What do we do when there is nothing left to offer? That is the dilemma many health care professionals face when going about navigating their daily work activities. The dilemma reminds me of the nursery rhyme:
There was an old woman
Who lived in a shoe
She had so many children, she didn't know what to do.
She gave them some broth without any bread;
Then whipped them all soundly and put them to bed.
The earliest printed version of this rhyme is in Joseph Ritson's Gammer Gurton's Garland in 1794 and has this last line:
She whipp'd all their bums, and sent them to bed.
Another version of the original rhyme is noted by Iona and Peter Opie (1997). They draw attention to the version published in Infant Institutes in 1797, which finished with the lines:
Then out went th' old woman to bespeak 'em a coffin,
And when she came back, she found 'em all a-loffeing.
Many other variations were printed in the 18th and 19th centuries. Marjorie Ainsworth Decker published a Christian version of the rhyme in her The Christian Mother Goose Book published in 1978:
There was an old woman
Who lived in a shoe,
She had so many children,
And loved them all, too.
She said, "Thank you Lord Jesus,
For sending them bread."
Then kissed them all gladly
and sent them to bed.
Paula Rego in her picture of The Old Woman who lived in a Shoe, 1989 depicts dysfunctional family relationships, a political system, and social structure. Rego describes being fascinated by what she calls “the beautiful grotesque” in life and in art. As she describes: “It’s the divine, perhaps. […] I mean some other kind of divine, which connects very strongly to Portuguese folk tales and stories—the strength of them and, very often, the enormous cruelty involved. The cruelty is fascinating.”
In the book “Fairytales and the Social Unconscious” written by group analysts Raufman and Weinberg ( 2017) their chapter six: “To step into someone’s shoes'' begins with an anecdote of a woman in a therapy group accidentally putting on another patient’s shoes. The other patient was the only man in the group. At first glance this is an anecdote that can be glided over quickly. Or, we can play word games with the metaphor of stepping on someone's shoes. However, the story can be used to step the reader into a sensory imagining of the experience of trying on someone else’s shoes. To imagine where the toes sit and the previous foot imprint. The wearing of the tread, the sight of a sole stained with sweat, the smell. To use your whole body to imagine and think about an experience.
The concept of stepping into someone else's shoes then, depending on the imagined shoe owner and their feet, can feel wordlessly odd and sensorily intimate. As mentioned in the book, trying on someone else's shoes, particularly a stranger's shoes can feel embarrassing as it is also has the potential to be somehow an erotically charged experience and communication. It can raise anxieties about exposing something, about cleanliness, and cross-contamination. The story invites the shoe to be seen as an object of “uniqueness, exclusiveness and matching”. The chapter goes on to explore the many different associations to shoes and shares stories from different cultures across the world, ancient and modern. Notably the many different versions of Cinderella.
A shoe is an item of footwear intended to protect and comfort the human foot. The human foot can adapt to varied terrains and climate conditions, however it is still vulnerable to environmental hazards such as sharp rocks and temperature extremes, which shoes protect against. Whilst useful to mediate between the body, the environment, they are not necessary. Some shoes are worn as safety equipment, such as steel-toe boots which are required footwear at industrial worksites. Shoes also symbolise the social part of our identity and are used as an item of decoration and fashion. The design of shoes has varied enormously through time and from culture to culture, with form originally being tied to function and social role.
In this regard the NHS and each of its different services can be described as different kinds of shoe, each service created and shaped to meet both the environmental needs and social popularity of the time. It seems fitting some services in the NHS are referred to as being Cinderella services.
Shoes are steeped in custom and symbolic meaning. For instance, removing one's shoes can be a sign of respect, especially when entering a sacred space. In Christian belief in the Bible, shoes sometimes signify servitude, lowliness, or unholiness. Many cultures consider shoes to be dirty, as they frequently touch the ground and occupy the lowest part of the human body. Indeed, Arabic cultural tradition regards it can signify insult to show someone the sole of your shoe. To hit someone with a shoe may be even more insulting. In other social spaces it can be seen as presumptuous or rude to remove your shoes without invitation.
In all cultures the shoe is deeply connected to group belonging and identity. Univeristy of Warwick's Associate Professor in Global History and Culture, Giorgio Riello, considers footwear to be one of the most emotive fashion . In this extract from the introduction to his book Shoes: A History from Sandals to Sneakers, Prof Riello suggests that shoes are, and always have been, far more than simply coverings for feet.
”Navigating the ground and one “edge” of the body i.e. the foot, footwear acquires different meanings related to sex, attractiveness, group membership and power. Such meanings appear in different ways through time from ancient Greece to premodern Japan and present-day Western societies. A case in point is the theme of identity, be it personal or collective. To wear white sneakers in present-day northern Europe is a signifier of a membership of a specific type of youth culture: “trainers,” kept rigorously white and spotless, are used by working-class youngsters. This means resorting to blacking and painting. An unexpected parallelism can be demonstrated in late eighteenth-century Europe, where the bleaching of boots was part of the ritual of a gentleman’s behaviour.”
So what does it mean to live in a shoe? In the above nursery rhymes the shoe becomes the container or identity for a caregiving experience. The idea of living in only a shoe gives a fantasy of limited space. But maybe also a protective space from the elements in times of limited resources. It also suggests something not quite right about the use of that particular container for the task at hand. There is a sense of shock and empathy for the absolute impossibility of the work set for the caregiver.
There is also something important about the changes made to this nursery rhyme over time. As mentioned in my blog :'The NHS worker who called me' When thinking about the mother archetype in stories, psychoanalysts follow the Brothers Grimm frame of ‘mother’ being both the loving birth mother in stories as well as the stepmother who symbolises the dark side of motherhood, the part that must deprive, abandon, kill and neglect. To quote Fay Weldon “Well, all of us are nice, charming enough people, until tried by circumstances and hard times, and then, only then do we find out what we really are.” Parenthood tries us. Caregiving tries us. You can’t be a mother and still believe you are a nice person. Sooner or later each of us meets our limits and the darker parts of our personality and our ability to hurt others are exposed, particularly the ones we love most. To give care consciously and in a 'good enough' capacity you learn to continually carry the uncertainty of the impact of ourselves on our children. You also learn to say no, as trying to work beyond our limits is dangerous for all.
Likewise you can’t be a caregiver in the NHS and believe your decisions result in you only doing good. To hold this consciously at times can feel unbearable. But what then is the alternative - denial? How often are we allowed to hold this dilemma consciously? Clinicians are rarely given space to talk about their anger, hate and despair of their situation and the depressing reality of being merely human when superhuman caregiving is desired and required. Where do those feelings of being small, useless and impotent go?
One way is through humour. The now ommitted line: "Then out went th' old woman to bespeak 'em a coffin, And when she came back, she found 'em all a-loffeing." Certainly speaks to a truth I recognise in how staff used to be able to cope with limited resources. Though I'm not sure now how easily people feel able to laugh at work.
Society asks for NHS clinicians to kill off their fear, ambivalence and exhaustion. How much of their experiences of being human are authentically contained before offering care to others? How available are spaces for clinicians to deal with the inevitable fall out of with working up close and intimately with the narratives of violence, denigration, self loathing, sex, hate, envy and humiliation. When these experiences are not allowed to be processed at depth, we inevitably foster an approach of ‘getting on with it’ and being seen to be ‘coping’ often leading to an avoidance of the limits of ourselves and what is happening in our personal lives. We begin to push ourselves out of our own lives by making ourselves more available to external demands. When we don’t see ourselves clearly, it becomes difficult to assess reality. It becomes more difficult to understand our body cues of tiredness and stress. We override them and begin to push ourselves out of our bodies. Inevitably the death mother archetype is evoked.
The death mother says the gods will provide and they do. Mobile phones, easy access Wi-Fi, caffeine, energy drinks, zoom, alcohol, open plan offices, hot desks, working from home, flexi hours, double pay bank staff, Xanax, Klonopin, Valium, Ranitidine. Be more efficient, more streamlined. More like a well oiled machine. But at what cost to the body, to the soul? When complaining and ambivalence are not an option. She says we must think of others. Don’t ruin it for the most vulnerable - the people who really matter. Save lives by staying quiet. You don’t want their blood on your hands. It would be your fault. She believes in care, just not for her own children, the ones who take care of the others - her children will always have more to give. Complaining is a sign of their greed and ingratitude. No one likes whingers.
This is how the death mother works - she starves the child of reality, of meaningful connection with the body, of play or 'bad' behaviour and instead gives rewards and disapprovals for worthiness. She says to the child - God always provides and we are grateful to God for these blessings. In the Christian version of the rhyme is it really bread this god provides - or more a psychological trick of distraction? The modern Christian rhyme aspires for children and babies to be good, calm and and quiet in the face of hunger and deprivation. We also must imagine in the second rhyme, the children miraculously get enough of mother's attention. But this God did not provide more time for the mother to care for children, only bread (real or imagined). You can’t just create more time, or press pause on it to help get things done. It always keeps ticking. The death mother knows that. She doesn’t care about reality. As long as children learn the lie that God sits in your mind, never in the body. Bodies are just things to drag around with you. Bread from god is so much better. The death mother says, God's acceptance, that is, social acceptance means peaceful living. She teaches her children to pass for 'normal’ - quiet, happy, high on life, euphoric even. No whingers here.
The death mother sees herself as life-giving and nurturing like any natural mother. In many ways she is. She saves lives. Of a sort. But unlike Mother Nature who both births and kills at her whim, who is both loving and cruel, sharing and deeply unfair. The death mother does not make space for her cruelty to be acknowledged or allow any grief in what she has killed off in her child. That wasn’t really her, she says. That was the choice of the child. They would complain if they didn't like it. Do you see anyone complaining? She believes in a better world, full of superior humans - quiet, kind ones. Children that don’t need to ever feel pain, that won’t suffer or hate or want to kill themselves. She lies and says life can be fair. Nature got it wrong. Her children learn how to push themselves out of their own lives and their own bodies, in order to be useful to others. To make the world a better place. With kind caring people. People who believe love is never having to say you are sorry - the bad ones deserve to be dead anyway, they want you to suffer, to feel, to hate, to love on a whim and get things wrong. Thank god we know how to spot them. That is what Death Mother creates. Children that can’t die because they don’t know how to live.
“Perfection does not allow for feeling. Perfection is not interested in staying in the body. It wants to fly, wants ideals, wants beauty, wants truth, wants light, and you sure don't get these here. Perfection massacres the feminine.” Marion Woodman
The fairytale of Hansel and Gretel also tells the story of famine, unsupported parents and abused/abandoned children. This story also has a magical force providing ‘bread’ for the hungry child - the wicked witch and her house made of gingerbread and sugar. In this story the house made of gingerbread is not what it seems and is actually a trap. The story provides a way out. The children are trapped in a house dedicated to the entrapment of children so as to put them to work in service of the death mother. To escape the children must learn how to trick the witch. They must learn to understand the importance of their body cues, to use their discernment in trusting different parts of their internal worlds - to delay gratification and use time to think. Likewise to discern trusting the minds of others. Not everyone that deprives us is inherently out to get us and not everyone that gives us what we want has our interests held in mind. Ultimately they must use their aggression and learn to say no, in the face of another's protest and manipulation.
To understand ‘the dynamic between the unsupported mother and the unwelcome child.’ We must develop ‘the capacity to negotiate the fine line between fact and fiction, conscious and unconscious reality, and matters between the sensible world and the ideas of the reasonable mind.’
The disavowal of the impossible choices faced by mothers did not just occur in stories. It was also happening in society. Violet Sherwood in her astonishing book ‘Haunted’ discusses the history of unsupported and overwhelmed mothers, when murder or direct abandonment became no longer morally acceptable. She discusses how in the nineteenth century desperate mothers found other ways to dispatch their children, getting rid of them psychologically whilst rationalizing that they had not abandoned the child but provided them with better care.
She describes how this social shift can be seen in mothers switching from abandoning or killing unwanted children to the use of baby farmers or foundling hospitals, "both of which had notoriously high mortality rates (Rose, 1986). Yet the double bind remained tightly in place – what other choices could a woman make without support and social acceptance?" (Sherwood, 2021)
The four themes Sherwood highlights as death mother institutional care are: violence/medical intervention to the body, abandonment, drugging, and neglect. All of these abuses were told as necessary and life affirming for the child - helping them to live in a more socially integrated way. Without their care the child would die. Of course most children died anyway. That was the most financially productive outcome. Importantly it couldn't be anyone's fault - only the weak constitution of the child, as they were providing the best treatment.
For the children that survived, they learnt in order to receive care more and more of their bodily responses need to be killed off. Learn to resist hunger, loneliness, tiredness, shame, laughter to escape oppression and the prize of freedom will follow, with all its euphoria. Both Marion Woodman and Violet Sherwood in their works on the death mother discuss that for survivors of death mother care, in adulthood these patterns of relating continue - sometimes this occurs symbolically though addiction processes - to alcohol, food, work, body dysphoria, work addiction, endless striving to be a better/helpful, person. Sometimes it is simply a literal wish to kill themselves so as not to be a burden.
What happens to the children whose bodies are held as problems to be silenced and are socially transitioned to exist only through the death mothers mind's desire:
“Children not loved for who they are do not learn how to love themselves. Their growth is an exercise in pleasing others, not in expanding through experience. As adults, they must learn to nurture their own lost child. There's personal anger, but underneath there's often universal rage; And when we are possessed, God help the man who's on the end of that. Deep rage is not about the man; Deep rage is this: Nobody ever saw me. Nobody ever heard me. As long as I can remember, I've had to perform. When I tried to be myself, I was told, That's not what you think, that's not what you ought to do. So, just like my mother and her mother, I put on a false face. My life became a lie. That's deep rage. We have lived our lives behind a mask. Sooner or later —if we are lucky— the mask will be smashed. What a relief to be human instead of the god or goddess my parents imagined me to be or I imagined them.” - Marion Woodman and Jill Mellick "Coming Home to Myself"
“Fears of abandonment, rejection and infanticide are universal childhood experiences that reveal the child’s awareness of its vulnerability and helpless dependency on the mercy of powerful adults (Bloch, 1979). Life sometimes brutally sacrifices our innocence through betrayals and breaches of trust. Archetypally, this should lead to the next stage of human development, that of the archetypal Orphan who must grieve the pain of abandonment and betrayal and learn to rely on her adult self to survive (Pearson, 1986, 1991).” Sherwood, Haunted.
So what does this mean for our services, for our patients and for us. I think another common occurrence is therapists projecting their own vulnerability and intolerance of having nothing to give onto a patient. Imagining the patient is too vulnerable to be left with any uncertainty. When actually it is the therapist that cannot not bear it.
“Like the caged bird that will not leave once the door is opened, the Feral Child may cling to her only known means of survival rather than risk trusting humans again. She may continue to live in a world of intensity and precariousness, always on the edge. She may not know any other way to be. We need tolerance for the need to be free, to live on an edge and to give expression to the fragile, damaged, mad self who holds so much creativity and sensitivity. In order to integrate our Feral Children, we need to be there with them on the edge and not force them into conventional compliance. Engaging with the Feral Child – the one who does not trust society or humanness at all, the one who lives like a wild beast, scavenging on the edge of society for enough sustenance to survive but terrified of being trapped or driven off – requires gentleness and respect.” - Violet Sherwood, Haunted (2021).
Learning to grieve our limits and trust our patients with honesty can feel like an overwhelming and unacceptable task. One we are also unlikely to be thanked for. But at what point do we admit we have nothing left. At what point can we see we are being the old woman who lived in a shoe. The children are already here and we don't know what to do. For some of us the gods of sciences might well provide answers to part of the problem, but they also demand sacrifices if we want their rewards and no -one can create more time. How do we focus energy on rebuilding resource and create spaces we can sustain ourselves and those who come under our care and protection?
