(p. 123) Paediatrics and Psychiatry
I have chosen the subject ‘Paediatrics and Psychiatry’ for my address because of the nature of my work. I am a paediatrician who has swung to psychiatry, and a psychiatrist who has clung to paediatrics. In an address from the Chair it is excusable, even usual, for the speaker to draw on experience that is peculiar to himself. My position, as I am a worker in two fields, ought to qualify me to communicate something that has interest for the children’s doctor and also for the doctor whose work is concerned with the insane. It is, of course, inevitable that one who works in two subjects must sacrifice some degree of expertness in each.
The researches that more or less started with the pioneer work of Freud have established the fact that in the analysis of psychoneurosis the patient’s childhood turns out to have harboured the intolerable conflicts which led to repression, and to the setting up of defences, and to the interruption in the emotional development of the individual, with formation of symptoms. Naturally, therefore, research became directed towards the emotional life of children. It was soon found that the reconstruction which adult patients gave of their childhood conflicts conflicts associated with their instinctual ideas and experiences could be seen in children, and seen clearly in the analytic treatment of children. It was not long before it began to be wondered whether the more psychotic illness of adults might not relate to the experiences of infants. Gradually a highly complex theory of the emotional development of the human being has been worked out, so that with all our terrible and at the same time exciting ignorance, we now have useful working hypotheses, (p. 124) hypotheses, that is to say, that really work. There is now sufficient material available for attempts to be made to formulate things about infants which concern equally the psychiatrist and the children’s physician, and I want to be one of those trying to say these things.
My thesis then is that the research worker in each of the two specialities has much to gain by meeting the research worker in the other. One assumption must be made; perhaps it will not be accepted. I assume a psychological basis for mental disorder. I assume that psychiatry can be studied in cases in which the health of the brain tissue is good. Naturally if a brain is diseased or physically disturbed, or cut about, mental changes must be expected. For myself I could learn but little from a study of the personality of an individual with a disordered brain, whereas there is so much that can be studied in the brain-intact individual and so much remains to be understood about normal emotional development and its vagaries.
I hope it will not be thought that I am ignoring heredity or G.P.I. or senile dementia, injury, encephalitis, toxic delirium, or brain tumour, or even symptomatic improvement following the induction of fits.
Let me restate my idea, that it is possible to establish a clinical link between infant development and the psychiatric states, and likewise between infant care and the proper care of the mentally sick.
To do research one must have ideas, there is a subjective initiation of a line of inquiry. Objectivity comes later through planned work, and through comparison of the observations made from various angles. In justice to those who are doing research into this matter of the emotional development of the infant I will give a catalogue of the various methods of approach to any one detail that is being studied. The following types of approach provide observations that can be compared and correlated:
1. Through direct observation of the infant-mother relationship
An example of this is provided by Dr Middlemore’s work (unfortunately cut short by her death) which is described in the book The Nursing Couple.
2. Direct periodical observation of an infant starting soon after birth and continuing over a period of years
In general practice and in a paediatric out-patient department of a hospital, parents attend when trouble arises or when they need advice.
3. Paediatric history-taking
In my own experience I have given a mother the opportunity of telling me what she knows of her infant’s development in about 20,000 cases. There is always more to learn about history-taking, but with this sort of experience one becomes, I hope, more and more accurate in one’s assessment of a mother’s description. (p. 125)
4. Paediatric practice, typically the management of infant feeding and excretion
In the course of my paper I shall give an example of the psychological aspect of infant feeding problems. One could say that in the ordinary case where there is no disease process the work on the physical side has already been done by the physiologists and biochemists, and the practical problems are largely psychological.
5. Diagnostic interview with the child
In the first interview it is often possible, and not harmful, to do a sort of analytic treatment in miniature. If analysis is undertaken later it will regularly be found to take many months to cover the same amount of ground again. In these interviews the doctor is not so sure of his ground as he is in a long analysis, but, on the other hand, he gets a deep insight into a large number of cases, and this to some extent balances the restriction of numbers in his analytic experience. Incidentally, in psychiatry, a diagnostic interview is only fruitful if it is a therapeutic interview.
6. Actual psycho-analytic experience
This gives a different view of the patient’s infancy according to whether the child is in the 2- to 4-year-old age group, or older, or near puberty, or in adolescence. For the analyst who is doing research on the earliest processes of emotional development, the analysis of fairly normal adults can be even more profitable than the analysis of children.
7. The observation in paediatric practice of psychotic regressions appearing as they commonly do in childhood and even in infancy.
8. Observation of children in homes adapted to cope with difficulties, whether these are antisocial behaviour, confusional states, maniacal episodes, relationships distorted by suspicion, or persecution, or mental defect, or fits.
9. The psycho-analysis of schizophrenics
This I am putting in a separate group because I think such analyses are for experienced analysts only. In my view the analysis of illness associated with depression and the defences against depression are now in the class of routine treatment and are not ‘research cases’. This is also true of manic-depressive and even paranoid cases. Schizophrenics, however, are in a different class and their treatment is more of a pioneering venture.
At this point I have learned to expect a misunderstanding unless deliberate care is taken to avoid it. It has often been said to me: the idea that mad people are like babies, or small children, simply isn’t true. Can I make it clear that I do not suggest that the insane are behaving like infants any more than that (p. 126) neurotics are just like older children. Ordinary healthy children are not neurotic (though they can be) and ordinary babies are not mad. The relationship between paediatrics and psychiatry is much more subtle than this.
The theory that I am putting forward is that in the emotional development of every infant complicated processes are involved, and that lack of forward movement or completeness of these processes predisposes to mental disorder or breakdown; the completion of these processes forms the basis of mental health.
The mental health of the human being is laid down in infancy by the mother, who provides an environment in which complex but essential processes in the infant’s self can become completed. It would perhaps be a good initial study to describe the task of the ordinary good mother, in so far as we can see what is happening in this partnership. I will attempt this, but before doing so there is something that must be said about the meaning of the actual mother to the infant.
It is fully agreed that eventually the infant comes to feel himself as a whole person, and to hold his mother to be a whole person; soon after this stage is reached other people enter his life as people, but the complications that belong to this state of affairs need not be gone into here. There is not a general agreement as to the first age at which an infant feels mother to be a person, and so feels concerned as to the results of his real and imaginary attacks on her when under the sway of instinctual tension. This puzzle, fortunately, can be left unanswered, as at the moment we are considering a mother’s care at the stage before the infant can feel concerned.
I think I see what Miss Anna Freud (1947, p. 200) is referring to when she states:
This first ‘Love’ of the infant is selfish and material. Its life is governed by sensations of need and satisfaction, pleasure and discomfort. The mother, as an object, plays a part in this life so far as she brings satisfaction and removes discomfort. When the infant’s needs are fulfilled, i.e. when it feels warm, comfortable, with pleasant gastric sensations, it withdraws interest from the object world and falls asleep. When it is hungry, cold and wet, or disturbed by intestinal sensations, it turns for help to the outside world. In this period the need for an object is inseparably bound up with the great body needs.
From the fifth or sixth month onward the infant begins to pay attention to the mother also at times when it is not under the influence of bodily urges.
Dr Friedlander (1947, p. 23) wrote:
… during the first weeks and even months of life the relationship of the child to the mother is a rather simple one. The mother is the instrument (p. 127) which satisfies the child’s bodily needs. Anyone who fulfils this function will arouse the same response in the child.…
However I think myself that by the seventh week or so a large proportion of infants show clearly that they have at times a contact with the woman who is their mother.
Let us attempt to study the mother’s job. If the infant is to be able to start to develop into a being, and to start to find the world we know, to start to come together and to cohere, then the following things about a mother stand out as vitally important:
She exists, continues to exist, lives, smells, breathes, her heart beats. She is there to be sensed in all possible ways.
She loves in a physical way, provides contact, a body temperature, movement, and quiet according to the baby’s needs.
She provides opportunity for the baby to make the transition between the quiet and the excited state, not suddenly coming at the child with a feed and demanding a response.
She provides suitable food at suitable times.
At first she lets the infant dominate, being willing (as the child is so nearly a part of herself) to hold herself in readiness to respond.
Gradually she introduces the external shared world, carefully grading this according to the child’s needs which vary from day to day and hour to hour.
She protects the baby from coincidences and shocks (the door banging as the baby goes to the breast), trying to keep the physical and emotional situation simple enough for the infant to be able to understand, and yet rich enough according to the infant’s growing capacity.
She provides continuity.
By believing in the infant as a human being in its own right she does not hurry his development and so enables him to catch hold of time, to get the feeling of an internal personal going along.
For the mother the child is a whole human being from the start, and this enables her to tolerate his lack of integration and his weak sense of living-in-the-body.
If I add that the mother continues to exist in spite of repeated attacks on her (made by the infant both in love and in anger), I am going too far ahead, reaching towards the functions of the mother relative to the infant who has instincts and the capacity to be concerned.
If we examine this admittedly incomplete description we can see that whereas some functions (such as the provision of suitable food) might be performed by anyone, much can only be done by someone who has a mother’s interest; moreover, continuity cannot be well provided by a multiplicity of minders; and in any case there is the actual continuity of detail as observed by the infant, starting perhaps with the close-up of the nipple or of the face, and (p. 128) including the smell and the details of texture, and so on. Moreover, how can anyone who is not in the position of mother with a mother’s love know the infant well enough to give well-graded enrichment, to give enough to foster growing capacity, yet not enough to engender confusion?
Here I think I come to the first statement of the paediatrician’s clinical gain from psychiatric contact. If it be true or even possible that the mental health of every individual is founded by the mother in her living experience with her infant, doctors and nurses can make it their first duty not to interfere. Instead of trying to teach mothers how to do what in fact cannot be taught, paediatricians must come sooner or later to recognize a good mother when they see one and then make sure that she gets full opportunity to grow to her job; mistakes she may, and indeed will, make, but if by these she becomes able to do better in subsequent attempts there is in the end a gain.
Mothers cannot grow if they are frightened into doing as they are told. They must first find their feelings, and while doing so they need support support against their own fears, their superstitions, their neighbours, and, of course, against physical accident and disease which can so largely be prevented or cured nowadays. I shall have more to say later about this support-without-interference, but if I were addressing a paediatric audience I could not too often mention the great danger to mental health that occurs when an infant is insulted by rude disruption of the delicate natural processes in the infant-mother partnership.
The environment is so vitally important at this early stage that one is driven to the unexpected conclusion that schizophrenia is a sort of environmental deficiency disease, since a perfect environment at the start can at least theoretically be expected to enable an infant to make the initial emotional or mental development which predisposes to further emotional development and so to mental health throughout life. An unfavourable environment later on is a different matter, being merely an additional adverse factor in the general aetiology of mental disorder.
Now let me briefly indicate the task of the infant happily placed in the care of an ordinary good mother. It will be understood that the task which can be said to occupy the infant (at least from birth) is not ever a completed task, and the achievements of the first weeks and months must be many times lost and regained according to the turns of fortune.
It is not difficult to see that in the case of every infant at least these three things have to happen:
1. The infant has to make contact with reality. (p. 129)
2. The personality of the infant has to become integrated, and the integration has to gain stability.
3. The infant has to come to feel he lives in what we see so easily as the body of that infant, but which at first is not felt by the infant to be significant in the special way we know it is.
Three things: reality contact, integration, sense of body.
The psychiatrist will readily see in the nature of these tasks the reflection of symptoms that are his continual concern; loss of reality contact and of reality sense, disintegration and depersonalization.
In order to follow up one theme in some detail I must take only one of these three, leaving the others aside.
I have chosen to examine the matter of the establishment of reality contact, and even so I have to confine my attention to one example, the contact that arises out of that most primitive form of love, which is called greed, and which persists as cupboard-love. Equally significant is the reality contact in quiet periods between excitements, but I must not go too far from my subject.
As soon as an object relationship is possible it is immediately a matter of significance whether the object is outside or inside the child. I assume, however, that there is a stage prior to this at which there is no relationship at all. I would say that initially there is a condition which could be described at one and the same time as of absolute independence and absolute dependence. There is no feeling of dependence, and therefore that dependence must be absolute. Let us say that out of this state the infant is disturbed by instinct tension which is called hunger. I would say that the infant is ready to believe in something that could exist, i.e. there has developed in the infant a readiness to hallucinate an object; but that is rather a direction of expectancy than an object in itself. At this moment the mother comes along with her breast (I say breast for simplification of description), and places it so that the infant finds it. Here is another direction, this time towards instead of away from the infant. It is a tricky matter whether or no the mother and infant ‘click’. At the start the mother allows the infant to dominate, and if she fails to do this the infant’s subjective object will fail to have superimposed on it the objectively perceived breast. Ought we not to say that by fitting in with the infant’s impulse the mother allows the baby the illusion that what is there is the thing created by the baby; as a result there is not only the physical experience of instinctual satisfaction, but also an emotional union, and the beginning of a belief in reality as something about which one can have illusions. Gradually, through the living experience of a relationship between the mother and the baby, the baby uses perceived detail in the creation of the object expected. In the course of breast feeding a mother may repeat this performance a thousand times. She may so successfully give her child the capacity for illusion that she has (p. 130) no difficulty in her next task, gradual disillusioning, this being the word for weaning in the primitive setting which is my interest in this paper.
It worries some people that there is no such thing in psychology as direct union, only an illusion of relationship; but I suppose psychiatrists are so used to patients’ descriptions of loss of contact with reality that they will not be among those to object. Most of us are so good at using the objectively observed and expected that we manage without hallucinations, unless we are tired or weak from physical exhaustion. For the infant this clever use of shared reality which is another aspect of objectivity is by no means established, and everything depends on the mother at the beginning.
The mother does her job in this respect by simply being devoted, that is, provided she is allowed by doctors and nurses and helpful people generally to act as she loves to do.
This is where the paediatrician comes in in clearing the way for the mother’s native feeling towards her child. In accepting the psycho-analyst’s help the paediatrician, incidentally, extends the usefulness of the analyst to a circle wider than that of his analytic practice. Doctors have made it very difficult for mothers to start off well in this function, one of the most important they have to perform. It is often very difficult for a woman, when preparing to have a baby, to be sure that she will be allowed to come to terms with her infant after birth in her own way, which is the infant’s way. Let me quickly turn to an exception. Professor Spence1 of Newcastle insists that each healthy baby in the maternity homes he supervises shall be in a cradle at the side of the mother. The mother has the skilled attention she so greatly needs, and she enjoys the confidence that is inspired by first-rate medical and nursing practice. At the same time she is expected to be the best judge of the feeding technique needed by her infant. There are no rules about regular feeding, and ‘the nursing couples’ (to use the late Dr Middlemore’s term) usually find a convenient feeding rhythm sooner or later. Contrast this with the worst case, not difficult to find, of a maternity home in which the babies are kept in cots in a separate ward, even when healthy. At feed times they are wheeled in on a trolley, tightly wound round by a shawl, and at the right moment the nurse clocks in by thrusting the screaming infant’s mouth at the breast of the bewildered, frustrated, often frightened mother.
This only refers to the initial stages of the feeding experience, and it will readily be seen that these ideas can be applied at all later stages. Nevertheless, if the beginning is bad the continuation is necessarily made more difficult. Moreover, clinically, serious feeding disturbances may start at the initial stage.
The paediatrician, taking careful histories of small children, cannot but be struck by the commonness of fairly or very severe feeding inhibitions.2 He finds that there are certain critical moments that can be enumerated. (I had a severe case in a three-year-old in analysis, a little girl whose feeding inhibitions had started at twelve months on a definite day when she was sat (p. 131) up at table to eat with her father and mother, that is to say, all three together.) A common time for loss of zest for food would be the near arrival of a new baby. In many cases the loss of zest for food starts in infancy. There is the inhibition in respect of self-feeding, or there is a change from eagerness to refusal of food at the time of weaning from breast or bottle or from a special person, or at the introduction of solids, and even at the thickening of feeds. The arrival of teeth may be accompanied by refusal of feeds. Even in very young infants one finds the refusal of anything new, and sometimes, conversely, an interest only in the new.
Some of the inhibitions, however, start from the beginning. The infant and the mother just never ‘click’. At this point the mother can be held theoretically responsible, though of course not to blame.
Ordinarily if breast feeding is difficult the baby is put on to a bottle, and there are all sorts of ways out of the difficulty when the breast milk does not come or suit. In a case of difficulty, to insist on the breast when a mother could easily feed her baby well by bottle is a mistake.
In these matters the infant’s doctor is at a loss if he does not understand what is going on behind the scenes in the emotional development of the infant; and he needs, too, to know something about the psychology of nursing mothers.
It is relevant here to describe a common problem of infant feeding, as I see it. I mean as I see it now, for I have struggled through the phases all doctors experience, in the heartbreaking attempt to deal with feeding problems along physical lines, altering quantities, intervals, proportions of fat, protein, and carbohydrate and switching from one brand of milk to another. Well do I remember the day when I made it a rule to get a feeding going well before altering the brand of milk. It took me years to realize that a feeding difficulty could often be cured by advising the mother to fit in with the baby absolutely for a few days. I had to discover that this fitting in with the infant’s needs is so pleasurable to the mother that she cannot do it without moral support. If I advise this I must ask my social worker to visit daily, else the mother will wilt under criticism and feel responsible for too much. Obeying a rule, she can blame others if things go wrong, but she is scared to do as she deeply wants to do. On the other hand, if all goes well she never forgets the fact that she had it in her to do the right thing for her baby, without help.
These are not clever things. They simply require an appreciation of what it is that the mother and the baby are doing together. With the human infant it is never adequate to think in terms of conditional reflexes.
I want to make it clear that I am describing the paediatrician’s task in the management of infant feeding, suggesting that he works blindly unless he knows what is going on behind the scenes. There the processes of emotional development are dominant, and they are of a nature that can be found in a ‘state of undoing’ in schizophrenic illness.
(p. 132) It is here that something can be said about play. The first play at the breast is of great value in that it enables the baby to find the mother and to communicate with her so that she can be prepared to act in the right way. Without the chance of play, the baby and the mother remain strangers to each other. How important are the hands in this. At twelve weeks, an infant will sometimes feed his mother while at the breast, putting his finger in her mouth.
W. H. Davies in his poem ‘Infancy’ said:
- Born to the world with my hands clenched,
- I wept and shut my eyes;
- Into my mouth a breast was forced,
- To stop my bitter cries.
- I did not know nor cared to know
- A woman from a man;
- Until I saw a sudden light,
- And all my joys began.
- From that great hour my hands went forth,
- And I began to prove
- That many a thing my two eyes saw
- My hands had power to move:
- My fingers now began to work,
- And all my toes likewise;
- And reaching out with fingers stretched,
- I laughed, with open eyes.
Psychiatry and Infant Care
It is time I linked this with something of interest to the psychiatrist.
In the psycho-analysis of a woman (who had done well in life but who came for treatment because of an increasing dissatisfaction, and a growing feeling that nothing meant anything to her) the following happened. There was an hour in which the important thing was that I kept absolutely still and quiet and said nothing at all. The next hour the same was happening, but after a length of time I reached for a cigarette. The result of the tiny movement I made was nearly disastrous, and the situation was only saved by my patient’s being able to see what was afoot. From what had gone before we both knew that she was right back in the infant-mother relationship. In the quiet my patient had been lying on her mother’s lap. Just when I made the movement the patient was (in her mind) starting to reach up with her hand, and in doing so she would have found the breast, and in the course of time the mother would have responded, and the feed would have started. The two would have (p. 133) come to terms. It was for this very experience that this patient was unconsciously looking. As I moved, however, I broke the spell and suddenly became the nannie. (Historically she had had the breast for a period of one month and had then been handed over to a nannie and fed by bottle.) Now this meant a disruption of natural progress. The nannie, although in many ways a better mother than the real mother, because not depressed, nevertheless at the moment for a feed had to get up and fetch or even prepare the bottle, and by the time all was ready the infant had lost much of the ability to ‘create’ the bottle or the milk; it had become a thing coming at her, with which she had to try to come to terms.
This sort of case material leads me on to the description of other analytic studies. It is very difficult to convey to those (either paediatricians or psychiatrists) who are not doing psycho-analysis the feeling of conviction that one digs down to solid rock, by which I mean that one sees real things re-lived in this work. However, each one of us can only get a certain number of types of experience, and therefore each must inevitably rely on learning from the work of colleagues.
I have long struggled with a case which illustrates my point in that, to help this patient at all, I have had to be ready waiting when she comes. This woman is one of twins, and the different treatment afforded her as compared with her twin sister by her mother has always been a source of grievance with her. Her twin being the weak one was taken over by the mother and fed and cared for by her, and taken into the mother’s bed, while my patient, being strong and large, was handed over to a nurse. This was the conscious reconstruction. Only gradually has the true early infantile situation come out in the transference. This patient comes to me from a mental hospital. She has a fairly severe degree of splitting of personality, and for the first two decades (apart from her infancy) she made an exceptionally good adjustment on a compliance basis. Then she broke down, and started on her long search for a chance to find her own self, and a relation to the world that she could feel to be real. Needless to say, she did not know what she was looking for, and at one stage, in despair, she developed rheumatoid arthritis with the unconscious aim of becoming bed-ridden and helpless, so getting her family to comply with her. Or, shall I say, she used her arthritis in that way.
Hope of getting what she needed from analysis brought with it the absolute need that I have mentioned for me to be ready for her. At one time I had to be at the front door myself, actually opening the door as the bell rang. It can be well imagined that there was an infinity of play round this detail of management. Sometimes she would telephone me on the way, otherwise not believing I existed at all. The reason why I had to take the trouble to do all this, which was very trying, was that otherwise it was no use seeing her at all; she would come, and talk and go, but would get no feeling of our having met. On the other hand, a long spell of my giving her direct access always brought its (p. 134) reward. In six years a great deal has happened but the basis of it all has been the provision of direct access. She is having an essential experience for the first time, although it belongs to infancy, and this fact comes out quite clearly in the detailed material that I have not time to reproduce here. In this case there is a strong regression element, the main trauma being related to early childhood rather than to infancy, namely a long period of rigid management by an almost insane nurse.
In case it should be thought that the analyst puts these ideas into the patient’s head I would give a detail out of the treatment of a boy who was an apparent mental defective, but who was really a case of childhood schizophrenia, with regression to a powerfully controlled introversion. When the boy came to me at the age of five years he spent his time over a period of two or three months simply coming towards me and going away again, testing my ability to give direct access and egress.
Gradually this boy let himself sit on my lap, and go on to make affectionate contact. In the next phase he would get right inside my coat, and out of this developed a game of sliding out on to the floor head first from between my legs. During all this period I made very few verbal interpretations. In the next phase he had so strong a need for honey it was wartime, and honey scarce that he strained all resources until mercifully he became able to accept malt and oil instead, of which he ate voraciously. He now covered everything with saliva and became destructive with the honey-spoon. His saliva would form a pool on the doorstep if he was kept waiting. Out of all this there came a slow but steady development which had previously ceased and had become negative.
In this experience I seemed to see a child re-living early infantile experience and out of some need in himself correcting the faulty introduction to the world, being born again. I saw one environment supplanting another. After this, analysis by verbal interpretation became not only possible but acutely necessary. But in the phase I have described my job was to provide a certain type of environment, thereby allowing the boy to do the work.
There is a direct application of all this to the care of adolescents. Here is a typical adolescent case. A boy of sixteen at a public school tells his school doctor that he insists on seeing a psychiatrist. In the end he gets his own way and his parents bring him to me. I take a detailed history from the parents, and in the interview with the boy I find him depressed, and flabby. In about an hour I get nothing from him, and I do not make any effort to bring him out. As I find later, the important thing in that interview was the lack of any urge on my part to get him to respond. On parting I let him know that I was expecting to see him again sometime.
The next I hear is through the telephone. He rings me up from school and asks if I can see him tomorrow, a Saturday. I know that I must do this, as the (p. 135) gesture has come from him, and I put aside everything to fit in with him. On the phone I immediately say yes, before I have decided how to manage it.
These conditions bring a very different boy to my room. He makes very considerable use of me, and in an hour or two he has done an analysis in miniature. Considerable results follow this, more I think than would have been reached in weeks of a set analysis at this stage. In the next holidays I find the boy has left school on his own initiative, decided on a career, made arrangements to attend a university, and to live in London where he can have analysis over a proper period, whether from me or a colleague. I think that this is the right way for such an analysis to start, and that many treatments of schizoid types of adolescent fail because they are planned on a basis that ignores the child’s ability to ‘think up’ in a way, to create an analyst, a role into which the real analyst can try to fit himself.
If this is true it follows that set techniques for interview defeat their aim, which, presumably, is to make a diagnosis and to initiate a therapeutic procedure. The set technique wastes the patient’s ability to make one sort of contact, and with a case of schizoid type this waste of opportunity may act as a negative therapy, and may do harm.
In the analysis of a schizophrenic adolescent girl I had to adopt a procedure over a long period of time by which I saw her or dealt with analytic material over the telephone just exactly when she rang. Claustrophobia was activated if any sort of definite arrangement was made. With this proviso good analytic work was done. Eventually a regular time was achieved. If, however, I had forced a regular arrangement too early this patient would have been unable to have made a contact with me that meant anything to her. Over a long period we talked chiefly of infant management and infant feeding; as a matter of fact before coming to me this girl had been giving infants in her care just the management that she needed from me and that she failed to get from her mother. The mother had been excellent except for a tremendous need to get reassurance from her feeding activities. ‘None of my children ever refused anything I offered them’, she would say, and as she was a trained dietician they all waxed fat, especially my patient. But till she came to me this girl scarcely knew what it was to make contact with reality from her end.
I now wish to describe what I can see of the theoretical basis of all this. In the favourable case the expectation of the infant meets impinging reality, and at this point I would place the word ‘Illusion’. In case this is not understood by someone the following story may help.
Recently, during a hot spell, an analyst had to do an extra analytic session in the lunch hour. He was tired and perhaps a little sleepy, and he had the following experience at the same time as being an ordinary competent analyst.
He could see out of his window, and on a roof some distance away he saw a man. This man was about 45 years old, and had a rather bald head. He had (p. 136) finished his sandwiches and had let his mid-day paper with its racing tips fall. Obviously he had allowed himself to drop off to sleep.
Dimly aware of all this the analyst would never have registered anything had it not been that there was a sequel. We all know the way in which a continuous noise may be unnoticed until it stops. Well, in this case the disturbing thing was that the man made no movement at all. After half an hour the analyst definitely registered the fact that the man ought to have woken up, and then suddenly: pop! the man’s head swelled to the size of the rather large stone spherical ornament that it had been all the time. The sight of the man going to sleep was no more than an indication that my friend wanted to go to sleep himself. He had failed to confine his hallucinations to situations that could absorb them.
To return, in the favourable case impulse or expectation of the infant meets impinging reality.
What are the consequences of failure in the introduction of the shared world to the infant?3 In the extreme of failure these two lines in a diagram would be parallel. The infant creates out of his native poverty, and the world impinges in vain. The lines never meet. In such a hypothetical case there must be mental defect even if there is normal brain capacity. Commonly there is some degree of this splitting at the earliest level, and the basis is thereby laid for the infant to have a relationship unshared by us with a self-created world, in which magic holds sway, and alongside this a compliance with mundane management from outside, convenient because life-giving, but unsatisfactory in the extreme to the infant. Later on in childhood or adult life the compliance breaks down, if it is too isolated from the other trend which contains all the child’s spontaneity. These parallel paths regularly appear in our analytic work, illustrated at the simplest by the patient who said that his analytic sessions were in duplicate, a rather dull one actually with the analyst, and the operative one afterwards in relation to an imagined analyst.
Paediatrician and Psychiatrist
The main point about this is that in investigating the phenomena of human contact and communication, the paediatrician and the psychiatrist badly need each other’s help. For instance very few psychiatrists can take a reliable history from a mother about early feeding details. Yet no history of a psychotic case is complete unless the last ounce of detail of the early nursing couple experience has been obtained, if it is available to skilled inquiry. Also, the paediatrician needs the psychiatrist. On his own he will fail to recognize the psychiatrically-ill infant, for such an infant may be in bursting physical health, never defiant or difficult, indeed most delightfully acquiescent. The ill baby may in fact be especially all the time good, ‘we never knew we had him, (p. 137) doctor’, able to be left on the arm of the chair with no danger of wriggling off, and so on. Healthy babies cry, do not by any means always take willingly, they have wills of their own, they are in fact a trouble. To their own mothers healthy babies are of course more rewarding than ill babies ever can be, because along with their nuisance value they also show spontaneous love feelings, so much more encouraging than the negative virtues.
In the matter of practical management I feel that those who care for infants (I mean mothers and nursery nurses) can teach something to those who manage the schizoid regressions and confusion states of people of any age. The provision of a stable though personal environment, warmth, protection from the unexpected and unpredictable, and the serving of food in a reliable way and accurately on time (or even following the whims of the patient), these things might help the nursing of schizoid cases.
The important thing for the psychiatrist, at the moment, however, is not practice but theory. I am saying that the proper place to study schizophrenia and manic depression and melancholia is the nursery, and if this be true then some modern trends in psychiatry are like barking up the wrong tree.
It may be asked, what do ordinary people do about this matter of contact with reality? Of course as development proceeds a great deal happens that seems to get round the difficulty, for enrichment by incorporation of objects is a psychical as well as a physical phenomenon, and the same can be said of being incorporated, including the eventual contribution to the world’s fertility which is the privilege of even the least of us. And especially the sexual life offers a way round, with the conception of infants, a true physical mingling of two individuals. Nevertheless, while we have life, each one of us feels the matter of crude reality-contact to be a vital one, and we deal with it according to the way in which we have had reality introduced to us at the beginning. In some of us the ability to use the objectively verifiable, to objectify the subjective, is so easy that the fundamental problem of illusion tends to get lost. Unless they are ill or tired people do not know that there is a problem of relationship with reality, or a universal liability to hallucination, and they feel that mad people must be made of different stuff from themselves. Some of us, on the other hand, are aware of a tendency in ourselves towards the subjective, which we feel to be more significant than the world’s affairs, and for such the sane may seem rather dull folk, and the common round seems mundane.
One of the ways out is the dreaming of dreams, and the remembering of them. In sleep we dream all the time and when we wake we need to carry something forward from the dream world into real life, just as we need to recognize everyday affairs turning up and weaving themselves into the dreams. Apart from this, is it not largely through artistic creation and artistic experience that we maintain the necessary bridges between the subjective and the objective? It is for this reason, I suggest, that we value tremendously the lone struggle of the creator in any art form. For us all, as for himself, the artist is (p. 138) repeatedly winning brilliant battles in a war to which, however, there is no final outcome. A final outcome would be finding what is not true, namely, that what the world offers is identical with what the individual creates.
I will end with an illustration which broadens the subject a little. A man dreamed he was driving a car up the curve of a hill when he saw a larger car coming at him down the curve of the hill, at speed. It was a flash dream. He swerved to the left, but he knew that if he had not wakened there would have been a terrific crash. It was a satisfactory dream, and he woke to the memory of banging his head on a pillar when walking with his mother as a little boy. This was an easy memory, an incident, never forgotten. Suddenly it occurred to him that the memory was a false one. He had been walking with his mother and it was another boy walking with his mother who had absent-mindedly crashed into the post and had badly hurt his head, producing a copious flow of blood.
The fact was that, because of analysis in respect of reality-contact, he had become able to understand that he envied the boy who crashed into the post. I mean, this crash seemed ever so real to him at the time it occurred, contrasting with his own growing and distressing inhibition and lack of reality-sense in his contact with his mother, secondary to the repression of his Oedipus wishes.
From this step forward in his analysis he got a new feeling about children’s love of the awful phenomena of gangster films, and of crashing Spitfires and bombers, and the like.4 I, too, realized more clearly than previously that in trying to unravel all the complex psychology of childhood behaviour it would be unwise to neglect the threat of feelings of unreality and loss of contact. I need hardly add to an audience of psychiatrists that the same applies to the study of adults.
It is those who feel that external reality lacks meaning whenever routine holds sway who need the refreshment of music or painting absolutely. Someone I know who is recovering from a long phase of loss of contact found the colour in van Gogh’s pictures painfully real. The colour came at her as the car did in the man’s dream. The colour was too much for her in a physical sense, and she had to go away and come back another day to complete the visit to the picture gallery.
In the management of children comparable happenings can be observed. Unreality feelings show as a craving for the new. This turns up in early feeding management, in the problem of the baby who is put on one food after another, and who does well for a few days on each, and then loses interest. But the new can also hurt. It would be wise to keep in mind that for the infant the new, whether in taste, texture, sight, or sound, can come at the infant as the colour did to my friend, and physically hurt. An ordinary good mother is sparing with new things, and yet provides them according to the infant’s ability to come to terms with them. In psychiatric practice, (p. 139) as I have already suggested, there could perhaps be room for the attempt to coax back a withdrawn person by the provision of an extremely simplified bit of the world, a world into which the patient could gradually come back without suffering painful impressions. In the analysis of borderline cases some such provision is made in the limited setting of the analytic session, and such provision is a prerequisite for the work based on the verbal interpretation.
I have tried to focus attention on one process, that of the individual’s contact with shared reality, and the development of this from the start of the infant’s life. I have hoped to encourage a co-operation between the children’s doctor and the psychiatrist in arriving at descriptive terms that have clinical meaning to each. I have made an attempt to do this in an examination of the normal establishment of reality-contact.
It was difficult to cast aside psychosomatic disorders, to turn a deaf ear to the common anxiety states, and a blind eye to depression, hypochondria, and persecution delusions. All these disorders affect the day-by-day work of the paediatrician. It was difficult to steer my course away from the pathological psychotic regressions and psychotic distortions which are much commoner in childhood than is generally supposed. Also it was difficult to choose the one process, and to ignore those of integration and body sense. However, as it is, I have had more to convey than can easily be listened to at one sitting, and I console myself that it is better to convey the idea that a thing is complex, if it is so, than to give a false impression of simplicity.
These things have been argued about by philosophers and psychologists, and psychopathologists of all schools have made their own attempts to state what they feel they see. Here is my statement, forged out of clinical work and a psycho-analytic training.