets, unresolved conflicts of previous generations. Such secrets emerge and become unbearable in the face of the child’s illness. Since the secrets are unprocessed, and their possessors are either detached from them or turn a blind eye, when the secrets burst to the surface as a result of the illness, the experience threatens the parent’s sense of integrity. It is an experience that is both familiar and uncanny (Freud, 1919), since it is not the parent’s first encounter with these secrets.

The Formation of the Parent’s Emotional Secret

Sometimes the parent has no way of expressing the feelings aroused by the child’s illness. As the violent reality causes cracks in the parent’s most hidden and private place, things begin to seep outward and inward. Part of the suffering of the sick child’s parent derives from the struggle of the psyche not to let the hidden things out.

When narcissistic vulnerability and the element of secrecy are more present in family life, the penetration of the parent’s private place will be more violent (Faimberg, 1988). In other words, the assumption is that those who bear traumas from the past as living memories may have a stronger manic defensive response and have difficulties moving from this defense to a depressive position of accepting reality. I propose that a parent who has disturbing, unprocessed secrets or a parent who as a child was able to sense his parents’ guilt, shame, and hostility about the secrets they kept from him, will have a stronger reaction to current events and will disconnect from his feelings to the point where they become secret and hidden even from himself.

1. The Parent Meets a Harsh Reality, Which Reduces His Potential Space and Makes Him Uncomfortable

Parents whose children have a serious illness lose their independence, the little moments in the day when they can be themselves and for themselves. There is no private self to which they can return and regroup. They are absent from work, outside the normality of daily life, away from sympathetic acquaintances. They become passive victims of their own lives. It is not only the body of the child that is examined, penetrated and pierced. They themselves, in green hospital robes, become invisible, or at least draw scant attention, and are invaded by questions and the intrusion of doctors and nurses. They feel themselves unbearably agitated or halfdead, with their lives on automatic pilot. Being unseen or unheard may be their only survival strategy. The fear of catastrophe, the hatred and the guilt, reduce the parents’ potential space. The facility of symbolization, playfulness and optimism, so vital in such situations, is in danger of collapse, and consequently the ability to think is blocked (Benjamin, 1999; Freud, 1896).

2. The Discomfort of the Parent Triggers Inner Unprocessed Conflicts, Which are Accompanied by Guilt, Shame, Hostility and Hate

These interlaced feelings become the parent’s secret by virtue of their aggressive, hate-filled and painful nature, regarding either the child or phantoms from the parent’s past

Guilt and Shame

Freud distinguishes between a sense of guilt following an actual event and pathological guilt. For Freud, guilt stands alone, and is not necessarily the result of something else. In many situations, the sense of guilt is unconscious; that is to say, there is a conscious effect of guilt without an awareness of an actual event (Freud, 1906). In defense based on isolation, the sense of guilt is transposed from an actual event to some other event (Klein, 1975). Another form of unconscious guilt is connected to faith or religious sentiment, which considers that a person is aware of the reward or punishment that attends good or bad deeds. If something bad happens, he is apparently to blame. If we think in terms of reward and punishment, the parent of a sick child might ask himself: “What have I done?” “How have I sinned to be punished in this way?” “I sinned, but it was my son (or daughter) who was punished.” An unbearable thought: Do the sons bear the sins of the fathers?

For Klein (1975), the source of an unconscious sense of guilt lay in the identification of urges of hatred toward the other, expressed as feelings of inferiority. A person burdened by guilt unconsciously fears that he is unable to love or to control his violent urges. A sense of guilt, experienced as concern for another person and fear of losing that person’s affection, is rooted in the infant’s hatred of its mother. The identification of the infant with its mother is a genuine consideration that arouses willingness to sacrifice and a fantasy about healing the hurt. Schizo-paranoid guilt reflects a dread of death and fear of revenge; depressive guilt expresses concern for the object (Klein, 1975).

Modell (1971) proposed the concept of unconscious bookkeeping based on phylogenetic development and an evolutionary biological approach with regard to survival guilt. The assumption was that society’s resources are limited. The individual understands that anything good that comes his way is at the expense of someone else. “Survivor guilt” relates not only to the victims, but also to the very continuity of life itself—to say nothing of the enjoyment and happiness that life can provide. There are cases in which psychic pain masks repressed feelings of guilt. The repression derives from a refusal to acknowledge loss and to grieve for it. In such cases it is necessary to expose the repressed guilt (Kogan, 1990). In other words, there is a need within the parent to explore the original secret guilt to which he has turned a blind eye. When that guilt is exposed, the parent will no longer need the acting out and the futile attempts at repair. He will be able to endure his thoughts about his child and about himself, thereby converting unthinkable thoughts into imaginable ones.

Solnit and Stark (1962) described the transition from caring about the ill or deceased child to narcissism, from grief to melancholy, and from feelings of guilt regarding the child to guilt regarding the self. In their opinion, a parent sometimes stops grieving for the child and is left with grief for himself, for what is lost in his internal world, and for the loss of his ideal–the idea of immortality or of undying relationships. In short, he grieves for the death of another.

The parent faced with a seriously ill child, mourns the loss of the ideal healthy child that occupied his fantasies, the loss of the perfect family, and the loss of the ideal self. The pain is for a reality that is gone forever, for one that has been replaced with a new, flawed and ephemeral reality. It is possible that the parent’s feelings of guilt toward the child’s illness may be guilt toward another person, and with it the guilt about something other than the child, genuine concern arises that arouses love for the child and a preparedness to sacrifice. On the other hand, the guilt could carry a touch of narcissism that reflects dread of death and fear of revenge. Perhaps, then, it may be said that the parent cries for someone else. The parent grieves for himself and for earlier losses. He feels he must keep his narcissistic guilt a secret. The parent is ashamed and guilt-ridden, forced to guard this terrible thought, keeping it a secret from his child and perhaps from himself as well. Perhaps he has agonized over it from his own early childhood. The parent now grieves over a more distant and primal loss, over the place at which reality breaches wholeness, leaving trauma in its wake. A hateful present reality meets the hatred of an early reality and arouses the pain of primal loss.

For the parent, the encounter with the child’s illness is fraught with traumas and secrets from the past, and brings him face to face with his own narcissistic vulnerability. In especially tenuous situations, the parent may find himself dissociated from the feelings of guilt and shame he has toward his child. The disturbing feelings will appear without reference to the object (the sick child, in this case), and may be transformed into a secret which the parent unconsciously rejects or with which he severs any connection. These feelings, in line with Freud’s theory (1917), will seek relief through conversion into overprotectiveness of the child (great concern for the child and, simultaneously, passive-aggressive behavior toward him, or unsuccessful treatment, disturbing symbiosis, and so on), somatic expressions, or object substitution (anger at the medical staff; internalizing the anger toward the parent himself, and so on). In other words, since the disturbing emotions will not find direct expression in fantasy and deed without being distanced from the consciousness, the parent may exhibit various symptoms, such as depression or dissociation, withdrawel from friends and family, etc. It is important to help the parent make space within for processing the current loss, sometimes by resurrecting phantoms from his past to allow movement between schizo-paranoid guilt and depressive guilt.

It is important to be able to reassure the parent that his feelings of guilt and shame are normal for his abnormal situation, and to give those feelings genuine legitimization.

Hostility and Hatred

Although Winnicott (1949) had much regard for the strength of a mother’s love for her baby, he also described the reasons for the mother hating her child. He grouped all the negative emotions, including the milder ones, under the title of hatred, which he juxtaposed with love as a list of equal weight. According to Winnicott, hatred that stems from unconscious identifications through counter-transference differs from hatred formed as a reaction to the child’s personality or behavior, i.e. objective hatred. In his view, the mother hates her baby before the baby hates its mother. The assumption is that the greater the gap between the fantasized child and the real child, so that the mother’s hatred for her real child grows.

Analytic examination indicates that disappointment, narcissistic mortification, and depression are the underlying reactions to the defective child. Thus, far from being over valued as a love object, the defective child is devalued by the mother who also devalues herself. To the extent to which an unconscious, negatively cathected self-image representation dominates the mother’s feelings about herself, the damaged, ill child will serve as a confirmation and a reality basis for such feelings. Depression, a feeling which can be conscious or unconscious, has many different facets: sadness, mourning, helplessness and hopelessness, as well as a feeling of worthlessness; rage, hatred, bitterness and anger turned towards the self or outwards are some of the other aspects (Lax, 1972).

Benedek (1959) suggested that the clinically observable rage and hatred of these parents is due to regression to negative identification with a bad, frustrating mother, which is provoked by the current failures and disappointments with the defective child. According to this model, the manifest relationships and interactions with the child become symptomatic or expressive of a regression to the mother’s own early conflicts. The frustrations with current parenting are symbolic of the parent’s early frustrations with the bad mother; difficulties in parenting a defective child are hence, ultimately, conflict-based and become conflictridden. The over-protective, over-solicitous, smothering-the-child attitude and the neglectful, indifferent attitude are opposite ways mothers use to cope with the hostile and frequently murderous impulses that they harbor towards their impaired children. These attitudes reflect unconscious feelings of selfhatred, projected upon the child, which represent the unconscious negatively cathected self-image. When the mother wards off her feelings of grief by establishing a guilty, depressed attachment to the damaged child, she may fail to adequately relate to other members of the family because she feels she must devote her life to the care of the damaged child. Conversely, the mother may identify with her defective child. In identifying with her defective offspring, the mother feels narcissistically wounded. This narcissistic injury is often intolerable because the mother feels painfully defective as she is caring for her damaged child (Solnit & Stark, 1961).

The mother’s withdrawal to a secret becomes, then, denial of the child’s needs, and in essence, denial of her own motherhood. In Winnicott’s view (1949), a mother can endure her hatred of the child and do nothing about it. Nevertheless, when the mother has no way of expressing her hatred (being angry with the child, confronting him, and so on)—and, I may add, is unable to allow herself to think hateful thoughts about the child, afraid of what she might do to him or fearful of the interlacing of fantasy and reality—and suddenly the child about whom she had hateful thoughts was hurt or ill, the mother finds her thoughts unbearable. She fears her thoughts have created reality; the very idea is terrifying and unimaginable. Can one sympathize with such a mother, despite her hateful thoughts?

Without maternal empathy, a woman experiences alienation and incompleteness. The absence of a woman’s empathy toward a child often reflects her lack of empathy toward herself, or toward the child or the infant within herself. The parents’ ability to connect to their hatred, or allow themselves space to feel the hatred, is what will allow the child to identify with those feelings and to both hate and, hence, love himself. This way offers hope of therapy that is tailored to the needs of the child and free of burdensome secrets. Only then can the ghosts and unthinkable thoughts be swept out of the treatment room.

3. The Parent is Disconnected from his Feelings to the Point at Which they Become Secret and Hidden Even from Himself

The parent cannot reveal his feelings of rejection, his fears and his hatred, nor can he separate from the object of his hatred. In his mind, internalizing these feelings (as introjection) and keeping them within endangers him. He imagines that externalizing these feelings (as projection) will create a sick, unbearable world. In either case, the parent struggles with an impossible situation (Britton, 1992). Trapped, the parent often distances himself from his true ego, remaining only with his dead-false and uncommunicative ego. We find traces of the struggle in symptoms that the parent develops. Some are physiological, like headaches, backache, exhaustion, insomnia, loss of appetite and memory loss. Emotional symptoms may include depression, anxiety, feelings of guilt or shame, hostility and unspecific hatred of the child. The internal struggle, in effect, robs the parent of the connection between the symptom and the buried emotional content.

The Therapist’s Work with the Grieving Parent

When treating the parent, therapists need to consider the feelings of loss, hostility and hatred, guilt and shame that accompany the attempt to cope with a sick child. The specific ways in which the parent attempts to cope need to be examined in the context of the interpretation he gives to his child’s illness. To this end, it is sometimes necessary to be oriented to understanding the parent’s history and internal conflicts. The intention is not to offer an interpretation of the parent’s past and his bad objects during the critical period of the child’s illness; however, if the therapist is able to identify the main conflicts in the parent’s past, it is possible to better understand his fears and unthinkable thoughts. The therapist may need to keep those thoughts within for a certain period of time, and work through them on the parent’s behalf. Later, the clinician can begin a gradual processing of the secrets that surfaced at the time of the child’s illness. It is important to give the parent’s secrets legitimization and a sense of the normality, even if he himself does not articulate them. A comforting statement (like the following example) can help the parent begin thinking about his hateful thoughts: “There are thoughts that go through a parent’s mind, but it’s hard to find a place for them because they are disturbing and embarrassing. But it’s important for you to know that many parents have these thoughts, and perhaps you do too…”

It must be taken into account that the parent’s struggle has various stages, and the confrontation with his hidden thoughts should be proposed at different levels and at different junctures. At the beginning, therapy should focus on the here and now related to the critical medical treatment. This is a maintenance stage, and the clinician will need to process some of the hard things within without interpretation. In the next stage, the therapist can gradually make connections between the parent’s disturbing thoughts about his child and the unprocessed disturbing thoughts from the parent’s past. It is important to try and identify situations where the parent bears past traumas as living memories that have not been processed. In this situation, there may be a malignant flare-up of the trauma. It is then important to face both traumas: one must process the initial trauma, thus drawing strengths for processing the current trauma.

This is a lengthy process that extends beyond the period of the child’s hospitalization. It is important for community social workers to be in touch with the parents, and to invite them to continue therapy after the child has passed the critical stage. Another option is for the parents’ social worker in the hospital ward to continue attending them for several months after the child has been discharged. Sometimes it is only at that later stage of the traumatic experience that collapse takes place, when the hard, turbulent phase of treating the child is ostensibly over, and the family is able to return to its normal routine.

Since the secrets are often multi-layered, they contain both the fears and the difficulties surrounding the illness of the child, and conflicts from the parent’s past that were exposed because of the violent intrusion of the illness into his secret and private place. Sometimes, the only indication that the parent holds inner secrets is that the therapist also experiences the secret during therapy. Situations of diminished thinking on the therapist’s part, blockages in therapy, a sense of two dimensionality, and the absence of therapist symbolization in the one-hour session may relate to the secret that the parent guards within. Very often, the goal of therapy is to release the blockage and restore movement without the parent’s awareness.

The unconscious may be conceptualized as a web of internal and external connections, within the person and between the person and the surroundings. There is constant work of weaving, building, and expanding. In traumatic situations, though, the movement is blocked and the building of the unconscious is halted. It is then that there is a collapse in the parent’s emotional space, and the retreat into the secret takes place. The question is how to restore the arrested movement in the parent’s mind. Achieving this purpose requires work with the clinician’s unconscious, and that in turn will reactivate the patient’s unconscious. To this end, the clinician must adapt and allow his unconscious to meet that of the parent. Together they can recreate the parent’s story and release the blockage of movement within the parent’s mind.

The shared structuring of the significance of collapse and withdrawal into the secret, and the place where it is produced, requires that the clinician not rely on past assumptions but allow the significance to be built in the here and now between his own unconscious and that of the patient. The therapeutic track is not one of deciphering the unconscious and remembering the repressed, but of experience, of facing the horror and the madness. The therapeutic sessions will provide the missing foundation for holding the patient, and the clinician will become the womb in which the patient will be held.

In some cases, the conversion of the parent’s thoughts to an inner secret can be avoided if the clinician is able to be an “environmental mother,” as

Winnicott (1965) puts it, and listen to the patient’s unconscious by means of his own unconscious, to dream him, and to play with him, without preconceptions and without prior knowledge. In dealing with the child’s illness, the clinician too can be drawn to a place in which his perspective narrows and he becomes unknown to himself. The fears, the pain and the secrets in his past might overwhelm him and reduce his ability to think and to play with his thoughts. The return from that to a vital rhythm becomes possible only when the therapist is able to be attentive to what the patient is experiencing, to what he himself is experiencing, and to structure something new that is not yet known to the patient. In other words, the experience needs to include the therapist’s analytical understanding and the patient’s insight. Freeing the patient from his secret is predicated on attentiveness to the motion between the clinician and the patient, a kind of joint structuring of the meaning of the secret and a restoration of movement. What is required is emotional attentiveness that can facilitate processing and transforming of what is happening—an attentiveness that creates emotional space in the clinician, repairs the collapse, and brings movement back into the room.

A Clinical Case: The Selection of the Living Child

H is the mother of a five-year-old boy who was diagnosed with cancer. After a year of chemotherapy and radiation treatments, the boy recovered completely and the prognosis was good. H began therapy following her son’s recovery. She had begun dreaming that he had drowned, that he’d been buried alive, that he had fallen to his death, and so on. She was terrified by these dreams, and after having one would spend the rest of the night sitting by her son’s bed, looking at him, protecting him with her gaze, until she eventually fell asleep.

In therapy sessions, she described her son: a beautiful curly haired child with large brown eyes; a curious child who, it was obvious, wanted to return to life. H was a very attractive woman, 35 years old, married, self-employed. She related that her mother was a depressive woman. Her father had left them when H was very young, and she and her mother moved in with her grandparents. She also related that her grandmother was an Auschwitz survivor. Her grandparents met in Israel and were able to offer each other solace, but she knew nothing about them beyond that.

In our sessions, H repeatedly told of the doctor’s announcement of her son’s illness, of the dread during the early weeks until the boy’s condition and the severity of the illness were clear, of the treatments, of the nights spent in the ward, of the nurses and doctors who talked among themselves in jargon she couldn’t understand. I said: “The hardest thing for you was not knowing.” She cried and said that although her husband was a good and caring man and the family was supportive, she felt alone. Ever since her son’s illness, H had become an extremely anxious mother, obsessively protective of the boy. She always wanted to know where he was going and with whom, and begged him not to go to crowded places so he wouldn’t catch any disease. I tried to talk to her about the feeling of dread when faced with death, and about premature loss of innocence. I felt that it gave H some temporary relief, but no more than that.

It seemed that H could not let go of death, and her grip only got stronger as the threat of death appeared to recede. H began taking her son for frequent (overly frequent) examinations, called the doctor that treated him in the hospital, was in touch with the doctor that treated him in the clinic, and asked about every small change she noticed in him. If the boy didn’t have much appetite on a given day, she would consult the doctor. If he had a cold, or felt slightly sore somewhere, she would be devastated. It felt as if the trauma was spreading and becoming incurable. I spoke about the difficulty of being cured and of letting go of the illness, as if there were something about the illness or thoughts about death that one needed to hold onto. It seemed that H was filled with guilt over her son’s condition. I thought about her sense of helplessness: There was nothing she could do to ease his suffering, and her mother’s love was not enough to cure him. Perhaps her attempts to treat him or control his surroundings were part of a manic defense through which H tried to deny a reality that was out of her control.

Her dreams changed a little at that point. One that recurred involved an open grave for her son, a grave dug especially for him. Was she the one who dug it? She was horrified by the thought. I tried to ask more about it. She felt heavy guilt and shame. Perhaps she was angry with the sick child? Perhaps she felt he had shattered her fantasy-image of the ideal child? She became silent and withdrawn, and retreated into herself. I said that she had secret thoughts that she was keeping from me and maybe from herself as well.

In one of our sessions, H described a dream in which she came down a staircase with her child, trying to flee from some high place. In her dream they were chased by dogs and people. Not finding an escape route, she got angry at her son, saying that it was because of him they had lost their way. H began to rock backward and forward in her chair, crying and hugging herself. In the long silence, and matching the rhythm of her rocking, I could almost imagine the footsteps of a Nazi officer with dogs barking by his side. I recalled the story my grandmother told me about the moment she was caught on a train by a Nazi officer as she attempted to cross the border from Poland to Russia. I felt terribly afraid. I thought to myself: for who was the open grave intended? Who was buried there, and what is the forbidden topic of conversation here? I remembered the secrets that were like a thread running through the Holocaust story in my own family, and I said: “death and thoughts about death have been with you, perhaps even before your son got sick. Death haunts you, perhaps from your earliest childhood.”

She said that she felt haunted and pursued but she didn’t know by whom or by what. I suggested that something in her dreams brought me back to thoughts of the Holocaust. I asked her to tell me about her grandmother’s house in which she grew up. In the following days, she began to tell me about her home and its secrets. They were not allowed to talk about the Holocaust at all; and, as a child, H felt that she didn’t want to know about it, that something in her grandmother’s pain was too frightening. Her mother, too, was an especially anxious parent who took care of H devotedly (maybe too devotedly), almost invasive in her parenting. Every time she left the house, her mother would tell her, ‘be careful when you’re out. Be careful’. She never asked her mother what she needed to be careful of, but it seemed she knew more than she wanted to know.

Following our conversations about her childhood home, H asked her mother to tell her more about the war. Her mother told her, for the first time, that H’s grandmother had a small child when the war broke out. When the grandmother was deported to Auschwitz, she stood in line for the “selection” clutching her son in her arms. Her mother (H’s greatgrandmother), who was standing next to her, said to her: “There’s no point in all of us dying. Give me the baby. If you hold him, you’ll die as well.” She did as her mother asked—and never saw them again. H’s grandmother immigrated to Israel after the war, started a new family and tried to forget the inconceivable choice she had made back then, but she was haunted by her memories and weighed down by the burden of guilt that she was alive and her son was dead.

When H was born, her mother suffered severe depression. Every joyous occasion in H’s life was accompanied by rejection and hostility from her mother. H returned to therapy with many thoughts about her mother and the ghosts that secretly followed H from childhood. We talked about the place of secrets in her life, and about there being something in her many secrets that protects her but also leaves her very isolated. In the following months, she began, painfully, to talk about the hostility she felt toward the weak, sick child, and the feelings of guilt she carried as a result. She was so alarmed by those emotions that swept over her that she turned away from them at once, and they became a kind of inner secret.

She thought about the way her mother and grandmother raised her. She was expected to be strong, not to display any weakness, because her mother was cold and aloof because of her depression, and also because it was their way of protecting her so that she would “pass the selection process.”

In the following sessions, H thought about her son and the cruel selection of fate. She expressed the hope that he would pass the selection, and her anger that he had to struggle with the illness. “Why him?” she asked; “Why me?” She talked about the disturbing feelings she had during his treatment. Sometimes, during the treatments, he appeared ugly to her, deformed, and she seldom took him outside, afraid of meaningful looks. She was afraid to think these thoughts, she was so ashamed. It was important for me to tell her that many parents have these thoughts in such circumstances, and that I understood that they were very threatening to her but that these thoughts were normal in such an abnormal situation. I found that processing the living memory of the familial trauma enabled us to return to the current trauma and renew the movement within.

Gradually H returned to herself and to her family. Hopeful thoughts began to emerge. It was possible to think that the open grave, in which the family secrets were buried, could now be closed. No further victims were needed.

I think, in retrospect, that the release of the secret demanded its own broad and multi-dimensional understanding. First, I needed to recognize that H was enveloped in secrets and to speak with her of the experience of harboring secrets, of knowing and not knowing, and of turning a blind eye to difficulties and pain. In addition, I was compelled to keep her disturbing thoughts within me, and to process them through my own unconscious for that purpose, so to speak. It was necessary to process the familial trauma that was frozen as a living memory. Once movement was restored to the past trauma, we could also restore movement to the current trauma.

There were places where, together with H, I turned away from the disturbing thoughts she had about her son. Those thoughts were so terrifying and so powerful that I too was unable to keep them within me. Only when I was able to restore emotional movement within myself and regain the ability to dream of/about H was she able to restore movement within herself. In other words, when the movement of the unconscious within me was renewed, emotional movement within H became possible, and a joint structuring of the trauma was created. Finally, when H articulated her disturbing thoughts about her son, it was important for me to normalize her feelings by emphasizing that many parents have these thoughts in difficult life situations.

Summary

This article attempts to provide a glimpse of the difficulties that face parents of children with serious illnesses. It examines the terrible feelings of guilt, shame, hostility, and hatred that may well up in the parents toward their sick children. Although such thoughts are natural and legitimate, they produce great anxiety; there are parents for whom such thoughts are especially disturbing. The parents’ encounter with their child’s illness, and their ability to cope with it, may depend largely on their inner space being devoted to themselves and their ability to empathize with themselves and their vulnerability. Beyond ontogenetic factors, it is possible that the greater the burden of unprocessed secrets the parent carries from his past, and the more he feels that he himself as a child was damaged, hated, and rejected by his parents, the harder it will be for him to confront his own terrible feelings about his child’s illness and the child that was himself.

Furthermore, I suggest that the greater the contact therapists have with the murderous and hateful thoughts of the child and the parent in their care, the greater their ability to help release the parents from their secrets, and allow them and their children some space in which to live their lives. The clinician needs to recognize when the parent faced with his child’s illness conceals secrets from himself and his environment. Sometimes the recognition occurs through the clinician’s inability to think (or limited thinking ability), feelings of fatigue, and desperation, which may be interpreted as projective identification. The clinician may also sense that the parent’s experience has become limited, two-dimensional, hopeless, unplayful, and lacking symbolization. In this situation, the clinician’s work must be multi-layered, touching both on the parent’s struggle with the here and now, and on the traumas from his past which threaten to engulf him. On occasion, for a critical period, the clinician needs to “lend” the parent his own ability to think and to dream, thereby helping the parent renew internal movement. When, during therapy, when parents articulates disturbing thoughts, it is important for the clinician to give them space and affirm their normality.

I recall the story of a young girl, about six years old, who contracted a terminal illness. Her parents concealed her real condition from her, or so they thought. After her death, they found hundreds of notes their daughter had left around the house. To her sister she had written “be strong,” to her parents she had written “I love you,” and so on. Her thoughts about her own death could live only upon her death—and thus, for her parents, she could continue to exist after her death. Imagine the things that could have been said to her while she lived and now go unsaid.

Consider that Freud (1905) said every secret will one day be revealed, and that secrets have a compulsion to emerge. Even when they remain unspoken, they hover above us. “He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips; betrayal oozes out of him at every pore” (Freud, 1905, p. 76). Everyone is familiar with such secrets at some level or another. It is no crime to think such thoughts. They are not really forbidden; they are the truth at unbearable moments. And we clinicians need to have the ability to help the parent bring them to the surface.