Through Paediatrics to Psychoanalysis

Collected Papers

Donald W. Winnicott

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367329259
• eBook ISBN: 9780429923005
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The value of Winnicott's work has become more and more widely recognized not only among psycho-analysts but also psychologists, educators, social workers, and men and women in every branch of medicine; indeed, all whose work or practice involves the care of children in health or sickness.An important part of the value of these writings lies in the uniquely binocular view with which the author regards the subjects of his investigation. With him, pediatrics informs psycho-analysis; psycho-analysis illuminates pediatrics.

This book is not concerned with innovation in basic psychoanalytic concepts or techniques, but with the formulation and testing-out of ideas whose origin was in the challenge of day-to-day clinical work that was the staple of Winnocott's medical experience throughout his professional life.This book is arranged in three sections. The first represents Winnicott's attitudes as a pediatrician prior to training in psycho-analysis, and demonstrates the degree to which a purely formal pediatric approach requires as an effective complement a deeper understanding of the emotional problems of child development.

Part 1

Chapter I
A Note on Normality and Anxiety¹

[1931]

BY TAKING the weights of a large number of children it is easy to work out what is the average weight for any given age. In the same way an average can be found for every other measurement of development, and a test of normality is to compare the measurements of a child with the average.

Such comparison may give very interesting information, but there is a complication that can arise and spoil the calculation—a complication not usually mentioned in the paediatric literature.

Although from the purely physical standpoint any deviation from health may be taken to be abnormal, it does not follow that physical lowering of health due to emotional strain and stress is necessarily abnormal. This rather startling point of view requires elucidation.

To take a rather crude example, it is very common for a child of two to three years old to be very upset at the birth of a baby brother or sister. As the mother’s pregnancy proceeds, or when the new baby arrives, a child that has hitherto been robust and has known no cause for distress may become unhappy and temporarily thin and pale, and develop other symptoms, such as enuresis, temper, sickness, constipation, nasal congestion. If physical illness should occur at this time—e.g., an attack of pneumonia, whooping cough, gastro-enteritis—then it is possible that convalescence will be unduly prolonged.

Joan, aged two years five months, was an only child till thirteen months ago, when a brother was born.

Joan had been in perfect health till this event. She then became very jealous. She lost her appetite, and consequently got thin. When left for a week without being forced to eat, she ate practically nothing and lost weight. She has remained like this, is very irritable, and her mother cannot leave her without producing in her an anxiety attack. She will not speak to anyone, and in the night she wakes screaming, even four times in a night—the actual dream material not being clear (wants pussy, etc.).

She pinches and even bites the baby, and will not allow him things to play with. She will not allow anyone to speak about the baby, but frowns and ultimately intervenes. When she was put in a welfare centre she worried a great deal, and, having no one to bite, bit herself, so that she had to be taken home again after three days.

She is scared of animals.

‘If she sees the boy on the chamber she heaves until she is sick’. If given chocolate she puts it in her mouth and keeps it there till she gets home, then she spits it all out again.

She constantly prefers men to women.

The parents are exceptionally nice people, and the child is a perfectly healthy and lovable child.

Now, had the new baby not arrived, with all that this implies to a child, Joan would have remained in robust health, but the value of her personality would have been to some extent diminished owing to her having missed a real experience at the proper age. Such an occurrence justifies the statement that it can be more normal for a child to be ill than to be well.

A doctor who does not understand the processes underlying such unwellness will think out a diagnosis and treat the illness as determined by physical causes. A doctor who understands a little about psychology will guess the underlying cause of the illness and take active measures to help the patient; for instance, he will instruct the parents not to make a difference in their treatment of the child after the baby’s arrival, or will send the child away to stay with an aunt, or advise the parents to allow the child animal pets. As a prophylactic measure he will advise parents to answer fearlessly their children’s questions about where babies come from, and generally to act without anxiety.

It is possible to go further and to say that a doctor who knows still more about psychology will be content to hold a watching brief, and do nothing at all, except be a friend. For he realizes that the experiencing of frustrations, disappointments, loss of what is loved, with the realization of personal unimportance and weakness, forms a significant part of the child’s upbringing, and, surely, a most important aim of education should be to enable the child to manage life unaided. Moreover, the forces at work in determining the behaviour both of the parents and of the child are so hidden, with foundations so deep in the unconscious, that intellectual attempts to modify events resemble the scratching of initials on the pillars of a cathedral—they do little more than reflect the conceit of the artist.

To illustrate this ‘normal unwellness’ an obvious example has been taken, one that can be observed in any practice that includes the care of children from birth to school age. But this particular emotional situation has only a certain frequency, whereas every child experiences similar, or even more disturbing, internal and external emotional situations which he or she must live through, and discover means of facing and altering or tolerating. When actual situations are absent, imagined ones are ever present—indeed these are often the more powerful—and it is not necessarily the normal child that passes through the first few years of life without showing in delayed physical development and impaired physical health the existence of emotional conflict.

This aspect of symptom formation is one which enables the observer to catch a glimpse of the cause of an enormous number of childish ailments, and in any work on clinical paediatrics the part played by anxiety must be frequently discussed. Such an explanation of deviations from the normal has the advantage that it violates no biological principle. If enuresis is explained as a disturbance of the pituitary or thyroid gland, the question remains, how is it that these glands are so very commonly affected in this way? If cyclical vomiting is explained along biochemical lines the question must be asked: Why is the biochemical balance so easily upset, when everything points to the stability of the animal tissues? The same applies to the toxaemic theory of tiredness, the glycopoenic theory of nervousness and the theory that stuttering is due to lack of breathing control. All these theories lead to blind alleys.

The theory which explains these symptoms by giving to emotional conflict the respect due to it is not only capable of proof in individual cases, but is also satisfactory biologically. These symptoms are typically human and the great difference between the human being and other mammals is, perhaps, the much more complicated attempt on the part of the former to make the instincts serve instead of govern. And in this attempt is naturally to be sought the cause of the illnesses which are common in man and practically absent in animals.

If normal development leads often to disturbance of physical health it is clear that abnormal quantities of unconscious conflict may cause even more severe physical disturbances.

In spite of the recognition that ill-health may be normal, it is legitimate, from another point of view, to use disturbance in physical health as one criterion of psychological ill-health, and to say that a child’s difficulties have become pathologically intense if physical health is so disturbed that, directly or indirectly, health is more than temporarily impaired, or even life itself is threatened.

At the same time it is necessary to remind a doctor who has under his care a child whose ill-health is due to difficult emotional development that he must keep a constant look-out for physical disease, not only because physical disease, e.g., encephalitis, chorea, etc., may co-exist with, and even bring out, anxiety, but also because continued debility due to emotional causes undoubtedly predisposes to certain diseases, such as, for instance, tuberculosis and pneumonia, by lowering general resistance. For this reason clinical medicine is complicated, but in early childhood complications can be unravelled which in adult life would be hopelessly complex.

Anxiety

Anxiety is normal in childhood. The story of almost any child might be cited as illustrating some phase or other of anxiety.

Case

A mother came into my room at hospital carrying a baby boy of two months and leading a little girl of two years. The little girl appeared frightened, and said very loudly: ‘He’s not going to cut his throat, is he?’ She was afraid I would cut the baby’s throat.

The baby boy had an ulcer of the soft palate, and on a previous occasion I had told the mother he must not be allowed a dummy, as the constant rubbing of the rubber against the soft palate was obviously keeping up the ulceration. It happened that the mother had already tried to break the little girl’s love of a dummy, and had once threatened, ‘I’ll cut your throat if you don’t stop it!’ and the little girl formed a logical conclusion, that I must be longing to cut the baby’s throat.

It must be understood that this was a healthy little girl, and the parents, though poor and uncultured, were kind, ordinary people.

For a while my attitude of obvious well-wishing succeeded in reassuring her, but eventually the fears broke out again: ‘He won’t cut his throat, will he?’ ‘No, but he’ll cut yours if you don’t stop fidgeting,’ answered the exasperated parent.

This new light on the emotional situation did not appear to affect the child, but in a half a minute she said, ‘I want to wee-wee’, and had to be taken post-haste to the lavatory.

This episode may be used to illustrate everyday anxiety in childhood.

Superficially there appears the love of the baby brother, the hope that he will not be hurt, and a request for reassurance from the mother. Deeper seated is the wish to hurt, due to unconscious jealousy, which is accompanied by a fear of being hurt in a similar way, represented in consciousness by anxiety. The mother’s last remark produced deeper anxiety. This showed in no immediate obvious mental change, but in a physical symptom, namely, the urgent desire to micturate.

The following case, which is representative of innumerable others, illustrates the onset of anxiety without obvious cause:

Lilian, aged two years six months, is brought to see me because a month ago she woke screaming, and has since then been very nervous. She is the only child.

She was born normally and naturally. She was at the breast till four months, when she was put on to a bottle because the mother had a breast abscess. After this she was even more healthy, having been a little cross when on the breast.

She has developed normally and has been very contented; she slept so soundly in her cot beside the parents’ bed that the parents congratulated one another. She had always been on the best of terms with both parents.

Then suddenly, without any ascertainable change in environment, the child woke up at 6 a.m. terrified, and said: ‘There’s no bikes in this room’, and since then she has been a different child. In the night she has to have the side of the cot down so as to be close to her mother; in fact, several times she has had to be taken into the parental bed because of being terrified. In the day she is all the time scared, won’t leave her mother, but follows her round, even when she goes downstairs to get water. Instead of being her own contented self, she now gets quickly tired of things, losing interest in one toy after another. Her appetite, now again good, was for some days very poor. She is always picking herself, and is fidgety and unmanageable. There are no physical signs of disease. Defaecation and micturition remain normal.

It is in the years between one and five that the foundations of mental health are laid, and here, too, is to be found the nucleus of psychoneurosis.

The importance of the feelings of early years can be proved in the case of any one individual in the course of a psycho-analysis, and is illustrated (as Freud and others have shown) in all forms of art, in folk-lore and in religions.

The knowledge of these details of underlying unconscious wishes and conflicts is of little or no direct clinical use, except in actual treatment by psychoanalysis. But it is often important to realize the intensity of the emotional strains and stresses even in normal emotional development, so that due allowance can be made for the anxiety basis of physical ill-health and abnormal behaviour.

When the child becomes four or five years old the wishes and fears associated with the position of the child in relation to the two parents or their surrogates become less intense, to be rekindled at puberty.

At ten or eleven years the child begins a new emotional development, according to the pattern of emotional development worked out in early childhood, but this time with physical development of the genital organs, and also with the power that comes with years to perform in reality what the child can only do in fantasy and in play.

The paediatrician, and the teacher and the parson, have great opportunities for observing the success or failure of children in this great early struggle, and without the desire to recognize the strength of the forces at work each must fail to understand the manifestations of failure to reach the ideal, whether it be in health, learning, or morals.

The following illustrates a common type of case where symptoms are apparently the result of alterations in the surroundings:

Veronica was a normal healthy infant until, when she was one year and five months old, her mother went into hospital and stayed there a month. The mother has now been home a month, and she brings the baby for advice because she is unwell, eats very little, vomits after food, and is nervous.

Whilst the mother was in hospital an unmarried friend, aged forty-three, looked after the infant. She seemed an ordinary sort of woman, but her treatment of the infant seems to have been tinged with cruelty. For instance, she kept a strap on the table as a constant threat to the child. The strap was to be used if she did not eat. Neighbours report how the child used to squeal, refusing food as a reaction to the apparent loss of her mother. But the woman was also fond of the child.

While Veronica was with this woman she grew nervous. For instance, it was noted by her father that she seemed afraid to go to him, though she had never shown fear before. When the mother came home and tried to undo the harm that had been done she only partially succeeded. It was some time before the child would go to her father without fear, and play again in a contented way by herself (she is an only child, another having died some years ago).

But besides the lack of appetite, for which the child is brought to me, there are also micturition and defaecation difficulties. Whereas formerly micturition was normal, now she has increased urgency and frequency by day, and enuresis, especially at night; also constipation has become obstinate.

At the second visit the mother tells me the child has pain with micturition, and for three days she has refused to defaecate. The urine is not infected and is normal.

The mother also explains that an attempt even to wash the perineal region gives rise to terror on account of the fact that the woman used to put her finger up the child’s anus in order to produce a motion. ‘You dare not let the child see a pot of vaseline.’

Formerly sleep was normal. Now the child wakes frequently and cries out for her mother.

Actual trauma, however, need have no ill-effect, as shown by the following case; what produces the ill-effect is the trauma that corresponds with a punishment already fantasied.

Helen, aged one year three months, is brought to me because of a cough. I notice a scar in the front of the neck and am told the following history:

When she was just over a year old, her brother, aged two, took advantage of his mother’s momentary relaxation of vigilance to heat a poker and stick it in the baby’s neck, just below the thyroid cartilage. He just did it for spite. He is rath...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Figures
• PREFACE
• ACKNOWLEDGEMENTS
• INTRODUCTION
• PART 1
• PART 2
• PART 3
• BIBLIOGRAPHY
• INDEX