Forensic Psychotherapy and Psychopathology

Winnicottian Perspectives

Brett Kahr

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781855752375
• eBook ISBN:
  9780429913853
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

This exceptional book adds to the fast growing area of forensic psychotherapy and shows the relevance of Winnicott's work to therapy with some of the most deprived in our society. Contributors:Brett Kahr; Jennifer Johns; Estela Welldon; Joan Raphael-Leff; Valerie Sinason; Jeannie Milligan; Donald Campbell; Em Farrell; Peter Giovacchini; Charles Socarides; Murray Cox.

Chapter One

Winnicott: a beginning

Jennifer Johns

It would require more than a single chapter to do any justice at all to Donald Winnicott’s life and his contributions to the understanding of the developing inner world of the baby and child, his view of the importance of relationships in that development, and the continuing story of the vicissitudes of human life both as they affect and are affected by the developing individual. Winnicott’s biography can be studied in the books about his work by Adam Phillips (1988) and Michael Jacobs (1995). Recently, Brett Kahr (1996a) has produced impressive details of his life. To summarize: Winnicott came from a stable English background that existed one hundred years ago, before the earthquakes of this century that were to affect both him and his work later.

Winnicott was the youngest child, the only boy, of a prosperous Methodist middle-class family with a strong sense of civic responsibility, living in Plymouth. He was sent to school in Cambridge, and then he later went to the University of Cambridge and studied biological sciences, before going to London to become a doctor. The son was special in a rather feminine family—his earnest father is described as being absent much of the time—with both the rewards and the burdens of specialness and responsibility. Going away to school seems to have been something of a relief and perhaps allowed room for his playfulness and the music that he loved all his life.

At school, he read Charles Darwin, and he was excited by the ideas of natural selection, those complex interactions between environment and heredity that are responsible for shaping the natural world. This interest seems to have foreshadowed and influenced both his capacity for detailed observation and his later understanding of the delicate interaction of environment and in born elements in the development of the individual human being.

In 1914, at 18 years of age, he saw his stable world plunged into destruction. At least five of his contemporaries from school were killed in the Great War, and he also lost university friends (Kahr, 1996a). In the military hospitals in Cambridge, as a student, he would have come across the wounded, gangrenous, maimed, gassed, and shell-shocked from the trenches, and he later saw action himself in the Royal Navy as a Surgeon Probationer on a destroyer. Following this exposure to trauma, he went to London to further his medical studies, and by 1919 he had discovered another great influence—Sigmund Freud and psychoanalysis. In particular, he relished The Interpretation of Dreams (1900a), Freud’s major piece of writing before the introduction of the structural model, when the term “ego” meant much what we mean by the word “self” today.

With the influences of Darwin and Freud inside him, Winnicott qualified in medicine in 1920, and by 1923 he had become a specialist in paediatrics. He practised both in Hackney and at the Paddington Green Children’s Hospital, where he remained for forty years, dealing with over twenty thousand cases, a volume of observational work unequalled by any other psychoanalyst. In 1923, Winnicott also married, and shortly thereafter he began his own personal analysis with James Strachey. He trained as an analyst from 1927 to 1934, during which time he published his first book, Clinical Notes on Disorders of Childhood (Winnicott, 1931). The book is now out of print, but it is quite remarkable for its careful descriptions of the physical examination and diagnosis of the sick child, as well as for its sensitivity to the emotional aspects of ill-health in children.

By 1935, Winnicott had also become a child psychoanalyst, having had supervision with Melanie Klein, his next great influence. By the time the Second World War broke out, he was a respected member of both the medical establishment and the British Psycho-Analytical Society. This “foot in both camps”—being both paediatrician and psychoanalyst—gave him the practical background to write and to broadcast widely on matters to do with the welfare of children and families. He spoke of early development, growth, feeding, school, siblings, the evacuation of children during the war, and the effects of separation from parents and subsequent difficulties, particularly delinquency. His information and ideas proved useful to parents, teachers, social workers, probation officers, doctors, and all students of human nature.

At the outset of the war, together with John Bowlby and Emanuel Miller, he had warned publicly of the dangers of the evacuation policy; their predictions came true in terms of the many children separated from their home environment who became distressed, difficult, and delinquent, requiring serious help and management (Bowlby, Miller, & Winnicott, 1939). It was while working with these children that Winnicott met another of his life’s great influences, his colleague Clare Britton, a social worker, who later became his second wife. At that time, he also began the major part of his writing.

During the Second World War, there was internal conflict in the British psychoanalytic world, to do with the differing theories of early psychic development held by Anna Freud and by Melanie Klein. These controversies had a subsequent effect on Winnicott’s psychoanalytic career, and he attended the famous Controversial Discussions. Winnicott, having been trained by Klein, became unable to align himself with her to the degree that she wished in relation to her theories about the inner world of the baby. Having observed so many babies and children with their mothers, he also valued Anna Freud’s ideas about the internal world of the toddler and older child, and he had his own ideas about the earliest stages of life, finding it difficult to accept that the internal world of an infant could be so necessarily conflictual and persecuted as Klein believed. Winnicott, in no sense a “joiner”, took neither side. He was a person who would question received knowledge, who could be challenging, even aggressive, to thinking that he regarded as wrong, or which was being used in a defensive way.

Besides, for Winnicott, during that war and the period of post war austerity including the beginnings of the Welfare State, there were other things to do than engage closely in these debates. As well as responding to the public issues of the time about the effects of the emergency on children and families, his own observation of mothers and babies in clinics continued. A beautiful early example is the description of the baby’s exploration of the set situation with the spatula, written in 1941, strengthening the foundations of his unique view of the earliest stages of individual development (Winnicott, 1941).

The dual focus of paediatrics and psychoanalysis is crucial to the understanding of Winnicott’s work. He started as a paediatrician, a body doctor who knew that babies live in and are their bodies. There is no split between body and mind for them. Skin, joints, and feeling, eyes and vision, ears and hearing, orifices and gut lining, genitals, limbs, and excitement—these both produce and express affect and the beginnings of thought and being. Out of this he became concerned with the way babies become themselves, how they develop their own sense of being. For him, the crucial question was how they come to know that they are persons, which they do in relation to their mothers—one aspect of the facilitating environment. He approached and refined his views on this topic from many angles throughout his life.

Winnicott held that no two babies are the same, and that each mother-baby couple is unique. He believed that most human beings are bom with what he called a maturational tendency towards growth and differentiation, given a more or less ordinary environment, and that an aspect of this was the tendency also to repair, given the facilitating environment. He described how, from the baby’s point of view, awareness of separateness and individuality comes gradually out of a state of undifferentiation, in parallel with awareness of mother’s separateness, and also in parallel with a sense of integration, all based on repeated experiences of body care, holding, nursing, gazing, exchange of vocalization. He observed that mothers and babies are always together, that one cannot be considered without the other, as encapsulated in his famous saying: ‘There’s no such thing as a baby.” He saw ordinary mothers unconsciously and in a bodily and psychological way adapting themselves to their babies, and he noted that pregnancy itself, with its enormous physiological and emotional changes, automatically lays the foundation for this primary maternal preoccupation. And he observed that normally the adaptation to the baby falters, becomes less perfect, in step with the baby’s growing capacity to survive these failures. He called this process of attunement and its gradual loss “good-enough mothering”.

Winnicott saw that as development proceeds and the difference between the baby’s awareness of “me” and “not-me” strengthens, many babies need a link, a way of bridging the gap that might be too much for them, and he explained the existence of transitional phenomena, the use of a comforting blanket or teddy, or even a sound or thought. The transitional space in which such phenomena occur provides room for the development of play and also of the ability to stand separateness for increasing amounts of time.

Like all medical theorizing about health and normal development, inferences have to be drawn from states where that development has failed or has been interfered with, and Winnicott’s observations were often of mother-baby couples where a “good-enough” environment had not been achieved—for instance, where a mother is absent, physically or emotionally, or is disturbed or intrusive, or when a particular baby has needs that cannot be fulfilled. One variety of “not good-enough” mother, when a mother cannot respond sensitively to what Winnicott describes as the baby’s gesture, but substitutes one of her own, may result in the baby who cannot be spontaneous, only compliant or imitative. Such people have what he called a “false self”. Such individuals may apparently lead successful lives, but at the price of their own vitality. He also wrote about the effect of mother’s unconscious states, including her unconscious hatred of her baby, and he linked this with the hatred that those responsible for delinquents can come to feel towards their charges (cf. Winnicott, 1949a).

Winnicott’s double and intertwined career continued, and in the 1950s and 1960s he was increasingly recognized, both in the paediatric world and in that of psychoanalysis and child psychiatry. He became a president of the Paediatric Section of the Royal Society of Medicine, and of the Association of Child Psychology and Psychiatry, among many other honours. Until his death in 1971, he continued to write about many subjects, such as play, the child’s sense of morality, adolescence, juvenile delinquency, and his own communication with children, both his clinical accounts and the use of the squiggle game—at every step refining his view of human development. Also concerned with social issues and contemporary matters such as adolescent problems, democracy, or the atomic bomb, he addressed national and international audiences of varying degrees of sophistication, and he always wrote according to his audience, whoever it contained.

At the time of his death, Winnicott had published a little over half of his work. Clare Winnicott became the driving spirit behind the publication of much of the remainder, aided by Madeleine Davis and Ray Shepherd. Later, realizing the approach of her own death, Clare Winnicott set up The Winnicott Trust, for two purposes: firstly, to complete the work of publication; secondly, to further the links between the world of psychoanalysis and other spheres, especially paediatrics and child psychiatry. The Winnicott Trust, originally under the chairmanship of the late Dr Martin James, and subsequently of Dr Jonathan Pedder and, more recently, myself, has been active in promoting the work of Professor Lynne Murray and her colleagues at the Winnicott Research Unit at the University of Cambridge, and it has also provided funds for other research, including that of Professor Peter Hobson at the Tavistock Clinic in London.

This can only be a short account of this small, at first meeting insignificant-looking man, with his high-pitched voice and wicked sense of humour, who has influenced our world so greatly. His own description of himself, given to a child psychiatric conference shortly before his death, includes the following words:

Among other things was always the fact that I am rather an ordinary person, neurotic along the English inhibited pattern, at one time being inordinately shy, and not quite so tall as I intended to be, which I have always felt to be a major fault. I spent the first two decades of my life half-drowned in a perpetual sense of guilt, from which psychoanalysis rescued me, except that I can never escape from the sense that I ought not to have escaped the death that eclipsed the careers of so many of my friends in the 14–18 War. [Winnicott, 1970]

Donald Winnicott escaped that death, but he spent his life studying the ways in which persons achieve life, a sense of liveliness, and ongoing being. His ideas survive, and they are carried on by workers whom he never met, in fields he might not have thought of, but whom he would have enjoyed, argued with, and, from my own memories and what we know of him, probably been troublesome to.

Chapter Two

Babies as transitional objects

Estela Welldon

I saw a man who had requested a consultation with a female psychiatrist. The first time he came, he asked me directly and emphatically: “Are you Jewish or Catholic?” Although the question did not take me by surprise, since patients or prospective patients would like to know all sorts of information regarding their psychotherapists, the tone of this man’s question conveyed a sense of urgency and despair that made me feel that it was necessary to take into account its deeper, unconscious layers. As usual, I explained that, though the factual information could be easily imparted, this would immediately pre-empt access to other immensely significant areas unknown to himself that could give us important clues to his present predicament.

This patient was a married man in his mid-40s with four children who had referred himself with the following letter:

“I have lived with a condition for most of my life which manifests itself in the form of transvestial [sic] or transsexual behaviour and feelings. Whilst I am able to suppress these feelings for a good deal of the time, there nevertheless comes a moment when I can cope no longer—has happened now […] and for the first time self-mutilation seems to be logical. […] I desperately need someone to help me decide upon the best way in which I could free myself of my now unremitting torment. […] The symptoms that I am experiencing at the moment fall into two quite distinct categories, i.e. mental and physical. Mentally, I feel that I am a woman in the cliché situation of having to masquerade my way through life simply because I am not as perfect as I want to be. […] I can quite see the clear possibilities of a “change”. To this end I have now almost cut myself off emotionally from those around me—and so the conflict rages, as I question: to whom does my first loyalty lie, my family, all of whom are and will be able to make lives of their own, or to myself, with one precious life only? […] On the physical side, the tension can only be relieved by wearing anything other than men’s clothes. […] More obvious symptoms, physical side that is, are: morning sickness, vomiting through the day, loss of appetite, feeling shivery, aching in the small of the back and the most obvious sign that tells me when I am about to “go under” again—that my breasts become tender and sore—and it is at these times that the sensation of my nipples touching against my woolly jumper makes me just want to scream. […]”

The letter continued in the same vein. From his own description of his problem, we can vividly experience his enormous despair and his sense of despondency and desolation.

He told me of his bizarre and complicated early childhood. He was the younger child in a family of two, with an older sister. When he was 1 year old, during the Second World War, he was sent to stay with one of his aunts for “reasons of safety”. His early recollections had to do with feelings of being lost. He remembered his time with his aunt as an extremely confused one. She was a warm and kind woman, but suddenly, when he was aged 3, she made it blatantly clear to him that unless he complied with all her wishes, she would withdraw her love. The conditions she imposed included not only wearing girl’s clothes, but behaving like a girl as well. He still remembers with trepidation that period of his life. At the beginning, he tried to go against his aunt’s whims, but he soon realized that the consequence would be complete isolation. After all, he had already been given away by his own mother, from whom he received a few postcards, but never a visit. He then started to comply with everything required of him. After an initial period of resistance during which he felt awkward, uneasy, and on the alert lest others should notice his being a “fraud”, his mood changed, and he acquired a growing sense of self-confidence while wearing girls’ dresses. Actually, to his own surprise, he began to thoroughly enjoy this “imposed” cross-dressing, when everyone took it for granted that he was a girl.

Tellingly, his aunt had had a daughter, who had died at a very early age, and this was followed shortly afterwards by her husband’s death. The aunt now decided to send her nephew to an all-girls school, and she taught him how to behave like a girl; for medical visits, she would come to London and have him examined by a doctor friend of hers. At the age of 12, he looked convincingly like a girl. On the occasion of a family member’s wedding, he was made the bridesmaid. He became the object of the most extraordinary scandal when, during the ceremony, his real mother—who had not seen him since she had sent him to live with his aunt—suddenly realized that this beautiful “girl” who was accompanied by “her” aunt was in fact her own son. Amid screams and shouts, he was taken away by his real mother, who not only severely punished him, but proceeded immediately to send him to an all-boys school. There, his suffering, torment, and humiliation became so great that eventually his mother decided to send him back to his aunt, but things were never to be as they had been before. He now had to suffer his aunt’s denigration for his “maleness”. I prefer not to go any further into this case here. What has been said will be sufficient to convey the horrors that the two women, in their role of mother, together inflicted on this poor boy from infancy to adolescence.

But what about his first question to me? His father and mother were Jewish, but the aunt, who had been married to the brother of the boy’s father and who had brought the boy up since the age of 1 year, was the only Catholic member of his family. He had been surrounded by all sorts of “maternal” perverting attitudes throughout his early life, both from his mother and from his aunt. The fact that I did not give him any information about my personal life—in this case, my religious affiliation—gave us the chance to explore his trepidation in his own search for who he really was. ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• SERIES FOREWORD
• CONTRIBUTORS
• ACKNOWLEDGEMENTS
• FOREWORD
• Introduction Winnicott’s contribution to the study of dangerousness
• 1 Winnicott: a beginning
• 2 Babies as transitional objects
• 3 Primary maternal persecution
• 4 Children who kill their teddy bears
• 5 Deprivation and delinquency in the treatment of the adolescent forensic patient
• 6 On pseudo-normality: a contribution to the psychopathology of adolescence
• 7 Vomit as a transitional object
• 8 Transitional objects in the treatment of primitive mental states
• 9 D. W. Winnicott and the understanding of sexual perversions
• 10 On the capacity for being inside enough
• REFERENCES
• INDEX