Holding and Interpretation

Fragment of an Analysis

Donald W. Winnicott

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780946439515
• eBook ISBN: 9780429914546
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In his illuminating introduction, Masud Khan, to whom Dr Winnicott's case notes were entrusted, relates this definite text of Holding and Interpretation: Fragment of an Analysis to an earlier phase of the treatment of the same patient described by Winnicott in his paper 'Withdrawal and Regression', also included in this volume. The case documents the therapeutic care of a highly gifted professional man who suffered a psychotic breakdown with acute depression, and who, through analysis, and hospital treatment, was gradually helped to recovery. It is remarkable for many things: Dr Winnicott's skill at 'holding' the patient in the analytical sessions, and providing guidance through sensitive interpretation; his ability to re-enforce the patient's sexual and ego functions; his instinctive recognition of the value of silence (as a way of showing trust, and of not destroying by intent); his capacity to accept the paradox that verbal communication can be both meaningful and a negation of psychic reality; and, not least, his acute judgment of when to stop the analysis.

Fragment of an Analysis

THIS fragment of an analysis is given as an illustration of the depressive position as it can appear in the course of an analysis.

The patient is a man of thirty, married, and with two children. He had a period of analysis with me during the war, and this had to be broken off because of war conditions as soon as he became clinically well enough to work. In this first phase he came in a state of depression with a strong homosexual colouring, but without manifest homosexuality. He was in a bemused state and rather unreal. He developed little insight although he improved clinically so that he could do war work. His very good brain enabled him to juggle with concepts and to philosophize, and in serious conversation he was generally thought of as an interesting man with ideas.

He qualified in his father's profession, but this did not satisfy him and he soon became a medical student, probably (unconsciously) retaining thereby his use of myself as a father-figure displacing his real father, who had died.

He married, and in doing so offered a girl who needed it a chance for therapy through dependence. He hoped (unconsciously) that in his marriage he was laying down a basis for a therapy through dependence for himself, but (as so often happens) when he in turn claimed special tolerance from his wife he failed to get it. She fortunately refused to be his therapist, and it was partly his recognition of this fact that led him to a new phase of illness. He broke down at work (as a doctor in a hospital) and was admitted into an institution himself because of unreality feelings, and a general inability to cope with work and with life.

He was not aware at that time that he was seeking out his former analyst, and was quite incapable of asking even for analysis, although as it turned out later this is what he was precisely doing and nothing else would have been of value.

After about a month of the new analysis he was able to resume work as a hospital officer.

He was by this time a schizoid case. His sister had had a schizophrenic illness treated (with considerable success) by psychoanalysis. He came to analysis saying that he could not talk freely, that he had no small talk or imaginative or play capacity, and that he could not make a spontaneous gesture or get excited.

At first it can be said that he came to analysis and talked. His speech was deliberate and rhetorical. Gradually it became clear that he was listening to conversations that were going on within, and reporting any parts of these conversations that he thought might interest me. In time it could be said that he brought himself to analysis and talked about himself, as a mother or father might bring a child to me and talk about him. In these early phases (lasting six months) I had no chance of direct conversation with the child (himself).¹

The evolution of the analysis at this stage is described elsewhere.²

By a very special route the analysis changed in quality, so that I became able to deal directly with the child, which was the patient.

There was a rather definite end to this phase, and the patient himself said that he now came himself for treatment, and for the first time felt hopeful. He was more than ever conscious of being unexcitable and lacking in spontaneity. He could scarcely blame his wife for finding him a dull companion, unalive except in serious discussion on a topic set by someone else. Actual potency was not disturbed, but he could not make love, and he could not get generally excited about sex. He had one child, and has since had a second.

In this new phase the material gradually led up to a transference neurosis of classical type. There came a short phase leading obviously to excitement, oral in quality. This excitement was not experienced, but it led to the work described in detail in the case notes that follow. The case notes refer to the work done between the excitement that arrived in the transference but which was not felt, and the experience of the excitement.

The first sign of the new development was reported as a feeling, quite new, of love for his daughter. This he felt on the way home from a cinema where he had actually cried. He had cried tears twice in that week, and this seemed to him to be a good omen, as he had been unable either to cry or to laugh, just as he had been unable to love.

By force of circumstances this man could attend only three times a week, but I have allowed this, since the analysis has obviously gone with a swing and has even been a rapid one.

Thursday, 27 January

Patient The patient said that he had nothing much to report except that he had had a cough. Probably this was an ordinary cold. It did occur to him, however, to think in terms of TB, and he had been going over in his mind the use he could make of it if it should turn out that he should have to go to a hospital. He could say to his wife: 'Now here I am . . .'

Analyst Various interpretations were possible here and I chose the following: I said that what was ignored was the relationship of this illness to the analysis. I was thinking in terms of the break it would make in the treatment. I said that I was not at all sure that this rather superficial working out of the consequences was the most important part of the anxiety. At the same time I dealt with the reality aspect and said that I was going to leave it to him. He was conscious of the fact that he wanted me to deal with this as material for analysis and he did not want me to take part in actual diagnosing.

Patient After my interpretation he said that in fact the idea came at him not as TB, but as cancer of the lung.

Analyst I now had more powerful material to work with and I made the interpretation that he was telling me about suicide. It was as if there was what I called a five percent suicide. I said: 'I think you have not really had to deal with a suicidal urge in your life, have you?'

Patient He said this was only partially true. He had threatened suicide with his wife but he had not meant it. This was not important. On the other hand he had at times felt that suicide was part of the make-up; in any case he said there was the fact of his sister's two suicide attempts; they were partial suicides and not designed to succeed. Nevertheless, they showed him how real suicide could be, even when not an urge involving the whole personality.

He now linked this up with the barrier that he felt he had to get through to get further.

Analyst I reminded him (and he had forgotten) that he felt that there was a person preventing him from getting through the barrier.

Patient He said he felt the barrier as a wall that he must break down or hit himself against; and he had the sensation of having to be carried bodily over the difficult patch.

Analyst I said that we therefore had evidence that between him and health was suicide and that I must know about this as I must see that he did not die.

Patient He had the idea of various forms of starting life again with things different. Pause. He spoke about his lateness which had become a feature recently. This was due to the fact that something new had happened; he could have come, setting aside all his work and hanging around for a quarter of an hour so as to be on time. Instead of that his work had become more important and he now finished things off before coming; with luck he might have been on time. He put it that the analysis had now become less important than his work in some sense.

Analyst I made an interpretation here, gathering together the material of the past and pointing out that I could see this more easily than he could: first he could only contribute into himself, then he could contribute into the analysis; and now he could contribute to the analysis in his work. I joined this up with the guilt which underlies the whole of this phase including the suicide. I reminded him that the thing that the analysis was leading up to was excitement with instinct including eating. The guilt about the ruthless destruction here was too great except insofar as constructive urges and capacities reveal themselves.¹

Pause.

Patient The effect of these interpretations was revealed in the next remark when he said in a much more easy way: 'I now think of the illness in amusing terms; it might be measles, a childhood thing.'

Analyst I pointed out that a change had come over him since I had taken away the suicide communication which was hidden in the fantasies about the illness.

Patient Following this he said that for the first time he felt if opportunity occurred he could use an affair and balance this with his wife's infidelity.

Analyst I pointed out that this indicated a lessening of the dependence elements of his relationship to his wife, these having been gathered into the analysis.

The week following 27 January

The report of the next three sessions is condensed into the following statement.

Patient The patient reported that before the last session he had in fact slept with the girl friend. This was after a party. All feeling was damped down. He said that it might have happened at any time apart from analysis. He felt no love (potency was not disturbed).

The whole of this session was toneless and unconsciously designed to make the analyst feel that nothing important was happening.

Patient Following this he reported that he had expected a great result. He had expected me to know without being told that he had had an experience with excitement in it.

The information came indirectly at first.

Analyst I pointed out to him that he had so damped down the report of what had happened that I had been unable to make use of it. I was now able to interpret the transference significance of the incident and at first I said that the girl represented himself so that in the affair he as a female had had intercourse with me as a male.

Patient He half accepted this interpretation but he was disappointed because there was no natural evolution belonging to the interpretation.

Analyst The following day he was depressed and I made a new interpretation, stating that my previous one had obviously been wrong. I said that the girl was the analyst (in the transference neurosis).

Patient There followed an immediate release of feeling. The interpretation led to the theme not of erotic experience but of dependence.

The analysis now came out of the difficult phase which had lasted throughout the week, and a powerful relationship to me developed which frightened the patient.

Patient His question was: 'Can you stand it?' He spoke about his father in particular among the people from whom he had sought the right to be dependent. His father could take it up to a certain stage, but then always he would hand him over to his mother. His mother was of no use, having already failed (i.e. in the patient's infancy).

Analyst I made another interpretation, which I had to withdraw because I could tell from the effect that it was wrong. I reminded him of the female version of himself that hovered around his male self throughout his childhood, and I equated my new position in the transference neurosis with this female shadow self. After withdrawing this I saw the correct interpretation. I said that now at last his thumb had come to mean something again. He had been a persistent thumb-sucker till eleven, and it would seem likely now that he gave it up because he had no one for it to stand for.¹

This interpretation of the thumb was clearly correct, and incidentally it produced an alteration in his very stereotyped hand movements. For the first time in the whole of his analysis, without being aware of doing so, he put his left thumb up into the air and brought it towards his mouth.

Tuesday, 8 February

The doorbell being out of order, he was kept waiting three minutes on the doorstep.

Patient He reported having a formula for starting, and compared it with history-taking. Patients assume that you know more than you do.

Analyst 'I have to bear in mind that you may have been upset by the waiting.' (Very unusual in the case of this patient.)

Patient He went on with the description of how one gets stuck in history-taking between going into great detail or simply satisfying the patient, presumably pretending that one knows as much as one is expected to know. Somewhere in the middle of this he had a withdrawal.¹ Recovering from the momentary withdrawal, he managed to report the fantasy belonging to the withdrawal, in which he was very annoyed with a surgeon who stopped midway in an operation. It was not so much that the surgeon was angry with the patient as that the patient was just out of luck; he was being operated on when the surgeon went on strike.

Analyst I linked this with the reaction to the weekend following my acceptance of the dependence role. I brought in the bell failure, but this was relatively unimportant; whereas the long breaks linked up directly with his statement at the end of the previous hour that I might not be able to stand his need for an extreme dependence, such as his living with me.

The effect of this interpretation was very marked; the analysis came alive and remained alive throughout the hour.

Patient The patient spoke of his negativity, how it bor...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Introduction
• Fragment of an Analysis
• Appendix: Withdrawal and Regression
• References
• Index