The Legacy of Winnicott

Essays on Infant and Child Mental Health

Brett Kahr

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367328153
• eBook ISBN: 9780429921292
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book highlights some of Donald Winnicott's contributions that particularly illustrate the originality of his thought. It focuses on some of his indirect as well as direct contributions to psychoanalytic technique.

Introduction

Donald Woods Winnicott: the cartographer of infancy

Brett Kahr

Winnicott’s contributions

Donald Winnicott died more than thirty years ago, and since his departure many new and vibrant theoreticians have burst onto the psychoanalytical scene. Why, then, should we continue to study Winnicott's original ideas? Before Winnicott passed away in 1971, he reflected to his colleague Mrs Barbara Dockar-Drysdale that "when your work is quoted ten years after your death, by someone who does not know your name—this is fame" (quoted in Dockar-Drysdale, 1974, p. 2). Without doubt, Winnicott has achieved the status of being famous, and students invariably refer to his work on the holding environment without citing his texts as the source. And as he longed to be memorialized in some way, Winnicott would have enjoyed his current celebrity status within the psychotherapy profession (cf. Kahr, 1996a, 1996b). But many people have idealized Winnicott, such as the late psychoanalyst, Mrs Eva Rosenfeld (1970), who referred to him as "St Donald"; while others have come to know about him simply by virtue of his fame. In view of the fact that Winnicott has become increasingly a "climate of opinion" (to borrow Wystan Hugh Auden's well-known description of Sigmund Freud), I thought it might be useful to remind readers of some of the very specific and particular achievements that have earned Winnicott an eternal place in the psychoanalytical pantheon.

Born in Plymouth, Devon, on 7 April 1896, Donald Winnicott attended school at the nearby Plymouth College, followed by four years of boarding-school at The Leys School, a Wesleyan Methodist institution in Cambridge. He received his undergraduate education at Jesus College of the University of Cambridge, and he then attended St Bartholomew's Hospital medical school in London, qualifying as a physician in 1920. From that time on, until his death more than half a century later, Dr Winnicott devoted himself to the care of the physically ill and, later, the mentally ill—first as a physician in children's medicine and then as a child psychiatrist, an adult psychoanalyst, and a child psychoanalyst. He held high offices within the British Psychological Society, the Royal Society of Medicine, and the British Psycho-Analytical Society, authoring numerous influential books and papers. The details of Winnicott's life can be studied in my book D. W. Winnicott: A Biographical Portrait (Kahr, 1996a), for ease of reference.

Although Winnicott worked with adults, adolescents, and children of all ages as well as with various psychopathological configurations, I regard his work on the psychology of infancy as Winnicott's most breathtaking and substantial contribution to Western civilization. Sigmund Freud knew, of course, that our behaviours as adults can be traced back to the vicissitudes of infantile feeding experiences, especially our relationship to the maternal breast; and years later Melanie Klein fleshed out Freud's rudimentary observations on infant breast-feeding by sketching a more complete portrait of the terrors and anxieties that plague the mind of the neonate. But in spite of Freud's paediatric experiences (Bonomi, 1994) and in spite of Klein's work with toddlers and other youngsters (e.g. Klein, 1932), neither giant could boast much formal clinical experience with actual, chronological infants. Donald Winnicott, by contrast, examined, observed, and treated literally thousands of babies as his bread-and-butter work, primarily at the Paddington Green Children's Hospital in West London, where he worked from 1923 until 1963, but also at the Queen's Hospital for Children in East London, and in his private practice.

As a result of this unusual and incomparable base of empirical data, Winnicott possessed a privileged glimpse into both the internal and the external worlds of neonates; but he also had the opportunity to learn about the psychodynamics of the mothers who cared for these infants. And furthermore, Winnicott could observe the interactions between babies and their mothers at very close range, thus permitting him to discover and to appreciate the ways in which the actual style of mothering could either impinge upon the child's development or facilitate the child's growth.

Winnicott's contributions to the psychology of infancy cannot readily be summarized, as they constitute the bulk of his corpus of writings. But one can nevertheless extract the basic discoveries and conclusions. Of greatest importance, Winnicott taught us that infants can be interesting individuals who are worthy of study. He encouraged the active observation of infants in his clinic as a means of obtaining diagnostic information about their psychopathology (Winnicott, 1941; cf. Kahr, 1996b). Furthermore, he observed that infants suffer from extensive primitive agonies (Winnicott, 1967), such as the fear of falling forever; and he noted that babies suffer in a state of "absolute dependence" (Winnicott, 1963b, p. 84; cf. Winnicott, 1963a), which must be greeted with reliable maternal care and protection. In other words, Winnicott helped us to appreciate that by watching babies, we can learn exactly how much infants will communicate to us both affectively and non-verbally, and that when we listen to these infantile messages, we learn only too forcefully about the vulnerability of neonates—a vulnerability that must be respected, and not abused. When adults behave sensitively to the needs of babies and strive to meet these needs, then mental health will ensue; but when adults fail their babies, varying degrees of damage will occur, resulting in different categories of mental illness, depending upon the severity of the impingement or deprivation. Stated concisely, Winnicott's greatest discovery may be the simple but vital recognition that actual parenting produces mental health or mental illness (Winnicott, 1960b).

Dr Winnicott also explored many other related areas of infancy, including the importance of foetal mental life, pre-natal and perinatal factors, the impact of birth experiences, and so forth (Winnicott, 1949b). Moreover, Winnicott concentrated intensively and extensively on the psychology and psychopathology of parenthood, examining the ways in which different caretaking experiences contribute to the emerging character. And, furthermore, Winnicott also wrote about the importance of parental phantasies towards their offspring, including, perhaps most vitally, the ease with which ordinary parents come to hate their children for being such dependent burdens (Winnicott, 1949a). Crucially, Winnicott recognized that parents must learn to verbalize their hatred towards babies, ideally to a psychological professional or to some other mature adult, rather than acting out the murderousness on the child in an unconscious manner. By writing about the normal human capacity for hating babies, Winnicott opened up the discourse on maternal ambivalence, thus helping mothers and other caretakers to feel less guilty about their negative affects, and thus providing an outlet for the release and abreaction of toxic emotions (cf. Parker, 1994, 1995).

Of greatest practical importance, Winnicott became the undisputed pioneer of parent-infant psychotherapy, tirelessly working with parents and with the babies themselves to understand the causes of disturbances of appetite and disturbances of sleep. His early paediatric case notes, as well as his first book, Clinical Notes on Disorders of Childhood (Winnicott, 1931), attest to his commitment to the unravelling of psychological and behavioural disturbances of infancy. On the basis of his work as a student of infant observation, as a theoretician of the psychology of infancy and the psychology of parents, and as an infant psychotherapist, I have come to regard Dr Donald Winnicott as the veritable cartographer of infancy. More than any mental health professional before or since, Winnicott drew the map of infancy as a good cartographer always does, and then he filled it in with precise details, examining the manifold ways in which a mother's ability to hold and handle her baby will influence the entire course of the infant's subsequent development.

Contemporary readers may smirk when reading Winnicott's original writings, because we now know only too well that infantile experiences do indeed serve as the substrate for adult mental health. But during the 1930s, 1940s, and 1950s few parents or professionals appreciated the vital links between early life events and subsequent psychopathology. More than anyone since Freud, Winnicott pointed us in the direction of infancy and early childhood as a means of comprehending the aetiology of mental disturbance.

But Winnicott championed not only infants and their parents, but also children, adolescents, and adults as well. He really helped to create the professions of child psychiatry and child psychotherapy in Great Britain, and he introduced the fruits of child psychoanalysis into the public sector, serving arguably as the very prototype of the contemporary British National Health Service child psychotherapist, processing, interviewing, and treating large numbers of cases (Kahr, 1996b). He also became one of the first individuals within the psychoanalytical profession to create a multidisciplinary team. Winnicott distinguished himself, of course, not only as a practitioner of intensive, long-term, full psychoanalytical treatment of children, but also as a craftsman of briefer, shorter, consultative work for those boys and girls who neither needed extensive analysis nor craved it; and he explored the possibilities of what he called "on demand" treatment for those children who did not require fixed sessions but, rather, needed to be seen only from time to time (e.g. Winnicott, 1971b, 1978).

Even more, Dr Winnicott became one of the founders of modern family therapy in England by working not only with child patients but also with their parents (Winnicott, 1956, 1960a). He knew so well that mothers and fathers could transmit their psychopathology to their offspring, and that such anxieties must ultimately come to be contained. In a hitherto unpublished letter written to a colleague, K. R. Llewellin, Winnicott observed that

I used to call my clinic at the Paddington Green Children's Hospital, when I was inclined to give it a nickname, a clinic for the management of maternal or paternal hypochondria. In the simplest cases, and they were very common, my job was to make an examination and to say: "At this moment your child is healthy as far as one can tell. Come again when you are worried." [Winnicott, 1966b]

Winnicott worked with parents, and he also enlisted the assistance of parents as auxiliary therapists, realizing that much of the containment and interpretation of childhood mental illness could be undertaken by mothers or fathers themselves (e.g. Winnicott, 1956, 1960a).

Also, Winnicott theorized extensively about the role of management and residential care in the treatment of the disturbed child, recognizing full well that many disorientated boys and girls required something more than 50-minute psychoanalytical sessions. Occasionally, hospitalization would be required, or at least confinement in a therapeutically orientated care home wherein a greater level of coverage could be provided (e.g. Winnicott, 1943a, 1945c, 1948; cf. Dockar-Drysdale, 1974). His future wife, Clare Britton, assisted him mightily in this clinical observational research on the importance of management (Winnicott & Britton, 1944, 1947). Together, they laid the foundation stones for the field that has come to be known as "forensic child psychotherapy"—the treatment of criminal children and adolescents (e.g. Vizard, Monck, and Misch, 1995; Vizard, Wynick, Hawkes, Woods, & Jenkins, 1996; cf. Kahr, 1996b, in press).

To summarize Winnicott's unparalleled contributions to the study and treatment of infancy and childhood, we can enumerate his legacy thus, in brief phrases:

1. theory of infant psychology;
2. treatment of infant psychopathology;
3. study of infant observation;
4. theory of maternal psychology and psychopathology;
5. theory of paternal psychology;
6. study of hatred of babies;
7. study of foetal psychology;
8. study of perinatal psychology;
9. study of birth trauma;
10. creation of public sector child psychotherapy;
11. development of the multi-disciplinary team;
12. creation of brief psychoanalytical consultations;
13. development of "on demand" treatment;
14. development of family therapy;
15. use of parents as auxiliary therapists;
16. study of management and residential care;
17. promotion of forensic child psychotherapy.

To provide a thorough review of Winnicott's contributions to the field of adult mental health would require an entire separate volume. I shall mention only certain exceptional highlights. Not only did Winnicott bequeath to us an entire theory of human development, tracing the ways in which we progress from the absolute dependence of early infancy to the more independent modes of adult living, but he forged a rich theory of psychoanalytical technique as well, explaining how the phases of treatment mirror those of early development. He also sketched a theory of psychopathology, elucidating various developmental pathways for delinquency, depression, and schizophrenia (Winnicott, 1961, 1963c), and he provided trenchant critiques of sadistic treatments in somatic psychiatry (Winnicott, 1943b, 1944b, 1944c, 1949a).

Winnicott explored the often terrifying world of regression within the clinical situation, and he bravely undertook analytical treatments of some of the most disturbed psychiatric patients, who occasionally lived with him in his home (cf. Kahr, 1996a). He also experimented with the boundaries of classical technique in order to ascertain which parameters would need to be introduced in order to heal the psychotic patient.

Along the way, he introduced an unusually robust selection of new terminology into the mental health literature, notably "transitional object", "transitional phenomena", "holding environment", "facilitating environment", "good-enough mother", "primary maternal preoccupation", "antisocial tendency", "capacity to be alone", "capacity for concern", "absolute dependence", "relative dependence", "towards independence", "hate in the countertransference", "playing", "the use of an object", and others too numerous to mention (cf. Abram, 1996).

As an educationalist Winnicott performed heroic feats to introduce psychological ideas to colleagues in various allied professions, such as paediatrics, social work, midwifery, and child care. Above all, he attempted to reach parents through his legendary radio broadcasts. Winnicott's extraordinarily lucid and non-persecutory approach to the enlightenment of parents remains a model for all contemporary mental health practitioners (e.g. Winnicott, 1945a).

No one but Donald Winnicott possessed sufficient internal benignity to find the value in depression (Winnicott, 1964a) or to realize that delinquency could be understood as a sign of health (Winnicott, 1968b). Winnicott's achievements can only be described as enormous, encompassing a wide range of fields within child care, paediatrics, psychology, and psychotherapy. Though the importance of Winnicott's work may be self-evident to contemporary professionals and scholars, I suspect that we will not even begin to appreciate the full import of his labours until several further decades will have passed.

The Winnicott Festschrift

I have divided this memorial volume, The Legacy of Winnicott: Essays on Infant and Child Mental Health, into four principal sections, each paying tribute to a different aspect of Winnicott's work. In the first part, "Overtures to Winnicott", two distinguished authors provide us with a preliminary glimpse into Winnicott and his world. Dr Robert Langs, one of the most erudite scholars on psychoanalytical technique, assesses Winnicott's place in the history of psychoanalysis, concentrating on Winnicott's sensitivity to the importance of the clinical setting and on the vital role of the interaction between the patient and the psychoanalyst. And Professor Paul Roazen, the distinguished biographer and historian, has very generously permitted me to publish the text of his interview with Donald Winnicott, which he conducted at Winnicott's Belgravia home in 1965. Roazen has furnished us with a document of great historical importance, which permits us the opportunity to enjoy a privileged glance into Winnicott's more private and spontaneous reflections and thoughts.

In the second section of the book, entitled "Mothers and Infants", three eminent psychoanalytical thinkers pay tribute to Winnicott's path-breaking observations about babies and their parents. Mr Lloyd deMause, the leading exponent of modern psychohistory and one of the first psychoanalytical scholars to investigate the psychology of the foetus, provides us with a richly referenced survey of the recent literature on pre-natal psychology—an area of study that proved of great interest to Winnicott, though in the absence of modern technology he himself could only speculate about its precise nature. Dr Stella Acquarone, director of the Parent Infant Clinic in London, has treated perhaps more infants psychotherapeutically than any other clinician since Dr Donald Winnicott. In her paper, Dr Acquarone has identified 11 types of psychoanalytical treatment strategies, which I regard as a highly original contribution to the growing literature on infant mental health. The last paper in this section, written by Dr Judith Trowell, the noted child psychiatrist, psychoanalyst, and child protection specialist, contains an account of Trowell's highly pioneering efforts to introduce Winnicott's infant observational work to such diverse professional groups as physicians and the police force.

The third section, devoted to "Children and Adolescents", contains four pieces by experienced clinicians who practise in a Winnicottian style. Dr Juliet Hopkins, one of Donald Winnicott's last supervisees, describes a rather touching case about a little boy who could not play. Mrs Sira Dermen, a British psychoanalyst and child psychotherapist of Armenian extraction, chronicles her courageous work with some of the child survivors of the devastating Armenian earthquake of 1988. Dermen's work provides a splendid modern illustration of Winnicott's concept of the psychoanalytically informed brief consultation. Dr Alasdair Honeyman, the only paediatrician contributing to this volume of essays, reflects most sensitively on the psychological requirements of contemporary paediatric work. The section concludes with an essay by Professor Susie Orbach, arguably the first British psychotherapist to provide us with a sophisticated psychoanalyti...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• ACKNOWLEDGEMENTS
• CONTRIBUTORS
• PREFACE
• FOREWORD
• Introduction Donald Woods Winnicott: the cartographer of infancy
• REFERENCES
• INDEX