(p. 513) The Effect of Psychotic Parents on the Emotional Development of the Child
In our consideration of psychosis and family life in the previous section, most of the cases were described in terms of the problems created by psychotic illness in the child. I now want to examine further the effect of psychosis in the parent on the emotional development of the child and on the family.
As a starting-point, I will try to convey something of the beauty of a poem written by an eleven-year-old girl. I cannot reproduce the poem here because it has been published elsewhere over the girl’s own name, but it gives in a sequence of economical short lines a perfect picture of home life in a happy family setting. The feeling conveyed is of a family of children of various ages, the children interacting with each other, jealousies being experienced but tolerated, the family pulsating with potential living. In the end night comes, and the atmosphere is handed over to the dogs and the owls and to the world outside the house. Inside all is quiet, safe, and still. The poem gives the impression that it comes right out of the life of the young authoress. How else, one wonders, could she possibly know these things?
The Story of Esther
Let me call the authoress Esther, and ask: what is Esther’s background? She is the foster child of intelligent middle-class parents who have an adopted son (p. 514) and now have another fostered girl. The father has always been devoted to Esther and he is very sensitive in his understanding of her. The question is, what is this child’s early history, and how does she come to the serenity of this poem, full of the atmosphere and the details of family life?
Esther’s real mother was said to be a very intelligent woman, who was at ease in several languages; but her marriage came to grief, and then she lived with a ‘tramp-type’. Esther was the illegitimate result of this union. In her early months, therefore, Esther was left with a mother who was entirely on her own. The mother was the last but one of many children. During her pregnancy, it was recommended to the mother that she should have treatment as a voluntary boarder, but she did not accept this suggestion. The mother nursed the child herself from birth, and she is described, in a social worker’s report, as idolizing her baby.
This state of affairs continued until Esther was five months old, when the mother began to behave strangely, and to look wild and vague. After a sleepless night she wandered in a field near a canal, watching an ex-police constable digging. She then walked to the canal and threw the baby in. The ex-police constable rescued the infant immediately, unharmed, but the mother as a result of this was detained, and was subsequently certified as a schizophrenic with paranoid trends. So Esther was taken into the care of the local authority at five months, and later was described as ‘difficult’ in the nursery, where she stayed till fostered out at two years and a half.
During the first months after Esther left the nursery the foster mother had to put up with every kind of trouble, and for us this means that the child had not yet given up hope. Among other things she would lie down and scream in the street. Gradually matters improved a little, but the symptoms returned when, five months after Esther had been fostered—that is, when she was nearly three years old—a six-months-old boy was accepted into the family. This boy was adopted and Esther was never adopted. Esther would not let her foster mother be called ‘mummy’ by the boy, nor would she allow anyone to refer to the mother as the boy’s ‘mummy’. She became very destructive, and then she turned round and became very protective of the baby boy. The change came when the foster mother wisely allowed her to be a baby like the boy, treating her exactly as if she were six months old. Esther used this experience constructively, and started on her new career of being a mother. Along with this there developed a very good relationship with the foster father, which persisted. At the same time, however, the foster mother and Esther became more or less permanently at variance, so much so that, because of the rows between them, a psychiatrist advised that Esther, who was then five, should have a period away from home. Perhaps this was bad advice when we look back and see what was going on. The father, always sensitive to his daughter’s needs, was instrumental in getting (p. 515) her home again. As he said, the whole of the child’s belief in her foster home had gone dead. The man seems to have become this child’s mother; and perhaps to this source can be traced the paranoid illness which he later developed, and his delusional system in which his wife appeared in the role of witch.
Esther steadily developed in spite of the great strain that was always present in the relationship between the two foster parents, who have since parted, and between whom there has arisen a perpetual legal feud. There is also the fact that the mother always openly preferred the adopted boy, and he has developed well enough to reward her in a straightforward way with his love.
This, then, is the sad and complicated story, in brief, of the authoress of the poem which seems to me to breathe security and home life. Let us follow up some of the implications of the case.
A very ill mother like Esther’s real mother may have given her baby an exceptionally good start; this is not at all impossible. I think Esther’s mother not only gave her a satisfactory breast-feeding experience, but also that ego support which babies need in the earliest stages, and which can be given only if the mother is identified with her baby. This mother was probably merged in with her baby to a high degree. My guess would be that she wanted to rid herself of her baby that she had been merged in with, that she had been at one with, because she saw looming up in front of her a new phase, which she would not be able to manage, a phase in which the infant would need to become separate from her. She would not be able to follow the baby’s needs in this new stage of development. She could throw her baby away but she could not separate herself from the baby. Very deep forces would be at work at such a moment, and when the woman threw the baby into the canal (first choosing a time and place that made it almost certain that the baby would be rescued), she was trying to deal with some powerful unconscious conflict; such as, for example, her fear of an impulse to eat her child at the moment of separation from her. Be this as it may, the five-months-old baby may have lost at that moment of being thrown into the canal an ideal mother, a mother who had not yet become bitten, repudiated, pushed out, cracked open, stolen from, hated, as well as destructively loved; in fact an ideal mother to be preserved in idealization.
Then followed a long period of which we do not know the details, except that in the nursery to which the child was sent she remained difficult, that is to say, she retained something of the first good experience. She did not pass over into a compliant state, which would have meant that she had given up hope. By the time the foster mother came along a very great deal had happened. Naturally, as the foster mother began to mean something, Esther began to use the foster mother for the things that she had missed: biting, repudiating, (p. 516) pushing out, cracking open, stealing, hating. At this moment, surely, the foster mother needed, badly needed, someone to tell her what she was in for, what to expect, what to prepare herself for. Perhaps an attempt was made to let the foster mother know what was happening, but we have no record to tell us. She took over the child who had lost an ideal mother, and who had had a muddled experience from five months to two and a half years, and of course she took over a child with whom she had not the fundamental bond derived from early infant care. She did not in fact ever achieve a good relationship with Esther, although she easily managed the baby boy; and when later she fostered another girl, a third child, she repeatedly said to Esther: ‘Now this is the child that I have always wanted’.
It was the father who was the good or idealized mother in Esther’s life, and this lasted until the family broke up. Perhaps it was just this that split up the family, the father becoming more and more compelled to supply the mothering which this child needed, and the foster mother being forced more and more into the role of a persecutor in the child’s life. This problem spoiled the otherwise satisfactory existence of the foster mother, who was doing well with her adopted son and her second fostered girl.
Esther has evidently inherited some of her mother’s joy in words, and her mother’s intelligence, and I think no one would say that she is in any way psychotic. Nevertheless, she suffers from a deprivation, one of her problems being a compulsion to steal. She also presents scholastic problems. She lives with the foster mother, who has become very possessive of her and has made access by the father almost impossible; and along with this the father has become awkward and has developed a serious psychiatric illness of a paranoid delusional nature.
The foster parents knew that Esther’s mother was psychotic, that is to say that she was a certified patient, but they were not told the details, because the psychiatric social worker at the time recognized that these parents feared that Esther would inherit insanity. It is interesting that the worry about the inheritance of insanity in such cases seems to overlay the much more serious problem of the effect on the child of the period in the residential nursery before the fostering starts. During this period in Esther’s case there was undoubtedly, from the child’s point of view, a muddle, just where there ought to have been something very straightforward and simple, and indeed personal.
Parental psychosis does not produce childhood psychosis. Aetiology is not as simple as all that. Psychosis is not directly transmitted like dark hair (p. 517) or haemophilia, nor is it passed on to a baby by the nursing mother in her milk. It is not a disease. For those psychiatrists who are interested not so much in people as in diseases—diseases of the mind, they would call them—life is relatively easy. But for those of us who tend to think of psychiatric patients not as so many diseases but as people who are casualties in the human struggle for development for adaptation, and for living, our task is rendered infinitely complex. When we see a psychotic patient we feel ‘here but for the grace of God go I’. We know the disorder, of which we see an exaggerated example.
Some sort of classification may help to distinguish the various types of illness. First, we can divide psychotic parents into fathers and mothers, for there are certain effects which concern only the mother-infant relationship, because this starts so early; or, if they concern the father, they concern him in his role of mother-substitute. It may be noted here that there is another role for a father, a more important one, in which he makes human something in the mother, and draws away from her the element which otherwise becomes magical and potent and spoils the mother’s motherliness. Fathers have their own illnesses, and the effect of these on the children can be studied, but naturally, such illnesses do not impinge on the child’s life in earliest infancy, and first the infant must be old enough to recognize the father as a man.
Then I would roughly divide the psychoses clinically into the manic-depressive psychoses, and the schizoid disorders which go right up to and include schizophrenia itself. Along with these disorders is a variable amount of delusion of persecution, either that which alternates with hypochondria or that which appears as a general paranoid over-sensitivity.
Let us now take schizophrenia, the most severe illness, and work towards clinical health (leaving out psychoneurosis, which does not concern us here).
If we look at the characteristics of schizoid persons, one thing we find is a weak delineation of the border between inner and external reality, between what is subjectively conceived of and what is objectively perceived. Then if we look we find feelings of unreality in the patient. Also schizoid persons merge in with people or things more easily than do normal people, and they experience more difficulty in feeling themselves to be separate. Further, we notice a relative failure on the part of schizoid people to become established on a body-ego basis; the psyche is not clearly linked with anatomy and the functioning of the body. The psyche-soma has a poor working relationship or partnership; perhaps the boundaries of the psyche do not exactly correspond with those of the body. On the other hand, the intellectual processes may run away with themselves. Schizoid men and women do not easily make relationships, nor do they maintain relationships well when they have made them with objects that are external to themselves, or real in the ordinary sense of (p. 518) the term. They make relationships on their own terms and not in terms of the impulses of other people.
Parents with these characteristics fail in many subtle ways in their handling of their infants (except in so far as they hand over their children to others, being aware of their own deficiency).
The Need to Take a Child away from a Sick Parent
There is another point that I wish to make: in my practice I have always recognized the existence of a type of case in which it is essential to get a child away from a parent, especially a parent who is psychotic or severely neurotic. I could give many examples in illustration, of which I will describe briefly one, a girl, with severe anorexia:
This girl was eight years old when I removed her from her mother, and as soon as she got away she was found to be quite normal. The mother was in a state of depression, which on this occasion was reactive to the absence of her husband on war service. Whenever this mother became depressed the girl developed anorexia. Later, the mother had a boy, and in turn he developed the same symptom, in defence against her insane need to prove her value by stuffing food into her children. This time it was the daughter who brought her brother for treatment. I was unable to get the boy away from the mother even for a brief period, and he has not been able to establish himself as fully independent of his mother.
Often, in fact, we have to accept the fact that this or that child is caught up hopelessly in a parent’s illness and nothing can be done about it. We have to recognize these cases in order to preserve our own sanity.
In various ways these psychotic characteristics in parents, and especially in mothers, do affect the development of the infant and child. It must be remembered, however, that the child’s illness belongs to the child, although in the aetiology of the case environmental failure must be given full marks. A child may find some means of healthy growth in spite of environmental factors, or may be ill in spite of good care. When we arrange for a child to be cared for away from psychotic parents we expect to work with the child, and it is but seldom that we find that the child is normal when taken away from the ill parent, as in the case cited above.
The ‘Chaotic’ Mother
A very disturbing state in the mother, which seriously affects the children’s lives, is the condition in which the mother is in a chaotic state—in fact, is in a state of organized chaos. This is a defence: a chaotic state of affairs has been set up and is steadily maintained, no doubt to hide a more serious underlying (p. 519) disintegration that constantly threatens. Mothers who are ill in this way are truly difficult to live with. Here is an example:
A woman patient who completed a long analysis with me had such a mother, and it may be that this is the most difficult kind of ill mother that one can have. The home looked like a good one, and the father was steady and benevolent, and there were many children. All the children were in one way or another affected by the mother’s psychiatric state, which was very much like that of the mother’s own mother.
This organized chaos compelled the mother constantly to break up everything into fragments, and to produce an infinite series of distractions in the children’s lives. In all ways, and especially as soon as words could be used, this mother had continuously muddled my patient up, and never did anything else. She was not always bad; sometimes she was very good as a mother; but she always muddled everything up with distractions, and unpredictable and therefore traumatic actions. When talking to her child she employed puns and nonsense rhymes, jingles and half-truths, science fiction, and facts dressed up as imagination. The havoc she wrought was almost complete. Her children all came to grief, and the father was powerless and could only hide himself in his work.
Depression may be a chronic illness, giving a parent a poverty of available affect, or it may be a serious illness appearing in phases, with more or less sudden withdrawal of rapport. The depression that I am referring to here is not so much a schizoid depression as a reactive one. When an infant is at a stage of needing the mother to be preoccupied with infant care it can be severely disturbing to the infant suddenly to find the mother preoccupied with something else, something that simply belongs to the mother’s own personal life. An infant in this position feels infinitely dropped. The following casei shows the operation of this factor at a rather later stage, the child being two years old.
Tony had a strong obsession when he came to me at the age of seven. He was on the point of turning into a pervert with dangerous skills and he had already played at strangling his sister. This obsession was stopped when the mother talked to him, on my advice, about his feeling of losing her. This (p. 520) feeling had resulted from several early separations. The worst separation, and the significant one, was the mother’s depression when the boy was two.
An acute phase in the mother’s depressive illness cut her off from him most effectually, and any return of her depression in later years tended more than anything else to bring about a renewal of Tony’s obsession with string. For him string is a last resort, joining together things which seem to be separated.1
So it was a melancholic phase in the chronic depression of an excellent mother in a good home that produced the deprivation which in turn evoked the presenting symptom in the case of Tony.
With some parents it is the manic-depressive mood swings which are a source of trouble for their children. It is amazing how even small children learn to gauge the parents’ mood. They do this when each day starts, and sometimes they learn to keep an eye on the mother’s or the father’s face almost all the time. I suppose later on they look at the sky or listen to the weather forecast on the BBC.
As an example I give a boy of four years, a very sensitive boy, much like his father in temperament. He was in my consulting-room, playing on the floor with a train, while the mother and I talked about him. He suddenly said, without looking up: ‘Dr Winnicott, are you tired?’ I asked him what made him think so, and he said: ‘Your face’; so he had evidently taken a good look at my face when he came into the room. Actually, I was very tired, but I had hoped to have hidden it. The mother said it was characteristic of him to gauge how people were feeling, because his father (an excellent father, a general practitioner) was a man who had to be nicely gauged before he could be used freely as a playmate. He was indeed often tired and rather depressed.
Children can deal, therefore, with mood swings in their parents by carefully observing them, but it is the unpredictability of some parents that can be traumatic. Once children have come through the earliest stages of maximal dependence, it seems to me that they can come to terms with almost any adverse factor that remains constant or that can be predicted. Naturally, children with high intelligence have an advantage over those with low intelligence in this matter of prediction, but sometimes we find that the intellectual powers of the highly intelligent children have been overstrained—the intelligence has been prostituted in the cause of predicting complex parental moods and tendencies.
Sick Parents as Therapists
Severe mental illness certainly does not prevent mothers or fathers from seeking help for their children at the right moment. (p. 521)
Percival, for instance, came to me in an acute psychotic episode when he was eleven. His father had had schizophrenia when twenty years old, and it was the father’s psychiatrist who sent me the case. The father was now over fifty and he had come to terms with his chronic mental illness. He was acutely sympathetic with his son when he became ill. Percival’s mother is herself a schizoid person, with a very poor reality sense; nevertheless, she was able to nurse her son through the early phase of his illness until he was well enough to be nursed and treated away from home. It took Percival three years to recover from his personal illness, which was very much bound up with the illness of both his parents.
I give this case because I was able to use both parents, although they were ill, or perhaps because they were ill, to see Percival through the first critical phase of his illness. The mother made herself into an excellent mental nurse and she allowed Percival’s personality to merge in with hers exactly in the way that was needed. I knew she would not be able to do this for long, however, and after six months, when I got the SOS that I was expecting, I immediately placed Percival away from home, but the main job had been done. The father’s experience of schizophrenia enabled him to tolerate extreme madness in the boy, and the mother’s condition made her participate in his illness until she began to need a new phase of mental nursing herself. Of course, as the boy got well one of the things he had to do was to learn that both his father and his mother were themselves ill, and he took this in his stride. He is now well on into puberty and, thanks very largely to his very ill parents, he is now healthy.
And what of this rather different story that comes from my hospital clinic?
The father in this family has cancer, not a psychiatric disorder. Doctors have miraculously kept him alive for ten years in spite of his cancer. The result is that his wife, the mother of many children, has not had a holiday for fifteen years, and she has absolutely given up hope. She just exists, and is completely taken up in the nursing of her bed-ridden husband and in the management of the home, which is dark, cramped, and depressing. She is full of guilt whenever anything goes wrong or when another child leaves home. One boy has become an alcoholic in adolescence. But the other children are doing well. The only happiness in the mother’s life comes from her job, which she does from 6 to 8 in the morning. She pretends that she goes out to get some money, but she goes out for a change of scene, this being her only recreation. It seems to me that the father’s cancer is a kind of joker which effectively disrupts the life of the whole family. Nothing can be done because cancer sits supreme at the head of the father’s bed, grinning and omnipotent.
(p. 522) This is a terrible state of affairs; nevertheless, it would seem to me to be worse when one of the parents in a family, although physically healthy, has a psychiatric disorder of psychotic quality.
Developmental Stages and Parental Psychosis
In the theory behind these considerations one keeps in mind always the stage of development of the infant at the time of the operation of a traumatic factor. The infant may be almost entirely dependent, merged in with the mother, or may be ordinarily dependent and gradually gaining independence, or the child may have already become to some extent independent. In relation to these stages we may consider the effect of psychotic parents and we may grade the illnesses of the parents in the following rough way:
(a) Very ill parents. In this case others take over the care of the infants and the children.
(b) Less ill parents. There are periods during which others take over.
(c) Parents who have sufficient health to protect their children from their illness, and to ask for help.
(d) Parents whose illness includes the child, so that nothing can be done for the child without violating the rights a parent has over his or her child.
I for one do not want legal power to take children from parents except where cruelty or gross neglect awakens society’s conscience. Nevertheless, I do know that decisions to take children from psychotic parents have to be made. Each case needs very careful examination, or in other words highly skilled casework.