The Clinic of Donald W. Winnicott

Laura Dethiville

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429674624
• Topic: Medicine
• Subtopic: Pediatric Medicine

Paediatric psychoanalyst Donald W. Winnicott is widely recognized as a remarkable clinician. Deprivation, regression, play, antisocial tendencies and "the use of the object" are part of the many clinical conceptions he conceived, and here Laura Dethiville explains each in a clear and precise way, highlighting Winnicott's originality and enduring relevance. The Clinic of Donald W. Winnicott offers all readers a glimpse of what Winnicott brings to the understanding of the human being, and will appeal to students new to his work, as well as practitioners looking for a concise overview of his work.

Chapter 1

Therapeutic consultation

It has often been said that Donald W. Winnicott was an atypical analyst. Even today, he is often referred to as being first a paediatrician, and later a psychoanalyst. But he was not a paediatrician who turned to psychoanalysis: “He was a consultant in a hospital for children, whose work was transformed by his personal experience of psychoanalysis” (Dethiville, 2014: 21). This perpetual back and forth influenced his maturing years considerably. As he would attest later, “no analyst was a paediatrician, and no paediatrician was an analyst. For twenty to thirty years I was an isolated phenomenon” (Winnicott, 1990: 72).

In 1920, Winnicott completed his medical studies, specializing in children’s medicine (at that time the paediatric specialist did not exist). In 1923 he was appointed head of the infantile medicine department at Queen Elizabeth Hospital for Children in Hackney. He was 27. He also directed the rheumatic and cardiac department of the London County Council.

Paddington Green Children’s Hospital

At the same time, he obtained a hospital post at the Paddington Green Children’s Hospital, where he worked for 40 years, in what he mischievously called a “department for the management of maternal and paternal hypochondria” (Winnicott, 2001: 52). In this department he treated children with various somatic disorders. These children, often very small, were of course accompanied by someone in the family, mainly their mothers, for their fathers were at work. We can find accounts at the very beginning of his work in his notes (Winnicott, 1931), clinical studies of such illnesses as chicken pox, encephalitis, enuresis, haemoptysis, heart murmur, or urticaria. The discovery of antibiotics totally changed the understanding of such life-threatening illnesses. In this same year he began a psychoanalysis with James Strachey. In 1927 he began training as an analytic candidate in the British Psychoanalytic Society.

His clinical consultations gradually evolved from paediatrics to infantile psychiatry with a psychoanalytical approach. With time, he worked increasingly less as a paediatrician and more as a child psychoanalyst, at the same time using his medical formation to treat somatic disorders. He often described himself as “a psychiatrist with paediatric formation”, which enabled him to save the lives of young patients, when he detected an organic disorder and was able to refer them in time to the relevant specialist.

It was at the Paddington Green Hospital where he developed empirically a method of working which he called “therapeutic consultation”, a term he invented to distinguish this psychoanalytical work from psychotherapy.

He saw children together with members of their family. This meant that often there were lots of people present – including brothers and sisters of the child and many students and trainees – which seemed in no way to affect his ability to establish a link with his patient.

“The first time I attended his consultation at Paddington Green Children’s Hospital,” wrote Anne Clancier,

I was amazed at how easily D.W. Winnicott established communication with a child. That very day one of the children brought to his consultation refused all contact; he stood still in a corner of the room, silent, avoiding eye contact. Winnicott sat down on the floor a little way from the child, took a pile of square pieces of paper, and a pencil, while another pencil lay on the floor next to the pile of papers; Winnicott rapidly drew a curved line, commenting all the while on what he was doing; the child became interested, drew nearer, and then sat on the floor.

Winnicott invited the little boy to complete the doodle, as if the conversation was already in progress. After a while the child drew a line on the same piece of paper; then Winnicott carried on with the drawing, commenting all the time. Then he took up another piece of paper and invited the child to start the game; he drew a curved line, which Winnicott completed immediately, then it was his turn to start a scribble on another piece of paper, which the little boy completed, and so on, each one either starting or finishing the drawing in turn.

(testimony of Anne Clancier in Clancier and Kalmanovitch, 1999)

These therapeutic consultations took place in a spacious room – an important factor because the topological layout was essential to his staging of the scene, which took place in the presence of an attentive, enthusiastic audience (student nurses, trainees and junior analysts).

The testimony of Joyce McDougall

Joyce McDougall was one of these observers, and she has often said how impressed she was by Winnicott’s clinical acuity. She liked to recount the following anecdote:

A young Cockney woman came into the interview room holding a little boy by the hand, Bobby, aged about three. Winnicott made him sit down and gave him a piece of paper and a pencil so that he could draw. Then he asked the mother why she had come. She pointed at her little boy and said: “Doctor, he doesn’t shit any more. Our doctor said that everything is fine in his body, and that we should see a specialist.”

“How long has it been?”

“It’s been more than two weeks now. Isn’t that strange?” And she went on to talk about her other child, an older girl, her husband and her work as a caretaker.

At one point Winnicott interrupted her and asked: “Tell me, Mrs X, how many weeks are you pregnant?”

“Oh, doctor! How do you know? I haven’t told anybody, not even my husband. Nobody knows!”

“Except him, he knows!” he replied indicating the little boy, who was busy drawing large circles.

Then he turned to Bobby and asked him “Would you like to know more about the baby in your Mummy’s tummy?”

“Oh yeah, I want to!” replied the little boy nodding his head emphatically. Turning to the mother, Winnicott said: “You don’t have to tell your husband if you don’t want to, but you could find time to tell Bobby, couldn’t you? Let him touch your belly and tell him that there is a little brother or sister waiting to be born.”

“I just have to talk to him, is that all doctor?”

Winnicott asked the mother to come back the following week.

Eight days later, Mrs X arrived and announced triumphantly: “Oh doctor, he shits, and shits and shits again. It’s a real miracle!”

(McDougall, 2009: 25)

We can find an account of this by Winnicott himself, dating from this period (his biographers estimate that he had met with around 60,000 families during his 40 years of therapeutic consultations!). It concerns his publication Therapeutic Consultations in Child Psychiatry (Winnicott, 1996), which appeared shortly after his death and contained a remarkable preface by Masud Khan.¹ We discover on reading this work that the essential point was to “allow a process to take place until completion”, a theme which he had already tackled in his article “The Observation of Infants in a Set Situation”, more often called “The Observation of the Spatula Game” (Winnicott, 1984a). In this text he describes his systematic use of the tongue spatula, an item usually found on a paediatrician’s desk, when facing young children (between 5 and 13 months) on their mother’s lap. This shiny metal tongue spatula captured the interest of the child and implemented a typical behavioural sequence.

Winnicott describes in detail the different phases of the process (the moment that the child reaches out to the spatula, hesitates, then puts it in his mouth before finally rejecting it), but the most important thing for him was allowing the child to pursue and complete its experiment. In fact what was important was not what was happening, but that it had happened. It allowed a process to develop completely.

For diverse reasons, the majority of the children he saw at the hospital were not able to benefit from the traditional psychoanalytical cure at that time:

•Distance: his reputation meant many people had to travel sometimes hundreds of kilometres to see him in London.

•Expense: the families he saw at the hospital were often from a modest background.

•Availability: for example, in one of the famous cases recounted by Winnicott, the parents of little Piggle could only come to see him sporadically, since they had to make a long train journey.

•Cultural reasons: at that time, child psychoanalytic treatment meant four or five sessions a week.

An overture, in the musical sense

The initial contact with the family and the child was essential for Winnicott. For him, almost everything happened in the first interview. He wrote “In my child psychiatry practice, I have found that a special place has to be given for a first interview” (Winnicott, 1964/1968: 299). This conviction was based on two elements. First, he was convinced that every human being hoped that somewhere a solution could be found, and he argued that the symptoms shown were a sign of this hope.

Second, he was equally sure that a patient, child or adult, would come to their first interview prepared to believe that they would find help there, and be able to trust him. It was not impossible that these first interviews might lead on to psychotherapy. Winnicott maintained that the manner in which the first interviews took place would lead to the establishment of satisfactory psychotherapy, since the child concerned would have encountered “some hope of being understood and perhaps even helped” (Winnicott, 1996: 5).

For Winnicott, the therapeutic consultation he had imagined/thought of had a very clear objective, that of giving the child and the family the help they needed to enable the dynamic lifelong process to continue – a kind of kick-start to revive the blocked process. It was positive code of ethics for him. And his invention of a therapeutic situation that was as brief as it was essential, involving one or very few sessions within a necessarily short period/time frame, was a flexible way of responding to the child’s need to be helped.

It was also a method of working that gave him great pleasure – he speaks of enjoyment, a practice which he compared to music, since he feels it is one thing to work to improve technique, and quite another to interpret the music. Just as he wrote “if they are a labour to read then I have been too clever; I have been engaged in displaying a technique and not in playing music” (Winnicott, 1996: 31). And since we also use this musical metaphor, we could say that the therapeutic consultation works like an “overture”, in the operatic sense. The elements are put in place for the events to come.

From the start, in his consultations Winnicott asked himself how he could know what the child needs, hic et nunc. He insisted on the term “needs”, which raises a problem for the French. In fact, the term “needs” in English is what I would rather translate as “what is a necessity”. It has never been question of satisfying a need, or meeting a need, but to find out what is a necessity (Winnicott, 1996: 31). For a need, however primitive, is above all a relationship and calls for interaction.

So the immediately related question is: “What means do I have to respond in the most economic manner psychically, hic et nunc?” – a therapeutic project implying the idea of “caring”, which means to take care of, care about, be concerned, that is to say to enter the same basic preoccupation as that of the internal attitude of the mother who, by her caring, establishes the foundation of the mental health of the infant.

Winnicott calls this internal process “primary maternal preoccupation”, a strange psychic state, often quite marked, which pregnant women enter into during the last weeks of their pregnancy, and which can carry on until a few weeks after the birth. It is this particular psychic state which allows the mother to provide what is “needed” “at the right time”.

His conception of the birth of the psychic apparatus justifies the Winnicottian argument that it is easier to cure madness than neurosis. Neurosis falls within the analytical cure. On the other hand, “madness” comes from the failure of primary environment. It has to do with ordinary life. Therefore, where children are concerned, he is not in favour of analysis at all costs (see Dethiville, 2014: 8).

In this discussion, Winnicott often compares analysis to an art. But, as he writes, he refuses the practice of art for art’s sake. “An analyst may be a good artist, but (as I frequently asked) what patient wants to be someone else’s poem or picture?” (Winnicott, 1992: 291). “Analysis for analysis’ sake has no meaning for me. I do analysis because that is what the patient needs to have done and to have done with. If the patient does not need analysis then I do something else” (Winn...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgements
• Introduction: Winnicott and his clinical work
• Chapter 1 Therapeutic consultation
• Chapter 2 The squiggle
• Chapter 3 The father
• Chapter 4 The family
• Chapter 5 Antisocial tendency and deprivation
• Chapter 6 Aggression and destructiveness
• Chapter 7 Adolescence
• Chapter 8 Regression
• Chapter 9 The area of playing in the cure
• Index