Therapeutic Consultations in Child Psychiatry

Donald W. Winnicott

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429922886
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Over a period of several decades, the author evolved a personal way of relating to and communicating with children, offering them a live professional setting in which to discover themselves. He believed that, in the right case, a full and free use of the first interview can yield rich rewards, and he claimed that the right cases for this are common. He hoped that, by presenting these case studies, he would introduce the reader to the exciting potential of his approach, which depends as much on selection (of therapist) as on training. Here is his presentation - seventeen case histories whose significance for child psychiatry is in the tradition of Freud's case histories of the treatment of adult neurotics. Therapeutic Consultations in Child Psychiatry provides a fruitful feedback to psychoanalysis itself.

Part One
Introduction

THIS book concerns the application of psycho-analysis to child psychiatry. To my surprise I find that my experience over three or four decades of the analysis of children and adults has led me to a specific area in which psycho-analysis can be applied in the practice of child psychiatry, thus making sense of psycho-analysis in economic terms. It is obviously not useful or practicable to prescribe a psycho-analytic treatment of every child, and the psycho-analyst often has found himself or herself in difficulties when attempting to put what has been learned to good use in child psychiatry practice. I have found that by full exploitation of the first interview I am able to meet the challenge of a proportion of child psychiatry cases and I wish to give examples for the guidance of those who are doing similar work and for students who wish to make a study in this field.

The technique for this work can hardly be called a technique. No two cases are alike, and there is a much more free interchange between the therapist and the patient than there is in a straight psycho-analytic treatment. This is not to decry the importance of the long analysis in which the work is done on the day-by-day emergence into the clinical material of unconscious elements in the transference, elements in process of becoming conscious because of the continuity of the work. Psycho-analysis remains for me the basis of this work, and if I were asked by a student I would always say that the training for this work (which is not psycho-analysis) is the training in psycho-analysis. I do believe, however, that selection is the most important part of the psycho-analytic training. It is not easy to turn a badly selected candidate into a good analyst, and no doubt the main part of the selection is always self-selection. The student's own analysis extends this matter of self-selection. One would rather have a really suitable person for doing this sort of work than an ill person made less ill by the analysis that is part of the psycho-analytic training. Of course it can be said that if one has been ill oneself one has greater sympathy with ill people, and that to be convinced of the value of reaching to the unconscious is to have experienced it. But somehow, it would always have been better if we had not been ill and in need of treatment.

If only we knew how to select properly we should know how to choose those who are suitable for doing the work that I describe in this book even when psycho-analytic training is not available. For instance, one can say at once that there must be evident a capacity to identify with the patient without loss of personal identity; there must be a capacity in the therapist to contain the conflicts of the patient, that is to say, to contain them and to wait for their resolution in the patient instead of anxiously looking around for a cure; there must be an absence of the tendency to retaliate under provocation. Also, any system of thought which provides an easy solution is of itself a contra-indication since the patient does not want anything but the resolution of internal conflicts, along with the manipulation of external obstructions of a practical nature which may be operative in the causation or the maintenance of the patient's illness. Needless to say the therapist must have professional reliability as something that happens easily; it is possible for a serious person to maintain a professional standard even when undergoing very severe personal strains in the private life and in the personal growth process which, we hope, never stops.

An extended list of desirable qualities of this kind would leave a big proportion of people who could come forward with an urge to do professional work either in psychiatry or in social work, and for me these things are even more important than the very important training in psycho-analysis. An experience of long deep-going personal analytic treatment is as near as possible essential.

If I am right, then the type of work that I am describing in this book has an importance that psycho-analysis does not have in meeting social need and pressure on clinics.

It must be emphasised at the start that this technique is extremely flexible; it would not be possible for anyone to know what to do by studying one case. Twenty cases might give a good idea, but the fact remains that no two cases are alike. A further difficulty in contributing to the understanding of this work is that there is no way of teaching by talking about the cases. It is necessary to demand of the students a careful and detailed reading and study and enjoyment of total cases.

Naturally the basis of this part of the demand that I am making on the student is the accuracy and honesty of the reporting and it is well known that it is difficult to report accurately. Neither tape-recording nor the video tape can provide the solution to this problem. When I wish to report a case I take notes of everything that happens throughout the interview, including the things I myself do and say, and although this imposes a severe task on myself this is counterbalanced by the reward that comes from the reconstruction of almost a whole interview from the notes taken, often illegible after two or three days. I have enjoyed making this effort to write a full account of case-work because as is well known, a great deal of an interview, and especially its rich detail, gets lost 'as a dream dies at the opening day'.

A certain amount of over-simplification must appear in these cases that I am presenting here because of the fact that in nearly all of them I have employed an exchange of drawings. My technique in these reported cases usually takes the form of what could be called the Squiggle Game. There is nothing original of course about the squiggle game and it would not be right for somebody to learn how to use the squiggle game and then to feel equipped to do what I call a therapeutic consultation. The squiggle game is simply one way of getting into contact with a child. What happens in the game and in the whole interview depends on the use made of the child's experience, including the material that presents itself. In order to use the mutual experience one must have in one's bones a theory of the emotional development of the child and of the relationship of the child to the environmental factors. In my cases described here an artificial link is made between the squiggle game and the psychotherapeutic consultation, and this arises out of the fact that from the drawings of the child and of the child and myself one can find one way of making the case come alive. It is almost as if the child, through the drawings, is alongside me, and to some extent taking part in describing the case, so that the reports of what the child and the therapist said tend to ring true. There is also a practical significance of the squiggle or drawing material in that there can be a gain from taking the parents into one's confidence and letting them know what their child was like in the special circumstances of the therapeutic consultation. This is more real for them than if I report what the child said. They recognise the types of drawing that adorn the nursery wall or that the child brings home from school, but often they are amazed when they see the drawings in sequence, drawings which display personality qualities and perceptive abilities which may not have been evident in the home setting. In several of the cases given here this aspect of the matter will come up for discussion, and naturally it is not always good to give parents this insight (that can be so useful). Parents might perhaps abuse the confidence that the therapist has placed in them, and so undo the work that depends on a kind of intimacy between child and therapist.

My conception of the special place of the therapeutic consultation and the exploitation of the first interview (or reduplicated first interviews) arose gradually in the course of time in my clinic and private practice. There was a point, however, which could be said to have been of special significance, in the mid-twenties when I was a practising paediatrician, seeing many patients in my hospital practice and giving the opportunity for as many of the children as possible to communicate with me and to draw pictures and to tell me their dreams. I was struck by the frequency with which the children had dreamed of me the night before attending. This dream of the doctor that they were going to see obviously reflected their own imaginative equipment in regard to doctors and dentists and other people who are supposed to be helpful. They also reflected to a varying degree the attitude of the parents and the preparation for the visit that had been made. Nevertheless here I was, as I discovered to my amusement, fitting in with a preconceived notion. The children who had dreamed in this way were able to tell me that it was of me that they had dreamed. In language which I use now but which I had no equipment for using at that time I found myself in the rôle of subjective object. What I now feel is that in this rôle of subjective object, which rarely outlasts the first or first few interviews, the doctor has a great opportunity for being in touch with the child.

There must be a relationship between this state of affairs and that which obtains in a much less useful way in hypnosis. I have used this in the theory that I have built up in the course of time in explanation of the very great confidence which children can often show in myself (as in others doing similar work) on these special occasions, special occasions that have a quality that has made me use the word sacred. Either this sacred moment is used or it is wasted. If it is wasted the child's belief in being understood is shattered. If on the other hand it is used, then the child's belief in being helped is strengthened. There will be those cases in which deep work is done in the special circumstances of the first interview (or interviews) and the resulting changes in the child can be made use of by parents and those who are responsible in the immediate social setting, so that whereas a child was caught up in...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• PART ONE Introduction
• PART TWO Introduction
• PART THREE Introduction
• Bibliographical Note
• Index