The psychoanalytic theories of D.W. Winnicott as applied to rehabilitation.
To most individuals the word psychoanalysis conjures up images of Sigmund Freud, the couch, infantile sexuality, Freudian slips, the tripartite structure of personality, dream analysis, transference, and toilet training. However, Freudian analysis, albeit the most visible, is only one of several approaches to psychoanalysis currently in use. In fact, the theories and techniques in psychoanalysis are seemingly as diverse as those of counseling and psychotherapy in general.
One way to make sense out of this diversity is to classify the theories of psychoanalysis into four basic categories: (1) orthodox or classical analysis, (2) ego psychology, (3) self psychology, and (4) object relations (Pine, 1985). An alternative approach is offered by Greenberg and Mitchell (1983), who argue that psychoanalytic theory can be reduced essentially to two major schools of thought-one based on drive/structure theory and the other based on relational/structure theory. The drive/structure model is best illustrated by the work of Sigmund Freud (1953-1974) and Anna Freud (1964-1981) and their disciples (Arlow & Brenner, 1964; Brenner, 1973; Fenichel, 1945), and the relational/structure model by the work of Melanie Klein (1964; 1975), W.R.D. Fairbairn (1952), D.W. Winnicott (1965; 1971; 1975) and Harry Guntrip (1961; 1969; 1971). Although some theorists [e.g., Heinz Kohut (1971; 1975; 1984) and Otto Kemberg (1975; 1976; 1980)] have attempted to mix the two models, the models themselves are based on fundamentally different conceptions of human nature, development and pathology. Specifically, the drive/structure theories emphasize the primacy of the drives (instincts), the role of libido and aggression, intrapsychic conflict, and the central importance of the Oedipal period. Relational/structure theories, on the other hand, emphasize the importance of pre-Oedipal development, self-object fusion and separation issues, self-cohesiveness, and the very early relationships between children and their primary caretakers.
These conceptual differences have implications, not only for patients who are believed to be suitable for psychoanalytic interventions, but also in terms of the specific techniques utilized in the treatment. For example, drive/structure analysts tend to limit their practice to patients who are relatively high functioning (e.g., neurotics) and to rely primarily on techniques such as free association, dream analysis, interpretation of transference and resistance, and the "neutral" therapeutic stance. Relational/structure analysts frequently treat patients who are more severely disturbed (e.g., persons with borderline or narcissistic personality disorders) and rely primarily on therapeutic techniques such as empathy, recognition and use of the real relationship, counter-transference interpretations, interpretations based on issues related to self-object fusion and separation, and the creation of what D.W. Winnicott (1965) has called a therapeutic "holding environment."
In a recent article titled "Freud and Disability," Cubbage and Thomas (1989) provided an assessment of Freud's theories and therapy as these relate to the psychology of disability and various rehabilitation interventions. Among some of the major concepts discussed in this paper were: castration anxiety, fear of loss of love, the death instinct, and the role of the defense mechanisms (especially denial). The purpose of the present paper is to extend this line of inquiry by discussing the writings of Donald W. Winnicott, who was one of the most prominent and prolific relational/structure theorists.
Although the work of D.W. Winnicott (1965; 1971; 1975) is well known and highly respected in psychoanalytic circles, his visibility is quite limited in the field of rehabilitation. This lack of visibility is unfortunate because Winnicott devoted much of his efforts to issues of direct importance to rehabilitation personnel, such as the effects of hospital stays on the psychological development of children and the relationship between physical and psychological concerns.
Initially trained as a pediatrician, Winnicott was analyzed by James Strachey [the primary editor and translator of Freud's works (1953-1974)] and Joan Riviere (an analysand of Freud and a close associate of Melanie Klein). In many respects, Winnicott was to the British what Benjamin Spock has been to Americans. That is, he wrote and talked widely about infant care, often in terms and through media intended to be consumed by lay persons. In the vicious political atmosphere of the British Psychoanalytic Society of the 1930's, 40's and 50's, Winnicott represented the "C" or "Middle Group." The "A Group" included Melanie Klein and her followers and the "B Group" included Anna Freud and her followers. Although a "developmentalist" and prominent member of the British object-relations school of psychoanalysis, Winnicott sought to maintain communication between the two warring groups and ultimately hoped for a theoretical and interpersonal reconciliation. Such a reconciliation was never to be, however, and the differences between the two groups persist. This striving toward unification, or Eros in Freud's terms, was a characteristic which pervaded not only Winnicott's personal life but his writings as well.
Over a span of approximately four decades Winnicott published literally hundreds of books, articles, lectures and other papers based on his practice as a pediatrician and psychoanalyst. Among the more important of these were: Through Paediatrics to Psycho-Analysis (1975), Playing and Reality (1971), The Child, the Family and the Outside World (1987), The Maturational Processes and the Facilitating Environment (1965), "Transitional Objects and Transitional Phenomena" (1951), "Ego Distortion in Terms of True and False Self" (1960), "Psychoses and Child Care" (1952), "Hate in the Countertransference" (1947), "The Antisocial Tendency" (1956), "Metapsychological and Clinical Aspects of Regression within the Psychoanalytic Set-Up" (1954), and "Withdrawal and Regression"(1954). In his first book, Clinical Notes on Disorders of Childhood (1931), he took what was then the very controversial position that emotional disturbance could cause arthritis in children.
Winnicott's writing style is efficient, penetrating, almost poetic. In one of his articles, "Psychoses and Child Care" (1952), he presented in a space of ten pages a model of psychosis which is at once elegant, revolutionary, comprehensive, and clinically useful. Because Winnicott writes so efficiently, the reader must proceed slowly, savoring and ruminating over each concept. Another characteristic is that Winnicott had a tendency to rewrite or reinterpret the ideas of others so that they fit nicely into his own conceptual frame of reference. For example, Greenberg and Mitchell (1983) have noted that one of the reasons Winnicott could claim loyalty to Freud was that he interpreted Freud's writings so liberally. A related problem was Winnicott's fear that he might be ostracized by classical analysts because of his frequently revolutionary ideas. As a result of these factors, readers of Winnicott must sometimes read between the lines, take metaphors literally, and be especially sensitive to nuances and unstated implications. A useful maneuver is to substitute the word analyst for mother and patient for child.
Since his death in 1971, a number of terms and concepts originally used by Winnicott have become part of the standard psychoanalytic lexicon. Some of the more significant of these are: holding environment, good-enough mothering, true and false self, antisocial tendency, transitional objects and transitional phenomena, and environmental impingement. Most of these terms and concepts are discussed in more detail below.
In the foreword of The Child, the Family and the Outside World (1987), Marshall H. Klaus observed that Winnicott likened an infant to a bulb in a windowbox, noting that you do not have to make the bulb grow into a daffodil. With fertile soil and the right amount of water and light, the bulb will grow and develop. It is wrong to mold an infant as you would a piece of clay because then you will inhibit development.
In our view these observations are highly relevant for counselors and other professionals in their work with rehabilitation clients. One need only substitute the word client for bulb and infant to see the potential implications. Implicit in this point of view is the assumption that clients possess within themselves the ability to grow and develop positively if a "good-enough" treatment environment is provided. In Winnicott's terms this environment would be called a "holding environment;" that is, an environment in which the helper is able to adapt to the client's needs. In such an environment the client would be able to redress developmental deficits and gain the strength to proceed autonomously.
To even the casual reader, this approach probably sounds quite Rogerian, and in many respects it is. For example, both Rogers and Winnicott placed considerable trust in the development potential of the individual, and both saw the environment as potentially inhibiting or inappropriately redirecting the individual's development. Rogers (1959) called the development potential of the individual the self-actualizing tendency, and the environmental inhibiting factors conditions of worth. For Winnicott (1952), the environmental inhibiting factors were environmental impingements. Similarities between Rogers and Winnicott are also apparent in the therapeutic situation itself. Specifically, both Rogers and Winnicott utilized the real relationship between therapist and patient to promote growth, both emphasized the importance of empathy, and Winnicott's "holding environment" embodies characteristics which are quite similar to Rogers' "core conditions." There are important differences between the two theorists, however. Winnicott, for example, like all other analysts, employed the technique of interpretation and placed considerable emphasis on transference and counter-transference phenomena. Rogers, on the other hand, eschewed interpretation and considered terms like transference and counter-transference to be mere intellectualizations of the real relationship. Also, of course, unlike Winnicott, Rogers has been treated rather thoroughly in the rehabilitation literature (e.g., See 1986; Thomas, Butler & Parker 1987; Thomas & Parker 1984).
In his classic paper "Psychoses and Child Care" (1952), Winnicott offered insight into understanding and facilitating disability adjustment processes. For example, Winnicott proposed in this paper that the infant begins psychologically in a state of undisturbed isolation. In this state the infant makes spontaneous movements and the environment is discovered without loss of a sense of sell However, in an environment where there is faulty adaptation to the child's needs (i.e., where there is environmental impingement), the child must become a reactor to this impingement. In this situation the sense of self is lost and is regained only by withdrawal and return to isolation.
A person with a disability, like an infant, is faced with a similar dilemma. That is, the environment (i.e., physicians, family members, counselors, psychologists, etc.) can either actively adapt to the person's needs, or the environment can fail to adapt, thus resulting in impingement, withdrawal and isolation. An example of active adaptation to client needs would be the provision of rehabilitation and other forms of assistance whenever the client is ready to receive them. Impingement would be the failure to provide needed assistance and services or to provide them when they were not needed.
Disability often results, of course, from environmental impingement. The success of the individual in adjusting to this impingement necessarily depends on two factors: 1) the adaptive and coping capabilities of the individual, and 2) the facilitating characteristics of the environment. Some individuals are more capable than others of converting a not-quite-good-enough environmental adaptation into a good-enough situation. Such variations result not only from intellectual deficits (which are alluded to specifically by Winnicott), but also from pre- and/or post-disability personality characteristics such as rigidity and "non-coping" defensiveness. In these cases especially, the helper may need to proceed more slowly and/or expand the treatment to include the resolution of broader personality concerns.
Another concept introduced by Winnicott which may have significant rehabilitation applications is the idea of a true self and a false self (Winnicott, 1960). The true self develops when there has been an active adaptation to the infant's needs. The false self, on the other hand, represents a compliance on the part of the infant to an environment which impinges. In a rehabilitation context the fostering of a true self would involve the creation of a good-enough (holding) environment in which sufficient adaptations were made to meet the client's needs. Such an environment would include the provision of non-possessive warmth and especially empathy. The helper's role in such an environment would be to respond to what the client is feeling rather than to what the client should feel. Another key ingredient of such an environment would be that the counselor or other helper allow the client to "play" with new roles, affects and cognitions which have been elicited by the disability. To Winnicott the concept of play was a critical aspect of any treatment situation; that is, he believed that it was only through play that reality could be tested and eventually accepted.
Issues and conflicts pertaining to independence/dependence and separation/individuation permeate the lives of both infants and persons with a disability. To explain how infants deal with such conflicts or developmental tasks, Winnicott (195 1) offered the concepts of transitional objects and transitional phenomena. For infants, transitional objects are those ragged blankets and teddy bears which have soothing and security-providing properties in situations of danger. Psychodynamically they are much more. In theory they stand for the mother or the mother's breast, and in a sense they represent internalized home bases to which everyone must periodically return. It is, in fact, the internalization of these ego supports and a sense of self relatedness which permits individuals to be alone without undue anxiety and a sense of isolation. By giving external objects the capacity to soothe and comfort, the individual is permitted a freer and safer exploration of and interest in the external world (Eagle, 1984). Similarly, for persons with a disability to become independent, they must first be able to be dependent on an external object. Through the creation of a holding environment, the counselor or helper may become the transitional object through which the person with a disability is able to gain independence and self-sufficiency.
A final concept discussed by Winnicott (1947) which may have important rehabilitation implications is the idea of "hate in the countertransference." What is essentially acknowledged in this concept is the idea that mothers (with good reason) sometimes hate their children and therapists sometimes hate their patients. According to Winnicott, this hate is natural and even healthy. In fact, Winnicott believed that without objective hate there can be no objective love. It is therefore important that counselors and other helpers learn to hate objectively because it is only through being hated objectively that clients can learn to trust and accept their own feelings of hate and love.
If one assumes that the ability to hate objectively is an important helper characteristic, it must be especially easy to feel but difficult to accept such an emotion when working with persons with a disability. That is, persons with severe cognitive and emotional problems are bound to give helpers many legitimate reasons to both hate and love them. It is, however, understandably difficult for many helpers to recognize and accept such feelings. What Winnicott is saying is that as an integrated person you can both love and hate the same person and that by admitting these feelings (to yourself) you will be a much better helper in the long run.
In this paper an attempt was made to relate some of the more important concepts of D.W. Winnicott to a rehabilitation context. Among the concepts specifically discussed were: the therapeutic holding environment, good-enough mothering (helping), the true and false self, environmental impingement, transitional objects, and countertransference. Winnicott believed that individuals could recover from environmental impingements in an atmosphere where an attempt was made to adapt to the individual's needs. It is our belief that disability, like any other impingement, can be better understood and treated through the therapeutic framework developed by Winnicott. It is, in fact, our belief that psychological adjustment to disability would be a naturally healing process if only good-enough environmental adaptations could be made to clients' needs.
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|Author:||McGinnis, James D.|
|Publication:||The Journal of Rehabilitation|
|Date:||Jul 1, 1991|
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