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(p. 149) Child Department Consultations 

(p. 149) Child Department Consultations
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(p. 149) Child Department Consultations
Author(s):

Donald W. Winnicott

DOI:
10.1093/med:psych/9780190271343.003.0022
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Subscriber: null; date: 23 October 2018

Originally published in International Journal of Psychoanalysis, 1942, 23, 139–146. Also published in Collected papers: Through paediatrics to psycho-analysis (pp. 70–84). London: Tavistock, 1958.
Given as a lecture to the British Psychoanalytical Society, entitled ‘Report on Child Department Consultations’, 3 June 1942. Winnicott was appointed Director of the Child Department of the BPAS during the war, and remained in this post until 1960.

What follows is a report to the Society on the cases that came through the Child Department of the Institute of Psycho-Analysis in London over a period of one year. What I have to say is therefore not directly analytic, though I think it is of interest to analysts.

One of the reasons why the Child Department was set up was to provide a clinic for children who are brought to the Institute for consultation. It was easy to foresee the difficulties and disappointments which this part of the Child Department’s work must entail, and which my description of this year’s work clearly shows. These cases simply fall into line with the thousands of cases that also assail me in my position as physician at a Children’s Hospital.

Over a period of one year I took trouble over each case, and gave up time deliberately in order to do so, and in order to be able to give this report to the Society.

It will be understood that I am giving an account of the cases that were actually sent to the Child Department in the course of a year, and that I am not including an account of the cases given for analysis to students, which were all taken from other sources.

Some cases never actually came for consultation. For instance, a doctor rang up about his little daughter aged three and a half who had recently started a bad stammer. She was an only child. It appeared that the child had become very attached to an aunt who had looked after her while her mother and father (p. 150) were away. Grief at the aunt’s departure did not appear until the child’s little girl friend also left the neighbourhood. She then became depressed and started the stammer. Inquiry showed that the child’s emotional development had proceeded normally till these events, and the home appeared to be reasonably stable and loving. As the child lived too far away to come for analysis without the risk of seriously tiring her physically, I answered the father’s query about analysis being necessary by saying that in my opinion it was normal for a child of three and a half to show violent symptoms, and that as his child’s development was satisfactory in other respects the best course would be to ignore the symptom and not look to psycho-analysis for help at present. A week later the doctor again rang up, this time to say that the child’s symptom had disappeared.

It will probably be agreed that it is wrong to extol the value that analysis would have, if applied, in a case where analysis is not applicable. Parents who come to consultation are feeling guilty about their child’s symptom or illness, and the way in which the doctor behaves will determine whether they will calmly return to taking responsibility which they can well take, or anxiously hand over responsibility to the doctor or clinic. It is obviously better that the parents should retain such responsibility as they can bear, and especially is this true if analysis cannot be given a chance to lessen the actual illness of the child.

Case 1. Ellen, aged ten years, living in London. A first and only child. I could not get a good history in less than an hour and I could not avoid spending four separate hours on the case. Here are a few details.

It can be taken that this child was physically, emotionally, and intellectually normal at one year. At that time, however, the mother left her husband and took the child away, after which the father only saw her at intervals. When the child was six and a quarter years old, the father arrived, unannounced, and picked his daughter up in his car as she was on her way to school. The child came away without a murmur, and was contented to be brought back to London. After this the father started divorce proceedings. When she was nine, the father remarried, this time making an excellent choice. The child’s home background now became good for the first time since she was one year old.

The complaint was that Ellen was artificial. She was nice, and good, and intelligent. The only thing was that ‘you could not get on to a sincere basis with her’, as her father said. In addition, she was childish for her age and it was said that one could never predict from her mood on rising what might or might not happen in the course of the day. School reports showed ups and downs, and the reason for consultation was one incident of thieving which stood out as more than the common petty thieving of school children, perhaps because of the absence of shame. It was a fatal thing to arrange a treat specially for her. Whatever it was, or whoever arranged it, (p. 151) it failed because she became depressed or irritable. Her parents said that if she was caught off her guard she would usually be found to be sorrowful. Her real mother’s moods were also unreliable.

Superficially the child was very happy with her father and especially with her excellent step-mother, to whom she clung. Yet it was easily found that she mourned the loss of her real mother, who had been anything but a satisfactory parent to her.

Analysis could not be arranged. One of the reasons for this was that no analyst capable of dealing with this case had a clinic vacancy. This, I am afraid, will be a recurring theme. I was also influenced by the value to the child of keeping on at the school where she stole the chocolates, where she had some fairly good contacts, at any rate with the staff, and where she might still make good. She was still welcome there, though as a problem child. In a letter to the school I asked that the attempt to ‘cure’ her, to make her normal, should be abandoned; it should be considered good if major incidents were avoided.

A special problem arises in regard to the possibility of analysing a child of this sort. I have known and know of the analysis of highly suspicious children, but nothing can get away from the great danger of the child refusing to come for treatment at an early stage.

I have to hold myself in readiness to see this child again as new crises develop.

Similar suspicion marked Case 2. Norah, aged thirteen years, living in London. Brought by her very intelligent sister because she refused to go to school. She was the youngest of several children.

I invited Norah to pay me a few visits. She came, and drew pictures. After two visits to me she wrote me the nicest possible letter stating that she did not wish to come any more. In this case I had refrained from interpreting, because I knew that if I succeeded in getting behind the suspicion at all I should have to go on with the analysis. And I was not in a position to do so.

Knowing the child’s distress, I transferred her to the Paddington Green Children’s Hospital and sent on her track the psychiatric social worker. The P.S.W. was welcomed, and in many regular visits she made a better contact than I had made. Eventually the P.S.W., valued friend by now, came up against another version of the absolute barrier that I had met so quickly. For an analysis to have been carried out in this case, an analyst would no doubt have had to visit the child daily, and to do the first part of the analysis in the child’s home and on walks and visits to museums. Naturally the clinic does not cater for this, although many of us can draw on experiences of this kind, if we go over in our minds the unexpected things that have happened to us in private practice.

(p. 152) The child gained considerable benefit from the P.S.W’s. visits, but did not get back to school. She has now reached the school-leaving age. She has managed to take a holiday away from her home, and seems likely to start work.1

A wealth of hidden feeling and fantasy was discovered in the course of discussing well-known paintings and studying the child’s own considerable artistic efforts, but this rich world of her fantasy was really a secret inner world, and she felt it dangerous to let even the P.S.W. (who is skilled at not forcing friendships) do more than know of its existence.

In my experience, many of these adolescent children, who seem to be failures at the time of consultation, come for help or even analysis when they are on their own, say at eighteen or twenty years old; and apart from this, children who are attempting to manage the acute problems of early puberty can get value from support which comes from outside the family, especially when the family is itself in unstable equilibrium.

Case 3. Maisie, aged three years. This was an acute case. Maisie had developed extreme restlessness and seriously disturbing compulsive rocking movements and neurotic anxiety in connection with her mother being near the end of her second pregnancy. The new baby was overdue, and my contact with the child extended over the period up to the birth. Tension was greatly relieved by the actual event of the baby’s birth. It would have been logical to have arranged analysis for this child at the end of that time, but no one could be found to undertake the onerous task of daily taking the child to and fro. Incidentally the child suffered severely from lack of anyone to take her out, even for a walk.

My only way of helping was to visit the child in her own home. I was given facilities for seeing the child alone, and I did not use toys. I found her to be maniacal almost to the degree of being inaccessible at first, but she heard and noted my interpretations, and came to value my visits.

Her play was clearly to do with the mastery of birth fantasies, and later of various fantasies dealing with the relation between the parents. In five visits spread over a fortnight I had a tremendous amount of material for interpretations, which I gave in the full sense of the word, making use of the transference from the beginning.

It is difficult to assess results. Naturally no permanent change in the child’s personality was looked for, but I had the satisfaction of seeing the chaos of the child’s fantasy world becoming organized and the maniacal behaviour developing into play, with a sequence in it, as in a satisfactory analysis. The fantasies were clearly expressed and dealt with many aspects of the child’s anxiety over her mother’s pregnancy, which seemed as if it would never end. Anxiety about harm to her mother was important. Much (p. 153) material dealt with the distinction between the bad man who puts her mother in such danger and the good man (her father was a doctor) who helps her out of danger.

Fantasies of incorporating the analyst were strong and had to do with her real need for me all the time.

The child was naturally relieved at the actual birth, and soon found a normal relation to the baby sister. She is still in need of analysis, and if someone could have been found to bring her to the clinic, I should by now have arranged for her analysis as an acute case, but not necessarily a very difficult one.

Case 4. Tommy, aged twelve years, living in London, was unsatisfactory from my point of view. This boy came with a letter from a clinic. Could he be given psycho-analytic treatment? The answer was: no, because in order to get the boy for treatment someone or some group of people would have to be found to bring him daily from a very distant part of London. Further, he was a definitely psychotic case, schizophrenic in type, and therefore only suitable for research analysis by an experienced child-analyst; and no such person would be likely to have a vacancy for a free case.

I saw the mother and the boy, and this took me about an hour. The mother was very suspicious and the lack of useful outcome from the visit increased her grudge against all sorts of clinics and hospitals.

I mention this sort of detail over and over again, because it is no good our pretending to do what we cannot do. It is no good anyone asking us to consider a case if the address is in a remote district, unless there are exceptional facilities for travel, or if the child can attend on his own. And then, of course, there is hardly ever a vacancy. Further, if there is a vacancy, a student cannot be given so difficult a case as this one was certain to be. That is why it is so futile to do consultation work, unless a wide view is taken of the duties of the consultant.

Case 5 was equally futile: Max, aged nine years, living out of London. A refugee from Germany.

The parents of this child both had knowledge of analysis and, naturally, when they saw their child in distress they decided to have him analysed. Certainly the boy needed it, but to have had him analysed I should first have had to find a hostel or school where he could live. The parents had failed to see in advance that it would not be possible to overcome this difficulty, and I fear they were very much disappointed. If at any time in the distant future we have quite a number of analysts doing child-analysis, a small home must be set up where children of various ages may live a family life of sorts and get education, while being near the clinic for analysis.

(p. 154) This boy had had many changes of physical background and he had reacted badly to each change. He was said to have no power of concentration, to be moody, to be suspicious of food and of children of his own age, and to be unloved. And then there was the matter of his being a Jew, this having hitherto been hidden from him. The parents badly wanted help for him. I wish they could have got it. It took me well over an hour to take his history and to get the mother to realize I had nothing to offer her.

Case 6 was a little less unsatisfactory. Tessa, aged thirteen years. Living in the suburbs.

This girl’s father rang up and asked for psycho-analysis for her, because she was not doing as well as he had hoped at school. In a short interview I formed the opinion that the girl was not psychiatrically ill. There were difficulties, including an unreasonable expectation on the part of her father. He wanted her to pull the family up by becoming a doctor, but she had no enthusiasm for this. I passed on the case to a colleague, who went into details and gave advice about the schooling in the way she is fully trained to do. There was no vacancy at the time for analysis, and in any case it would have been impossible for the girl to have stayed at school and also to have travelled up to the clinic every day.2

Case 7 was entirely different. Queenie, aged three years, living in London.

Some friends of mine who are acquainted with psycho-analysis sent this child, the daughter of their charwoman, because she had started stealing. The mother brought her to me personally to treatment in my private rooms two or three times a week over a period of six months. This was quite a difficult thing for the mother to manage, and during her next pregnancy she ceased bringing the child. It was always clear that I could not reckon on daily visits in this case, nor could I expect to be allowed to give the treatment for long. However, I just went ahead, as if I were doing analysis, recognizing the limitations, but not wanting to send away with nothing but a useless consultation a child who had been brought to the clinic.

As a matter of fact quite important work was done, for the material brought by the child enabled me to show sequence and order in it, and I obtained specific results from interpretations, just as in real analysis. The play with toys and by drawing and cutting enabled me to interpret and to show that I could tolerate penis envy and ideas of violent attacks on the mother’s body and on the father’s penis and on babies unborn. She told me of sexual play with her brother. The stealing stopped, and the mother, as so often happens, forgot that the child had ever stolen.

(p. 155) I would say that a real analysis had begun, and that sufficient work had been done on the child’s reaction to week-ends and holidays, and so on, to enable her to deal with the end of the treatment when the visits could no longer be arranged. What I did, though it was not analysis, could only have been done by an analyst, experienced in long, unhurried analysis, in which material can be allowed to force itself on the analyst’s attention while he gradually learns to understand it.

Case 8 was a possible analytic case: Norris, aged six years. Living in the suburbs.

In this case both parents are doctors. The mother came and discussed the problems that had arisen in the boy’s management, and this of course took at least an hour. It appeared that the father had been timid all his life, and hoped to find in his son all the robust qualities he had missed in himself. He had married a wife who was very forceful indeed, and this the only child of the marriage was a timid boy, almost exactly like his father. It became evident that the parents could both manage this child well if they could settle down to the idea that he was of a timid type. Actually the boy’s passive-masochistic organization was near-pathological. I should have liked to have arranged analysis, and it is not yet certain that analysis is impracticable here. But although I am hoping to be able to send this case to an analyst, I find it bad to let the parents feel that analysis is their salvation. They must adjust themselves to the situation without thinking of analysis, which I shall only offer them when I know it is available. I mean that one must avoid giving the impression: ‘Yes, psycho-analysis will cure him, that is to say, will make him as you want him, without any more effort on your part’. I have not yet seen the boy.

I am talking to myself here. At one time, in consultations, I always thought of psycho-analysis as the treatment of choice, and this led to my feeling I had done my bit if I had tried to bring psycho-analysis about. But consultations are of negative value unless analysis is kept completely out of the picture except in so far as it can definitely be arranged. If in addition to what is advised and to other benefits, psycho-analysis can be offered and actually brought about, so much the better.

The following case was definitely more satisfactory, though its satisfactoriness depended on my being able to do something immediately. I do not know how we shall one day solve this problem of always having a vacancy ready waiting. But white-hot material has a special interest of its own, and an analyst who never has room to take an acute case misses valuable experiences.

Case 9. Francis, aged eleven. This boy was brought direct to the clinic by his mother, who claimed urgent help. Francis was violent and in many ways (p. 156) pathological, and was also distressed about his own condition and often asking for help.

The original consultation with the mother in this case took two hours and was of great importance. I found that there were two ill people in the case, the mother as well as the boy. There is a mass of interesting detail that could be given about this case, but to give it all here would be to overreach my present aim.

I would say that there is special interest in the way the boy’s mania was related to his mother’s depression: intolerance of her depression would make him maniacal. In order to help her I had to start her son’s treatment immediately. The result of the first few weeks, in which he behaved like a restless adult and chose to lie on the couch rather than draw or play, was that he changed in his attitude to his real father. He recovered belief in him, following direct Oedipus interpretations of material supplied at white heat in terms of play with his sister. In his fantasy the sexual father was bad and did harm to his mother’s body, so that the Gestapo were acting on his behalf when they took his father away by force, and he was strongly identified with them. He soon took me on as a good father, helpful but nonsexual, and asked me to see his mother sometimes, especially as she had seemed less depressed since I had come into their lives. It is noteworthy that he did not think of me as ‘in love with mummy’, which would have been according to his pattern with all the men he had liked before his analysis started.

Do not be disappointed when you hear that the mother’s depression recovered so far that she arranged for the boy to go away to a boarding school. This in the circumstances was a real advance in the home situation, and meant that a father figure had returned to the home. The analysis is quite firmly planted. The boy comes to me whenever there is any holiday and makes use of treatment as fully as possible in the circumstances.

Case 10. Nellie, aged seventeen years.

Nellie has a brother two years her junior. Her father had been a doctor, and he and his friends made a lot of her. But when she was four her father died, whereupon her mother and she and her brother moved to town and to an entirely different life, where the grown-ups were mostly women, and the boy was now the centre of interest. Perhaps the change of surroundings, coming on top of her father’s death, was too much for her, for she stopped what till then had been a satisfactory intellectual and emotional development. At sixteen she had an illness with persisting body movements, which some doctors diagnosed as chorea. Her own doctor, a friend of her late father, pronounced that this was not true chorea, because of the existence of obvious and long-standing psychological difficulties. On careful enquiry, however, I was bound to say that I regarded this as true chorea, (p. 157) which simplified my advice to the school. For it is easier to tell a teacher to allow for bad hand-writing because of chorea than because of emotional hold-up. The main complaints, however, could not be ascribed to chorea, and included a difficulty in making friends. The teacher wrote: ‘There is a turning away from, instead of a turning out towards, in a way which is not the normal reserve of adolescence, nor just a characteristic of normal “introversion” ’. I saw this girl several times and she liked the interest of a new doctor; but she was terribly contented to be exactly as she was, and I did no good whatever in this case, except by pointing out that the girl was still in the convalescent stage of chorea.

Analysis could not be arranged in this case, and were an analyst willing to take her on I should advise him or her to do so only for research. At any rate this is no analysis for a student.3

Case 11. Nancy, aged twenty. Living in London, billeted in a home county. I give the following case because, although the girl is twenty, she is clinically adolescent.

Nancy came to me with a dossier from her Teachers’ Training College which it took me half an hour to read. I had to have long interviews with her mother and to read many letters from her, and I had to see the girl herself at intervals over a period of six months, perhaps ten times. Nancy’s father had died when she was six, and her mother had devoted herself to the care of her two children. There is a clever, healthy brother of seventeen.

It might be said in two words that Nancy was a sweet and clean and beautifully dressed girl who was in a state of delayed adolescence. The atmosphere of her otherwise excellent home, as well as her internal difficulties, made it hard for her to take the next step in her development, which was to assert herself. The best thing she had done, psychiatrically speaking, was to kick the girl who was billeted with her, a fellow-student at a training college for teachers. This ‘symptom’ had become magnified into so great an affair that the school had decided that they could not recommend her as a teacher on account of it, unless I was willing to take responsibility. This I was willing to do. She was supposed to be dangerously impulsive—‘might hit a child’!

It was touch and go whether Nancy would withdraw for ever from impulsive aggression and get set upon the path that leads to some kind of break-down, or would bravely face the nastiness that is there somewhere in this clean and carefully folded person just as it is in other people. I think I helped her to the latter course, but to do this I had to see her; and I also had to see her mother repeatedly in order to keep her from writing vilifying letters in defence of her perfect offspring; and further I had to (p. 158) go personally and find her a billet, that is to say a billet that had nothing to do with the training college. For the officials in the training college (really quite an ‘advanced’ institution) had fully made up their minds that the girl was dangerous. Actually she has the making of an exceptionally good teacher of tinies, if she can bear to hurt her mother by living away from her.4

Obviously a case for analysis, but I do no good by putting her on a waiting list. I have let her know that psycho-analysis exists, and I think that one day she will take a teaching job in London, and then apply for analysis. The tragedy is that at the moment when she applies, free psycho-analysis may not be available.

Here is a child who was able to get help from me although he could not come for analysis.

Case 12. Keith, aged three and a half years, living in the suburbs.

Keith is sent to me by a relation who is a doctor friend of mine. This doctor is a bit of a psychologist, and he said it was clear to him that the child’s mother (a non-Jewish girl who had married into a clannish Jewish household) was neglecting the child. After I had gone into the case, I felt that here was a clash between two methods of child-upbringing. The mother turned out to be badly in need of support. She immediately got some help through being allowed to give me the usual detailed case history, which I cannot take in less than an hour.

The boy had been easy to feed at the breast (six months) and was easy to train at first. Difficulties started at the introduction of solids. He was always forward intellectually. As a baby he was of the passive type, contented to lie and smile. He hardly ever cried, in contrast to his new brother (nine months) who is behaving quite ordinarily. Complaints were: not sleeping, even with drugs; screaming with rage; negativistic from two years; a continuous nuisance to feed, since beginning on solids; no ‘guts’ in relation to other children, so that he turns any child into a bully; cannot take ‘no’ for an answer; also, cannot be left alone with the baby, because of jealousy that did not appear till about eight months after the baby’s birth.

I saw this boy once a week, as analysis could not be arranged. As long as he could be brought, I acted with him exactly as if he were in analysis, and he produced material for analysis that had to do with the management, in his mind, of his father and mother. As a result of the work his relation to his mother improved, he became actually demonstrative with her and said ‘I love you, I want to kiss you’, for the first time. He also started to sleep in a way which he had not done since he was two, and he stood up to his father’s going into the army quite well. When his mother (p. 159) found it difficult to come any more I supported her in the idea of leaving off treatment, because the alternative would have been to say to her husband’s family that the child was needing more care than she could manage to give, which would have again undermined her confidence in herself.

If I had said that nothing could be done here except analysis I should have missed a good opportunity for therapeutics, and if I had confined my work to giving the mother advice I should not have found the child’s new ability to tell her he loved her, which came as a result of the treatment. The adverse external factor was the rather robust but not pathological homosexuality of the father, which this particular child could not stand till he had expressed his hostility to his father in play. He dramatized this with a toy figure, pretending to pull the figure out of his anus, and made a deliberate effort to get me to understand his meaning, naming the figure ‘daddy’. He rid himself of the homosexual daddy in play, and then improved in his relations to his real father and mother.

I also helped the next girl a little.

Case 13. Gertie, aged seventeen, living in London.

This girl was referred by the headmistress of a High School. It was reported that she had reached no satisfactory academic standard, that she had no beauty, no friends—in fact, that she was incredibly lonely. She could give lucid answers to questions, but she had speech difficulties. For a time she had had treatment at another clinic, but without result. All this came over the telephone from the school.

It took a good hour for me to take a history from the mother, who had been successful in bringing up her son (who is four years older than Gertie). The mother was already nervy while carrying Gertie, and after the birth of the child she could not help worrying about her. She wished to wean her, but the G.P. (probably unwisely in this case) persuaded her to persevere with the breast, which she did for the full nine months.

Early signs of intelligence appeared normally, so that the child cannot be said to be backward because of brain tissue defect. During the history-taking the mother remembered that at five the girl had hit her brother on the head and made him bleed, and she thought this may have been a turning-point. From about this time Gertie failed to develop at a normal pace intellectually. The family is a clever one.

The child told me she had ‘doctor fright’, and indeed she had seen plenty. We made the following list of things needing cure: pimples, tendency to fester, excessive sweating, being bad at exams, writing and speech clumsiness, difficulty over making friends, difficulty over knowing what work to do, and also her mother’s hypochondriacal worrying.

(p. 160) What she seemed to need immediately was for a doctor to say firmly to her, in front of her mother, that she would be wise to see no more doctors. I did this. A month later she came to me to let me know that she had taken a job and was making friends and was beginning to feel more confident.

If I had put her on a waiting list for analysis, I should have been a bad doctor. I wish to be understood here. I believe that there is no therapy that is in any way comparable with analysis. But as this could not be arranged in this case the alternative was to do as I did, to act apart altogether from the existence of psycho-analysis, and to put the girl off therapy of any kind.

The next case came to me from a doctor, following a visit from me to a Child Guidance Clinic.

Case 14, a boy aged ten years, living in a home county. This boy urgently needs help, and is conscious of this need. He could, however, only be analysed if there were a house where he could stay, and from which he could attend at the clinic. I hope there will one day be such a house, because as a result of the recent advances in psycho-analysis, research on insane children can now be done.

It took me an hour to get a good history of this case, and another hour to establish the contact with the boy, contact which I needed in order to form a conclusion as to his intelligence, his emotional development, his illness, and the prognosis. I have seen the boy a dozen times, because he implored me to do so, on account of the very great psychotic anxiety to which he is liable.

His trouble started with his difficult birth, which was a month delayed, so that he was a very big baby. He was born blue, and badly cut about. He was thought to be dead, but to the doctor’s surprise the baby showed signs of life after having been abandoned. The doctor said: ‘Well, you’ve got a baby, and he’s going to give you a hell of a lot of trouble’—an accurate prognosis. At five he was pronounced mentally defective at a famous children’s hospital. Actually he is not intellectually backward, but he is ill in a way that interferes with his relationships. His school puts up with him as odd, and rather likes him.

He is liable to attacks of extreme terror with no external factor to account for them, and he has times of uncontrolled temper, and all sorts of insane ideas appear. For instance, he once came to me with a tank on his hands. By this I do not mean that he had a toy tank or that he had an idea of a tank in his head, I mean that he felt he really had a tank on his hands. He constantly tried to get it off, by squeezing his hands between his legs, passing his hands between his closely drawn thighs. He drew a picture of what he felt like. Also, for a long time, whenever he went to the lavatory to defaecate, a certain brick would seem to him to come out of the wall and wander round.

Further details of this case would be out of place here, but it seemed good to do something more than just see the boy in consultation. While I go on (p. 161) seeing the boy (which at first I did weekly, though I can now increase the interval to a month), he is able to avoid giving trouble at school, and he has less severe attacks of panic. This is not because of anything specific that I do.

He is clever at carpentry and sewing, and loves the idea of farming. He studies aeroplanes in great detail from books, and shows signs of making an exceptionally interesting, restless adult with patchy brilliance.

My object has been, as I stated at the beginning, to report a series of consultations. There is nothing particularly interesting about the series except that it comprises all the cases sent to the Department over a period of time and presumably indicates the type of case to be expected if an attempt were made to widen the range of the Department and to establish a consultation clinic.

It may be that some of this non-analytic material has proved of interest to analysts. It is a personal opinion of mine that it is to analysts that non-analytic material is really interesting. For instance, when a mother gradually pieces together an almost complete history of her child’s emotional development, who but an analyst is likely to supply what she wants, which is the true recognition that all the pieces do weld together into a whole?

Also many odd flashes of insight from parent and child remind the analyst of material patiently acquired in analytic work. I would go further and say that I have learned much that is of value in analysis from the therapeutic consultation, and from the study of other non-analytic material.

One practical point emerges. The primary aim of consultation at the Institute, I take it, is the provision of suitable cases for students, or for analysts of adults who wish to go on to do child analysis. I have never expected that this aim would be achieved, and I think my fears have been justified by this report. It is a matter which we shall have to work out gradually, but it does seem to me possible that the proper place for seeking good cases for students is a paediatric department of a hospital.

There are two possible points of view. According to one, we can encourage vast numbers of cases to impinge on the Institute, and retain a percentage on the ground that they are suitable for training purposes, letting the rest fall off as their fingers tire and when they can no longer keep a hold on the waiting-list, which is their one hope. The other is for someone to be seeing and dealing with a large number of psychiatric cases of all kinds; in this way social pressure could be met, and occasionally and as required under the training scheme, suitable cases could be transferred for analysis.

In the case of children, it is possible that the second is actually the only possible method, since the adults who bring the children are in most cases normal healthy adults; and if a child is simply put on a waiting-list the adult goes elsewhere for advice. Even a fortnight’s wait for consultation is usually (p. 162) enough to discourage a parent or guardian. A series of children put on a waiting-list and left there would be a constant source of ill-feeling, and would all the time be seriously interfering with the relations of the Society with the external world.

As far as I can see it then, while it will remain necessary for someone to attend to the consultations at the Institute as at present, it will continue to be necessary also to draw on other clinics for good analytical material for teaching purposes, especially as the best way to start teaching child analysis is to provide a little child of three, not too ill.

It might not be out of place to give a list of conditions that must be fulfilled when I am trying to supply a student with a child patient. I have to find a child of the required sex and age, of the right diagnostic grouping and degree of illness, with a mother who is genuinely, yet not hypochondriacally, concerned about the child’s disorder, whose address is within easy reach of the clinic; external circumstances must allow the mother to give up two or three hours a day to one child; the parents’ faith in the doctor must carry them over the period in which there is but little encouragement to be got from the changes in the child’s symptoms; and the social status of the family must allow the mother to spend money every day on trains and buses.

In only a small proportion of cases can these demands be met. At present nothing approaching what is required for training purposes is to be expected from the cases coming to the clinic direct, and I am in doubt whether it should ever be our aim to make it so.

It will be felt that there is a note of frustration in my paper. I admit this. I am always wanting to arrange for the patient to be analysed, knowing well that nothing else that can be done approaches or can be compared with the results of analysis. At the same time I am acutely aware that analysis is very seldom both applicable and available. Often the patient cannot be brought to the clinic, or too complex external circumstances would have to be managed, and usually when a case could be treated it is unsuitable for a student. It must be remembered also that it is quite rare for even one new child to be required for analysis. I may go three months without being asked to supply a case.

My sense of frustration must therefore arouse your sympathy. It is clear that the only solution is for more analysts to train, and to learn to do child analysis. We all long for this, and we also know that it is just here that it is difficult to bring about changes, and that no good can come from hurry.

Postscript (1957)

From the date of this communication up to the present time there has been no child clinic at the Institute, and therefore no waiting-list. When a child (p. 163) is needed for a student analyst a child is found from some other established clinic.

Happily two changes have come about in the intervening decade; there are now many clinics on which to draw when a vacancy occurs for a child analysis, and also there are now thirty instead of two to six analysts taking the additional training in child analysis. (p. 164)

Notes:

1. Later: Norah is now at work, doing well. She appears to have successfully negotiated her difficult pubertal phase.

2. On looking back I think this father intended to get into touch with the National Institute of Industrial Psychology, but did not know its correct name.

3. This girl wrote to say that she had passed matriculation and was learning to be a masseuse. She seemed to think her interviews with me had something to do with her improvement!

4. Later: Nancy has completed her college career without further trouble, and has started in a good post. Her defences are organizing into a tendency to explore spiritualism, for which there is strong precedent in her family.