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(p. 275) Anxiety (continued) 

(p. 275) Anxiety (continued)
Chapter:
(p. 275) Anxiety (continued)
Author(s):

Donald W. Winnicott

DOI:
10.1093/med:psych/9780190271336.003.0055
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Subscriber: null; date: 19 January 2020

Treatment

When a doctor is asked to treat a child whose health is disturbed because of too great an emotional conflict, he will watch for physical disease, and will approach the psychological condition according to the following three principles:—

First, he will try to become the child’s friend, for owing to the deep roots of friendship he may thus produce good results. Whenever possible he should have a few minutes alone with the child.

Second, if the parents are markedly neurotic the child will benefit if put in charge of a non-neurotic person. If the parents are not neurotic, the ideal should be for the child to stay at home, for a child that can only be well when away from reasonably normal parents and near relatives, cannot be said to be normal.1

Third, the child’s difficulty lies in the existence of conflict in the unconscious. The normal process of emotional adjustment, which means to some intent, disappearance of symptoms, is a very complicated one and not to be lightly interfered with. If psycho-analysis is available the conflict may by this means be brought into consciousness,2 and resolved. There is no evidence that a child can become or remain ill as a result of emotional strain and stress that is not connected with unconscious conflicting desires and fears. But it cannot be too strongly urged that attempts to probe into the unconscious without intending to do a complete analysis is likely to be harmful and cannot be truly valuable. Anxiety that the child was formerly avoiding, or dealing with, may by such means be brought to the surface, and may then lead to severe exacerbation of symptoms and of unhappiness.

In the same way removal of symptoms by hypnotism can never be good for the child, though such treatment may occasionally be justifiable from the point of view of an institution in which the children cannot be allowed individuality (see p. 321 [CW 1:3:18]).

(p. 276) Treatment by bromide and other drugs can only be intelligently applied if the above considerations are taken into account, and at best it is an acknowledgment of failure.

A medical practitioner, on reading this discourse on treatment, will probably say: ‘But here is the patient ill and unhappy, and here are the parents clamouring for me to do something that will cure the child; what am I to do’?

But the real question is: What is to be done with the practitioner’s urge to cure, seeing that cure, in the sense intended, is impossible? This is the problem of the future of medical practice as distinct from medical science. Flight into special departments and into scientific medicine merely leaves this great territory for the quack. State medicine cannot understand the problem, and certainly cannot offer a solution.

For myself, I see no sane middle way between psycho-analysis and the specialised form of friendship which the general practitioner can offer. This latter depends in the end on the man, on the richness of his own experience and on the degree of freedom of expression in his own personality.

The relationship between a doctor and his child patient, within its own self-imposed limits, is free and uncritical. The doctor who is not afraid to act on intuition, who can easily establish contact with children, who can feel a child’s feelings, and who is ready at a moment’s notice to play the rôle of playmate, stern parent, kind parent or hated rival, or willing if necessary to introduce to the child the mysteries and beauties and joys of life—such a doctor will be as successful as it is possible to be in the treatment of psychological symptoms (apart from the specialised technique of psycho-analysis).

The doctor can make an enormous difference in fostering the child’s desire to live and to get well, especially where there is a real or imagined lack of love in the child’s immediate surroundings. He stands for a great deal to the child, and the love evoked in the child by the trouble he takes,3 even by his examining the child, or by his taking away the urine for special investigation, can be a big factor in the healing process.

When a symptom, e.g., enuresis, does not undergo spontaneous cure it is necessary bravely to recognise the failure of therapeutics, psycho-analysis not being available at present in the ordinary case. It is as if an appendix abscess were diagnosed in the days before safe surgery became universal. It would be bad medicine to treat an appendix abscess by thyroid extract, yet treatment by thyroid extract is a recognised way of avoiding the realisation of failure to treat enuresis.

A child of ordinary parents who has a psychological disorder so severe as to remain unmodified by the practitioner’s friendship is best left untreated. The doctor’s rôle then is to help the parents to feel they are doing all that can be done.

(p. 277) The Parents’ Part

It will have been noted by the reader that in the discussion of emotional disorders little has been written about the parents. The fashion at present is to put down abnormalities and delinquencies of children to parental stupidity, over-fondness, ignorance, neglect, and so on, and it is true that few parents are perfect. But normal children can remain normal in quite markedly abnormal surroundings, and the chief factors in production of psychological health are more deep-seated than is usually imagined.

The influence of the parents and of other persons and events in the child’s surroundings is nearly always indirect. Take the common example of a parent who is cross and hits her child. The result is not due to the anger or the hit, but is due to the relation of this event to what the child already wanted and feared. The child may feel ‘I have been hit, now I may go and do something naughty’; or ‘I was naughty and expected a terrible punishment, but all I get is a slap; this is a great relief’; or ‘If you hit me it rouses in me such a terrific rage that I am scared of the things I might do to you; that is why I scream and tear my hair till you show me love’; or ‘If you hit me I’ll hit my small brother’.

The simple sequence—naughtiness, slap, repentance, goodness—is merely a phantasy of those who have forgotten the instinctual urges and conflicts of their own babyhood.

Parental influence is very important in the first months of life. A healthy mother’s feelings towards her infant are relatively simple and positive, but most mothers give some evidence of conscious and unconscious hostility, mixed with their love for the infant.4 When unconscious hostility is a big factor the child suffers, not only at the time, but especially when, at three or four years, the big anxieties lead to a revival of the earlier situations.

No amount of good advice can alter this and similar abnormalities in the mother, though through his specialised friendship a doctor can often help a mother over difficult periods and so indirectly benefit the child. By understanding intuitively the mother’s feelings he may relieve her sense of guilt a little, and by taking over some responsibility for the child he mitigates her anxiety.

Notwithstanding the great advantage enjoyed by the non-neurotic child, whose parents are neither neurotic nor psychotic, it cannot be too clearly stressed that anxiety, delinquency, conversion hysteria, and physical disease are produced and kept up chiefly by emotional causes in a child, and are not (at any rate by the time they come for treatment) indications for castigation of parents. They are illnesses of the child, and an indication for treatment of the child. Possible exceptions are certain cases of conversion hysteria in which the symptom is a link between the equal neuroses of the child and some other person.

(p. 278) The effect on a mother of her child’s neurosis has been stressed by Klein, who has reported improvement in the mother’s state following improvement in the child’s mental health.

Of course it is often possible, on visiting the home of a neurotic or delinquent child, to find unsuitable conditions. For instance, the child may be sleeping in the parents’ bedroom, even in their bed, or a boy and girl of six years may be sleeping together in one bed; or the father may be a drunkard, and may beat his wife, so that the children must witness innumerable quarrels between the parents; or a child is bullied by an older brother or sister. But it is not immediately certain that those factors, when present, are the cause of the symptoms of the child. It seems, however, that some who are interested in child guidance use these external factors as a screen to hide from themselves the importance of internal strains and stresses.

Moreover, it is frequently impossible to alter an external factor when it is an important one, so that treatment by modification of surroundings is in the author’s experience very disappointing in its results. The most that can be done by this method is to get a child away for a holiday, and occasionally to arrange for a child to be adopted by an institution.

The tendency of the enthusiastic children’s doctor is to take the side of the child against the parents. The feeling is that the parents are actual failures while the children are potential successes. But surely the future is only worth working for on the grounds that someone in the future will call it ‘present’, and enjoy it as such. In the same way the past is not justified unless someone can enjoy the present now.

The only sane attitude results from a simple desire to help the parents and the children, where definite help can be given, with recognition of the unalterable factors, and of the fact that the present struggle, not the future hope, is life.

Note on Sexual Enlightenment

Anxiety plays a prominent part in the emotional development of every child. When anxiety is not manifest it cannot thereby be assumed that it is not easily produced by an event that disturbs the delicate mechanism by which anxiety is always being avoided.

For instance, a child may avoid anxiety about death by a belief in a future life; one day a scientific, intellectual outlook on the world and on mental process may cause the individual, now adolescent, to doubt the existence of a future life: as a result of this doubt anxiety develops.

All children wish to know the central truths of life, love, propagation, pregnancy and birth, but any one child can only learn the truth in so far as this does not reactivate anxiety.

(p. 279) What children want to know most of all, and at the same time least of all, is that the parents enjoy coitus. This they can find out by watching animals, and not plants. Susan Isaacs has recently stressed the fact that small children tend to choose zoology, and not botany, if left with free choice.5 In this book Mrs. Isaacs describes a school curriculum that allowed unusual freedom of discussion and investigation of zoological details, and the eagerness of the children to learn is shown, also their shyness.

What is needed is freedom from anxiety on the part of the parent or teacher who is asked about sexual matters, so that the child who so wishes is enabled to watch natural phenomena, and can obtain by asking what information cannot be got from observation. It is just as much a symptom of anxiety to try to force children to know as to try to keep them from finding out. A child need not be encouraged, and must not be discouraged. The result will then depend on the relative freedom or lack of freedom in the individual child’s personality, and will be the best that is possible for the particular child.

Notes:

1. The present tendency to dub almost all parents ‘neurotic’ is bringing discredit on pædiatrics.

2. In psycho-analysis the becoming conscious is an automatic process occurring during treatment. For this there is a time factor for each individual that cannot be altered, and even complete understanding on the part of the analyst of the causation of the repression cannot appreciably hasten this automatic change in the patient.

3. The accepted special manifestation of love is the bottle of medicine, and no doctor need feel ashamed to give medicine to a sick child who wants it, even though he knows the colour and taste are more important than the contained drug. The only need is that he shall be convinced the drug will do no harm. There are also the parents to consider, for otherwise intelligent parents become suspicious of a doctor who does not give medicines. And, further, there is the doctor himself. Although in one case here and another there he may give so much of his time and personality that he can withhold drugs, yet it must be remembered that he sees patients all day long, as well as a part of the night. It would be impossible to earn a living and to become the intimate friend of every patient, and what an economy there is in the giving of a bottle of medicine! But it is a tragedy when at last the doctor begins himself to ascribe to drugs, gland extracts, tonics, sedatives, etc., magical properties that have no relation to their proven pharmacological action.

4. This ambivalent attitude is well illustrated when a mother of twins shows great fondness for one baby and dangerously hates the other. The common manifestation of unconscious hatred is over-fondness, perceived by the child as love plus hate.

A woman with a marked love and hate tendency married late and produced twins when forty years old. Her life, already difficult, became now impossible. Her problem became concentrated into this picture: she loved one (male) baby exceedingly, her (unconscious) hatred of the other baby showed as conscious worry over the baby’s (p. 280) feeding and excessive reaction to her cry. The consequence was that the mother was near a breakdown, and was much helped by being temporarily relieved of one of her babies.

But she insisted on giving the good baby, the one that she loved, to the care of the institution, and on keeping for herself the one that caused all the worry. For her hostility was unconscious, and at conscious levels she could only feel the need to prove to herself by expenditure of extra care that she really did not hate this baby, indeed, that she loved her.

5. ‘Intellectual Growth in Young Children’ (Routledge, 1930), by Susan Isaacs.