In his paper, Casework with mentally ill children, written in 1959 but published in 1965 in his book The Family and Individual Development, Winnicott divides up his work into four parts. Though a somewhat loose and incomplete division of his activities, it can nonetheless be seen as providing a useful way of putting his many-sided professional life into some sort of overarching perspective:
‘My work has always been divided into four parts. The first belongs to my position as a physician in a children’s hospital. It is an attempt to meet social need in an outpatient department, and my clinic at the Paddington Green Children’s Hospital has become notorious as a psychiatric snack-bar.
The second has been the work that we carry out in the psychology department at Paddington Green, where we take cases from the snack-bar when the psychiatric social workers have room for new patients. Here I suppose we are more definitely doing casework.
Then my third interest has been the psycho-analysis of children, and the training of men and women to do this work.
Lastly, there has been all along my private practice in child psychiatry. Private practice is perhaps the most satisfactory, because there I take full responsibility unless I definitely call in help. My failures, and these are many, are definitely my failures, and they stare me in the face.’
One of course needs to add to this list his work as a psychoanalyst of adults, his involvement in psychoanalytic training and institutional life (he was President of the British Psychoanalytical Society, 1956-9, 1965-8), and his work as a prolific author.
What comes across to my mind about his many writings is that the talks, and even some of the contents of the letters, are as interesting and significant as the more formal papers. One frequently finds in them passing comments that strike a chord, or make one sit up with surprise, or that summarize his theoretical positions very succinctly. One gets the impression of a creative mind constantly at work, finding new connections, exploring possibilities, carving out new ideas, all with an almost complete lack of pomposity – which I think comes from working so much with children. I also suspect that it was in his talks and more informal papers that Winnicott was able to feel free from the various intense rivalries between different groupings of analysts, which still dominated the institutional life of the British Psycho-analytical Society, following the ‘Controversial Discussions’ that took place during the nineteen forties.
While a psychoanalytic identity was fundamental to Winnicott’s work, so was his vast experience of working with children and parents. Unlike the adult psychoanalyst who will see a relative handful of patients in a professional career, Winnicott must have seen thousands of child patients, observed at first hand hundreds of mothers and babies and worked with many families and their professionals. While he is capable of psychoanalytic speculation, he invariably goes back to observation and experience to search for conformation of ideas, an attitude typical of the empiricist tradition of the Independent school of psychoanalysis (see Rayner, 1990, p.6-8). Seeing so many families with such a wide spectrum of disturbance, from severely pathological to mildly problematic, gave Winnicott a broad sense of what was normal and adaptive, which allowed him increasing confidence about when not to intervene, when to wait for growth and development to achieve therapeutic results, and to understand what kinds of environment were helpful to children and what disruptive. As he put it in his Lecture on advising parents (1957), ‘The fact is that in health we are constantly engaged in keeping time with natural processes: hurry or delay is interference. Moreover, if we can adjust ourselves to these natural processes we can leave most of the complex mechanisms to nature, while we sit back and learn.’
Time and again, while not ignoring the role of instinctual processes, he will emphasize the importance of the child’s innate tendency towards integration and growth, provided of course the early environment is facilitating in a good-enough way, with someone holding the infant and adapting well-enough to changing needs. Such integration appears for Winnicott out of a primary unintegrated state (see The first year of life, 1958, and Fragments concerning varieties of clinical confusion, 1956). Integration gradually becomes a settled fact and the infant becomes more and more knitted together into a unit when there is good enough maternal provision.
Many of the papers and talks focus on the issue of environmental provision, particularly in the first year of life. This preoccupation probably needs to be seen in an historical context, in particular Winnicott’s complex relationship with the thought and the person of Melanie Klein.
With regard to their personal relations, they began warmly. She had supervised him between 1935 and 1940, and he was her son Eric’s analyst. Following his analysis with James Strachey (1923-33), he was analysed by Joan Riviere (1936-1941), a close follower of Klein. His second wife, Clare, was analysed by Klein. However, by about 1957, the Klein-Winnicott personal relationship had cooled, probably because he had become increasingly critical both of aspects of her thinking and also of what he saw as the fundamentalist attitude of her followers. The fact that his wife was also in analysis with Klein meant that there was bound to be a necessary distance between them.
In the dense paper, Psychoanalysis and the sense of guilt (1958), he outlines three contributions made by Klein to understanding the origin of guilt. Firstly, the infant’s primitive love impulse has an aggressive aim; being ruthless it carries with it a variable quantity of destructive ideas unaffected by concern. Secondly, the infant subsequently needs an opportunity to make reparation and restitution, if oral sadism is to be accepted by the immature ego. Thirdly, he writes that she enriched our understanding of the complex relationship between fantasy and inner reality, by describing the interplay between what is felt by the infant to be malign or malevolent in terms of forces or objects within the self – the interplay between good and bad experiences and objects.
However much he appreciated Klein’s contributions, one can see in this paper the clear development of his own views about early life, placing much more emphasis on the infant’s actual environment, on the mother-baby relationship and the ability of the mother to hold the infant through experiences. At what Klein calls the depressive position, when the infant becomes aware of their destructive impulses and phantasies, Winnicott describes how ‘the infant is not so much dependent on the mother’s simple ability to hold a baby, which was her characteristic at the earlier stages, as on her ability to hold the infant-care situation over a period of time during which the infant may go through complex experiences…The mother, still being there, is able to be ready to receive and understand if the infant has the natural impulse to give or to repair.’ Rather than use Klein’s concept of the depressive position, Winnicott soon (1963) prefers to describe the development of a capacity for concern, a term he uses to cover in a positive way a phenomenon that is covered in negative way by the word ‘guilt’.
In his paper, A personal view of the Kleinian contribution (1962), Winnicott places Klein’s work very much as a genuine development of Freud’s thinking, ranking her notion of reparation alongside that of Freud’s concept of the Oedipus Complex. But he also does not hesitate to criticize her when she effectively ignores the fact of environmental provision, never acknowledging that it is not possible to describe an infant without describing the mother whom the infant has not yet become able to separate from. He states that ‘Klein claimed to have paid full attention to the environmental factor, but it is my opinion that she was temperamentally incapable of this.’ Her emphasis was on the infant’s destructive impulses, however gradually modified by the urge for reparation; while he, in contrast, often focused on the health and normal maturational processes in the infant, always in relation to the environment. Her views came from the analysis of children and adults, while his views were also heavily influenced by his wide experience of working with many children and parents in his clinics.
Thus one can see by the early sixties, Winnicott had become more confident of his own position and where it diverged from that of Klein. I the mid to late 50’s, His formulation of the difference between them was evolving and had not yet fully formed. As can be seen in some of the letters, he was still trying to gain Klein’s approval, still trying to persuade her to take more allowance for the reality of the mother-infant relationship. But by the end of this period, he seemed to have finally given up the attempt to persuade her to come round to his view.
I shall now look at some of the key writings of the period 1955-61, after which Winnicott had found his independent voice, in order to provide some guide to the development of his thought. The aim is not to describe every work but to emphasize key themes and to look at some of the more significant contributions. Because of the wide ranging nature of his writings, I have divided them into three sections – Theory and Practice of Psychoanalysis, Psychoanalysis as applied to Child Psychiatry and Other Disciplines, and Winnicott and Psychoanalytic Politics, a glimpse through his letters. It must be emphasized, however, that despite these divisions, there is continuity in Winnicott’s thinking. Themes are developed in his talks to mental health professionals just as much as in his more formal psychoanalytic papers; there is a mutual influence between different kinds of writing.
- Theory and Practice of Psychoanalysis
At the outset, it must be said that much of Winnicott’s approach to psychoanalytic theory and practice is directly informed by his views about early development, particularly by what happens in the first year of the child’s life. His paper, The theory of the parent-infant relationship (1960), brings together all the previous contributions into a clear and succinct statement of his position, which had become by then very much one he felt he could defend with much greater confidence. That paper summarizes early development in terms of the earliest anxiety faced by the infant, that of annihilation anxiety – a notion explored in his 1956 paper on Primary maternal preoccupation; on the way that psyche and soma become integrated, and how the mind, or intellectual functioning, becomes distinct from the psyche – concepts that go back to his 1949 paper, revised in 1953, on Mind and its relation to the Psyche-Soma; and the notion of the good-enough environment provided by the mother as necessary to allow the infant to move from absolute dependency towards independence – a notion already outlined in his 1957 paper On the contribution of direct child observation to psycho-analysis.
The paper, The first year of life (1958), the opening chapter of his book The Family and Individual Development, provides a vivid description of Winnicott’s approach to understanding emotional development, and has the advantage of elucidating his ideas with particular clarity. He sets down what he calls a series of statements, and expands on each, in an exploratory way that is a difficult in a more formal paper, and yet is probably more effective at conveying his thinking.
After the introduction, he describes how in psychological matters there is an innate tendency towards development, which corresponds to the growth of the body and the gradual development of functions. However, we do not witness this natural growth unless conditions are good enough. As I mentioned before, this approach comes very much from his child psychiatry work. It is vividly illustrated in his book Therapeutic Consultations in Child Psychiatry (1971). There, he gives many detailed examples of clinical encounters between children and himself, usually involving the use of the ‘squiggle game’. This is a game where Winnicott would make a squiggle and ask the child to make a picture put of it, and then the child would make a squiggle for him to complete. Out of these drawings, here could emerge key themes interfering with the child’s development. The task of these consultations was often to ‘loosen a knot in the developmental process’ (Winnicott, 1971, p. 5), allowing the child to use his environment more fully.
The next section of the chapter tackles the issue of dependence, a key Winnicottian term and one whose meaning and significance in his body of work continued to evolve. He writes that the ‘great change that is noticed in the first year of life is in the direction of independence. Independence is something that is achieved out of dependence, but it is necessary to add that dependence is achieved out of what might be called double dependence,’ the infant is doubly dependent on the mother as he or she is unaware of their dependence, of their merging with the mother. Winnicott will later refer to the infant being in a state of absolute dependence.
Once more he emphasizes that the journey from double dependence to independence is an expression of the innate tendency of the infant to grow, but that this growth requires the mother’s sensitive adaptation to her child for it to occur without any hitch.
Alongside the gradual development of independence, most infants have achieved at the end of one year the status of an individual, in other words the personality has become integrated. Winnicott clarifies what he means by integration in a talk he gave in 1959 and published as a chapter in The Family and Individual Development, Group influences and the maladjusted child.
He describes the state before integration as one when the individual is ‘unorganized, a mere collection of sensory-motor phenomena, collected by the holding environment. After integration the individual IS, that is to say, the infant human being has achieved unit status, can say I AM (except for being unable to talk). The individual has now a limiting membrane, so that what is not-he or not-she is repudiated and is external. The he or she has now an inside, and here can be collected memories of experience, and can be built up the infinitely complex structure that belongs to the human being.
‘No doubt the instinctual experiences contribute richly to the integration process, but there is also all the time the good-enough environment, something holding the infant, and adapting well enough to changing needs.’
He also emphasizes, as he develops in detail in is paper on Primary Maternal Preoccupation (1956), that the person holding the infant has to have a particular form of love at this stage, love that carries a capacity for identification with the infant, and a feeling that adaptation to need is worthwhile.
The I AM moment is beautifully elaborated in his paper, The capacity to be alone (1958). This capacity is possible once integration has been achieved. The words ‘I am’ represent a stage in the individual when they have shape and life. ‘In the beginnings of ‘I am’ the individual is (so to speak) raw, is undefended, vulnerable, potentially paranoid. The individual can only achieve the ‘I am stage’ because there exists an environment which is protective; the protective environment is in fact the mother preoccupied with her own infant and oriented to the infant’s ego requirements through her identification with her own infant.’
The stage when the child can say ‘I am alone’ in the presence of the mother is one where unit status and integration has been achieved.
The first year of life paper also describes what he calls ‘Personalization’. This is a process first described in his 1945 paper on Primitive emotional development, and refers to the time when, if all goes well, the person of the baby starts to be linked with the body, and the psyche and soma have come to terms with one another. Personalization is a crucial aspect of the establishing of unit status, and hence identity; it describes the process when the person of the baby starts to be linked with the body and the body functions, with the skin as the limiting membrane. The infant’s psyche begins to dwell in the soma, or, one might say, feels ‘at home’ in the soma, with a sense of being self-centred inside his body; this process depends upon the mother’s handling, her ability to join up her emotional and physical involvement.
Winnicott distinguishes the psyche-soma from mind, which is the child’s intellectual functioning; the mind depends upon the existence and functioning of those parts of the brain that are developed at a later stage than the parts that are concerned with the primitive psyche.
Other sections in the paper refer to fantasy and imagination, how both normally develop as part of the natural tendency to growth but may become stunted or distorted under certain conditions; how the inner world of the individual has become a definite organization by the end of the first year; how the triangular relationship becomes a new factor in the child’s life at about the time of the first birthday, but does not reach its full status until the child is a toddler and until the time of the dominance of the genital over the various types of alimentary instinctual functioning, thus making his thought nearer to that of Freud than Klein, who pushed the triangular relations back much earlier in time; issues about object relationships, and how at the end of a year the infant is related to whole persons. The last sections of the paper introduce ideas which very much bear the Winnicottian hallmark. Spontaneity as opposed to compliance is seen as a crucial capacity for healthy living. Spontaneity may be threatened by the mother trying too hard to ‘train’ the child, or by the development of complex mechanisms of restriction from within the child. The notion of compliance was introduced in his paper Psychoses and child care (1952), but it was in his 1960 paper, Ego distortion in terms of true and false self, that he more fully developed a theory of compliance, when it is seen as a reaction to excessive environmental impingement and trauma.
Linked to spontaneity is the creative capacity, that which ‘proves to the child as nothing else that he or she is alive. The innate creative impulse withers unless it is met by external reality. Each infant must re-create the world, but this is only possible if, bit by bit, the world arrives at the moments of the infant’s creative activity. The infant reaches out and the breast is there, and the breast is created. The success of this operation depends on the sensitive adaptation the mother is making to her infant’s needs.’
There is a brief section on aggression, with motility seen as a precursor of aggression. In health, a large proportion of the aggressive potential is fused with the infant’s erotic drives. But in ill health and a lack of good enough environmental provisions, only a small proportion of the aggressive potential becomes fused in this way. This will eventually lead to destructiveness in the relationship to objects. In his paper Aggression in relation to emotional development (1950-55), he expounds his definitive views on the nature of aggression, distinguishing them from those of Klein. Later, he will develop the notion of a healthy destructiveness in the use of an object paper (1968), or the positive value of destructiveness, when the object survives destruction by the subject, allowing the subject to move forwards into living a life in the world of objects.
There is a section on possessions and transitional objects, which he states will form the basis of the whole cultural life of the adult human being. This was a theme that Winnicott would further develop in his last writings, such as in his book Playing and Reality (1971. The most significant mention of transitional objects in the period is in a talk in 1959, The fate of the transitional object. Such objects are to be seen in several lines of transition, that of object relations when there is gradually the use of an object which is neither part of the infant nor that of the mother; when there is a changeover from an object which is subjective for the infant to one which is objectively perceived as external; and there is a transition which belongs to the developing powers of the infant, developing co-ordination and a gradual enrichment of sensibility.
The transitional object may be supplanted but kept, or worn out, or given away, or kept by the mother. But the most significant development of the transitional object and transitional phenomena refers to the claim ‘that these phenomena mark the origin in the life of the infant and child of a sort of third area of existing, a third area which I think has been difficult to fit into psycho-analytic theory…This third area might turn out to be the cultural life of the individual,’
He clarifies what he means by the three areas of existing. The first area, the fundamental one, is the individual psychic or inner reality, the early unconscious. The second area is external reality, the world that is gradually recognized as NOT-ME by the healthy developing infant who has established a self with a limiting membrane and an inside and an outside. The third area is the area of living which corresponds to the infant’s transitional phenomena and is at the basis of symbolism. This third area does not pass, at least in health, for it forms the basis of adult cultural life.
The final section of the first year of life paper is on love, and shows how as the infant develops, the word ‘love’ alters, or the meaning gathers to itself new elements. Thus love begins with just being alive, then goes through affectionate contact with the mother, then integration until the stage when the child has concern for the mother, a preview of an adult attitude of responsibility.
His conclusion is that these developments, and many others, can be seen in the first year of life, but almost all can be lost by a breakdown in environmental provision after that date, or even through anxieties that are inherent in emotional maturation.
Winnicott’s paper on Primary Maternal Preoccupation (1956), first published in his collection of papers, Through Paediatrics to Psychoanalysis, (1958), adds important details to the way that he conceived of the infant ego’s early development.
It is his thesis that the in the earliest phase of the infant’s life, we are dealing with a very special state of the mother, a psychological condition which involves a state of heightened sensitivity during, and especially towards the end of pregnancy, and which lasts for a few weeks after the baby’s birth. It is inevitable that the baby will experience various frustrations and impingements from the environment, which produce at the earliest level the threat of annihilation. This latter anxiety is, in Winnicott’s view, ‘a very real primitive anxiety, long antedating any anxiety that includes the word death in its description.’
If the mother is in a state of primary maternal preoccupation and tuned into the needs of the baby, there comes into existence an ‘ego-relatedness’ between mother and baby, from which the mother recovers and out of which the baby may eventually build the idea of a person in the mother. The mother’s failure to adapt in the earliest phase does not produce anything but an annihilation of the infant’s self. The normal infantile ego develops out of the experiences of dealing with the threat of annihilation and then recovering from that threat. Whereas the abnormal infantile ego may become caught up in primitive defence mechanisms such as the development of a false self which belong to the threat of annihilation.
Winnicott’s important paper on the Clinical varieties of transference (1955-6) links a number of aspects of his theory of infancy to the psychoanalytic setting. Work with neurotic patients was based upon the fact that the patient’s ego could be taken for granted by the analyst. But work with borderline and psychotic patients required an awareness of primitive states of mind. Good enough adaptation of the analyst helps shift the patient towards operating from a false self towards a true self. This means the analyst having to bear the patient testing them out, and even using their mistakes. It is inevitable that the analyst will make mistakes, as repetitions of past failures are repeated in the transference. How the analyst deals with those mistakes is crucial to how the patient can work towards developing a true self. The paper outlines a special kind of analytic work that has to take place with those patients who have experienced significant environmental failures; it may also be part of ordinary analytic work from time to time.
Winnicott’s paper on Counter-transference (1959), offers some insight into how he worked with adult patients. He describes the work the analyst does with his mind as his professional attitude or technique.
‘ Now I say this without fear because I am not an intellectual and in fact I personally do my work very much from the body ego, so to speak. But I think of myself in my analytic work working with easy but conscious mental effort. Ideas and feelings come to mind, but these are well-examined and sifted before an interpretation is made. This is not to say that feelings are not involved. On the one hand I may have stomach ache but this does not usually affect my interpretations; and on the other hand I may have been somewhat stimulated erotically or aggressively by an idea given by the patient, but again this fact does not usually affect my interpretative work, what I say, how I say it or when I say it.’
In contrast to this ordinary work, the analysis of borderline and psychotic patients can have drastic effects on the analyst, but he focuses on two types of case which he considers completely alter the analyst’s professional attitude – those with an antisocial tendency, which is covered in section two, below, and those who need a regression. As he did not consider that the former were good candidates for analysis, he particularly focuses on the latter. These latter are those patients, for example those with a false self personality structure, who need to pass through a stage of deep and even absolute infantile dependence in the analysis in order to allow the patient to find their true self. This is what Winnicott described in his paper Metapsychological and clinical aspects of regression (1954) as a controlled regression to dependence. Such a therapeutic regression, as opposed to a malignant and anti-therapeutic regression is well described by Christopher Bollas (1987) as a situation when ‘the analysand giving over to the analyst certain important mental functions and management duties in order to bring the personality back to its childhood moments of origin and experience.’ The analyst at these moments needs to hold the analytic process and not intrude too much with analytic interpretations.
Here one can see a direct connection between Winnicott’s views about early development and the vital role of the facilitating environment in the person of the good enough mother and his technique of working with those patients who have been deprived of such good enough environmental provision.]
- Psychoanalysis as applied to child psychiatry and other disciplines
Embedded in the many talks and papers about working with children and families the paper, The antisocial tendency (1956) stands out as exceptionally important. He distinguishes the antisocial tendency from delinquency, which refers to an organized antisocial defence overloaded with secondary gain and social reactions which may make the delinquent child difficult to treat. Though deprivation is at the root of both the antisocial tendency and delinquency, the former can be seen in relatively normal children who may, for example, go through a phase of stealing or lying.
There is a very clear summary of this theory in Winnicott’s book, Therapeutic Consultations in Child Psychiatry, 1971, p.216-8), which also contains several examples of how he helped children overcome the presenting symptoms through contact with them. I quote from the book:
‘..where the antisocial tendency…is the character disturbance for which the child is brought there is regularly to be found in the history an early period in which the environment enabled the child to make a good start in a personal development…Then in some cases there is to be found an environmental lapse of some kind or other as a result of which the maturational processes become blocked, perhaps suddenly. This blockage of the child’s reaction to the new anxieties cuts across the line of life of the child. There may be a kind of recovery, but there is now a gap in the continuity of the child’s life from the child’s point of view. There has been an acute confusional state in the time-phase between the environmental failure and whatever there may be in the way of recovery. In so far as the child does not recover the personality remains relatively disintegrated and the child is clinically restless and dependent on being directed by someone, or restrained by an institution. In so far as there is recovery the child can be said to be (a) most of the time in a somewhat depressed state, hopeless but not knowing why, and then (b) the child begins to get hope. There is hope perhaps because of something good happening in the environment. It is at this point, the point where hope appears, that the child becomes alive and reaches back over the gap to the satisfactory state that obtained before the environmental failure.’
Winnicott distinguishes two types of antisocial tendency. In the one the illness present as stealing or claiming special attention through minor delinquencies which give the parents extra worry. In the other there is destructiveness which provokes firm management, that is management without retaliation.
The treatment of the antisocial disorder is not psychoanalysis, but is informed by psychoanalytic thinking and consists of the provision of child care which can be rediscovered by the child, and into which the child can experiment again with their impulses, and which can be tested. It is the stability of the new environmental provision which becomes therapeutic.
A number of Winnicott’s other talks and papers which involve the application of psychoanalysis involve considering how to manage the immediate environment of the child in order to help the child overcome their symptoms. This may even include removing the child from the home situation, or on the contrary keeping the child in a home situation that can become therapeutic, with some professional help.
Of course this ‘active’ involvement with children and parents may seem strange to those who only work as psychoanalysts, or even to those who only work with adults in various settings. But to those, like myself, who are child psychiatrists, it is part and parcel of the work. One can of course provide as part of the assessment a psychotherapeutic experience, and I certainly endeavour to do that. But the presenting problem may involve having to manage the child’s school or home environment in active ways in order to effect significant change. In this sense, Winnicott’s descriptions of his practice are still very relevant to today’s families, the more so now that the provision of services for children has been so undermined by massive budget cuts.
I worked for nearly thirty years as an NHS Consultant, at the Family Unit of the Cassel Hospital in Surrey, now defunct; but now that I work as a child psychiatrist in the private sector, I see many families who can no longer access NHS facilities. As a result, Winnicott’s paper on Private practice (1955) is particularly relevant to the current situation concerning child services. While he wrote there that it would be a tragedy if private practice in child psychiatry were to disappear, the situation today can be turned round – it would be a tragedy if the practice of child psychiatry in the public services were to disappear, as it appears to be doing. There is in my view a difference between a child and family seeing a consultant child psychiatrist experienced in talking with children and seeing a ‘mental health professional’ with little in-depth experience of making therapeutic contact with children.
He argues that private practice is economical in terms of man-hours, compared to the involvement of a whole team, as necessary as that may be on occasion, especially with those cases that require a team and a clinic for management. He puts forward five points to support his assertion. They are that in private practice the psychiatrist has responsibility for the whole case, though that means having to bear the ‘stomach-ache’, that is the anxiety, alone. In private practice, one can more easily see anyone concerned with the child. One can also act more on impulse, that is spontaneously; this is much more difficult in the clinic or in other institutional settings, which means that one may avoid some simple intervention. One can act more speedily in private practice, and, finally, one tends to get the type of case in private practice in which the parents are able to take a responsible part in the search for the right school – a situation common to today’s practice.
This period contains several papers and talks concerned with the family. This includes a remarkable account of a working-class family who were enabled to see their six year old child through a psychotic illness lasting 15 months – A case managed at home (1955). It is difficult to imagine such a treatment being possible these days, given the difficulty professionals often now have in taking professional risks in the service of their patients and clients.
The paper concerned a six year old girl who developed psychotic symptoms prior to being a bridesmaid at her aunt’s wedding. She developed paranoid ideas, became negativistic, started talking to herself and talked about the wedding being her own and not her aunt’s. There had been some preliminary neurotic symptoms and had also been a somewhat sensitive and even touchy child, but the psychotic illness was a surprise and became increasingly worrying, when she began to hallucinate; it coincided roughly with the marriage.
Winnicott traced the illness to internal conflicts between her male identifications, heightened at the time of the marriage. But the main point of the clinical account was to show how an ill child could be helped by the home becoming almost like a mental hospital, adapted closely to the child’s paranoid organization, until she gradually recovered, being able gradually to let go of her paranoid system. He would see the mother and child for brief sessions each week for a period of months, and contacted the local authority to make sure they did not intervene to remove the girl. As he put it, the ‘burden of the case rested on the mother and indeed on the whole family, and the successful outcome was very largely the result of the work done in the child’s home over a period of a year.’
In other papers, Winnicott would look at the effect of depressed and psychotic parents on family functioning. Rather than see psychiatric illness as a psychiatrist would, that is as a disease, his general approach was to think of ‘psychiatric patients not as so many diseases but as people who are casualties in the human struggle for development for adaptation, and then for living…When we see a psychotic patient we feel ‘here but for the grace of God go I,’ (The effect of psychotic parents on the emotional development of the child, 1959).
He charts with some clinical examples the various effects that the disturbed parents had on their children, and how it was necessary to help the children make sense of what is going on.
Winnicott very much tried to work with the positive tendencies in parents where possible, as with the example of the family who treated their psychotic child at home. He also emphasized the ‘tremendous reassurance that the live human infant brings through being a fact; real, and…neutralizing fantasy and eliminating expectations of disaster,’ (Integrative and disruptive factors in family life (1957). Yet each child falls into what he calls the ‘imaginative elaboration of the important function of sex’ – the way that each child fits specifically, or fails to fit, into a certain imaginative and emotional setting which can never be the same twice, even when everything else in the physical environment remains constant. The child, then, can enrich and elaborate the parent’s physical relationship.
However, family life can become disrupted, not only by illness but also if they fail to meet the challenges coming from their children, particularly at adolescence.
One particular gem of a talk is his Contribution of psychoanalysis to midwifery (1957), which remains a model of how psychoanalysts can talk to other professionals with clarity and respect, as well as being particularly relevant to today’s obstetric practice. He emphasizes the human aspects of the professional network, the need for the mother, the doctor and the midwife to get to know one another, if possible throughout pregnancy, particularly because of the mother’s vulnerability at this time. He examines the relationships between the various parties, including the father, and how the mother can have complex feelings towards the midwife, including seeing her as a revengeful mother figure. By looking at the complex network of relationships around the emerging baby, Winnicott sees psychoanalysis as bringing to midwifery, ‘and to all work involving human relationships, an increase in the respect that individuals feel for each other and for individual rights. Society needs technicians even in medical and nursing care, but where people and not machines are concerned the technician needs to study the way in which people live and imagine and grow in experience.’
- Winnicott and Psychoanalytic Politics – a glimpse through his letters
As I have already indicated, this period was in some ways a difficult one for Winnicott institutionally. Though he served as President of the British Psychoanalytical Society at this time, his professional relationships with colleagues were at times strained, partly as a result of the increasing development of his own ideas, which, thanks to the publication of his papers, by the end of this period were being greatly appreciated abroad. I have already described how he gradually moved away from Klein’s influence as he formulated his own very different views about infant development. He retained a great respect for her contributions to psychoanalysis, but he felt that she ignored the reality of the child’s environment. In that sense, he was nearer to Anna Freud, to whom he gradually became closer. He also found the behaviour of Klein’s followers irritating, believing that they were doing Klein herself no good by their belligerent attitude.
These struggles can be followed by reading through some of his letters, now available in his Collected Works, which can be quite frank about his views. Thus in his letter to Wilfred Bion, he compliments him on the paper he had read at the British Psychoanalytical Society, seeing him as someone with a big future, then says that,
‘The strength of your personality makes it difficult for people to get up and tell you that you in a muddle or that you have said something wrong, and at the meeting on Wednesday your relation to the Society was completely spoiled by the fact that the first three or four speakers were Mrs Klein and the Pro-Kleinians. The impression was given that you were being protected from the Society and I really believe you must hate this sort of thing… I have tried very hard to get into contact with the Klein group in order to point out to them the harm they are doing to the Klein cause by this sort of behaviour.’
Further on, he bemoans the ‘plugging of theme-songs’ and the disruptive effects on the Society of unhelpful group behaviour, a theme he also picks up in letters to Roger Money-Kyrle, where he complains about Kleinian ‘propaganda’.
In the letter to his second analyst Joan Riviere, he expresses considerable distaste for Klein’s concept of envy. This is preceded by a rather bitter complaint that Klein no longer listens to him. Thus,
‘After Mrs Klein’s paper [on Envy and Gratitude], you and she spoke to me and within the framework of friendliness you gave me to understand that both of you are absolutely certain that there is no positive contribution to be made from me to the interesting attempt Melanie is making all the time to state the psychology of the earliest stages. You will agree that you implied that the trouble is that I am unable to recognize that Melanie does say the very things that I am asking her to say. In other words, there is a block in me. This naturally concerns me very deeply and I very much hope you will give me a little bit of your time…’.
His hurt feelings did not prevent him, however, from sending notes about Klein’s paper and his areas of disagreement. He feels she has ‘let herself down badly by making statements which it is very easy to pull to pieces’. Hardly surprising, then, that Klein and her followers were not that pleased with his comments.
By the time that he reviewed Klein’s Envy and Gratitude in 1959, Winnicott seemed less desirous of having a direct conversation with Klein, no doubt having finally realized it was not going to happen. He makes a clear distinction between their approaches. He sees envy as a sophisticated phenomenon, implying a high degree of ego-organisation. He also states that if ‘envy is described as an infantile characteristic without any mention of the behaviour of the object and all that that implies, then I consider that something is wrong. Talking about infants is not the same as talking about primitive stages in the emotional development of persons as seen in the study of patients.’
While Winnicott could see that the baby may ruthlessly attack the mother’s body, he is adamant that ‘it is another Kleinian mistake…to talk about the infant apart from the mother’s care of the infant,’ (Letter to Barbara Lantos.}
One of course gets glimpses of Winnicott’s personality in these letters, his independence of thought, his wish to share whatever has been sparked off while listening to a paper, regardless of whether or not the person he writes to wants his opinion, and at this period a certain amount of insecurity and sadness about no longer being close to Klein. But by the end of this period, he seems finally to have become secure in his own thinking. It is a period that lays the foundation for his last phase of work, where he brings together his thinking; it is then, one might say, that Winnicott’s true analytic self finally becomes established.