The Development of the Capacity to Differ

In the training of psychoanalysts and the like we must not place the students in the position of being related to the primitive needs of psychotic patients, because few will be able to stand it, and few will be able to learn anything from the experience. (Winnicott 1965: 164)

The above statement was made by Winnicott in a paper he gave in 1959 to the Medical Section of the British Psychological Society during a symposium on counter-transference. Two years later, in his paper ‘Ego Distortion in terms of True and False Self’, he adds the following:

My experiences have led me to recognise that dependent or deeply depressed patients can teach the analyst more about early infancy than can be learned from contact with mothers who are involved with infants. At the same time, clinical contact with normal and abnormal experiences of infant-mother relationship influences the analyst's analytic theory since what happens in the transference (in the regressed

Page 55

phases of certain of his patients) is a form of infant-mother relationship. (Winnicott 1965: 141)

At the 1959 conference, Winnicott took issue with Michael Fordham on this topic. Fordham put forward Jung's notion that the analytic relation is akin to alchemy, an interaction in which there is mutual influence between patient and doctor involving the whole being of both. Jung claimed that by allowing so-called ‘professional defences’ to come between oneself and the patient, the analyst, ‘denies himself the use of a highly important organ of information.’ (Winnicott 1965: 161)

Winnicott is adamant that Jung is wrong and goes as far as to say, ‘I would rather be remembered as maintaining that in between the patient and the analyst is the analyst's professional attitude, his technique, the work he does with his mind.’ (Winnicott 1965: 161 italics in the original). However, Winnicott goes on to qualify this statement and fully agree with Fordham, when the latter is speaking specifically about borderline and psychotic patients.

Another criticism he levels at Fordham is the use of Jungian jargon. He lists: ‘transpersonal, transpersonal unconscious, transpersonal analytic ideal, archetypal, the contra-sexual components of the psyche, the animus and anima, animus-anima conjunction’ and confesses that, ‘I cannot be communicated with in this language. For some in this hall these are household words, and for the rest they have no precise meaning’. (Winnicott 1965: 159)

What is sauce for the goose is sauce for the gander. Winnicott invited Fordham to clarify his terms so that his terminology became accessible rather simply jargon. It will be helpful for our purposes to do the same with Winnicott's own language. We cannot begin to make sense of Winnicott's writing without understanding that he uses the terms such as ‘primitive’, ‘needs’, ‘psychosis’, ‘dependent’, ‘transference’ and ‘infant-mother relationship’ in a highly specific theory-based fashion.

Six months before his death in 1972, Winnicott was invited to talk to a group of young Anglican priests. On his return he told Masud Khan that he was taken by surprise when the group told him that what they needed from him was ‘guidance about how to differentiate between a person who seeks their help because he is sick and needs psychiatric

treatment, and one who is capable of helping himself through talking with them.' (Winnicott 1986: 1)

Winnicott, reported Khan, was taken aback by the ‘awesome simplicity of their question’ and after a long pause he replied, ‘If a person comes and talks to you and, listening to him, you feel he is boring you, then he is sick, and needs psychiatric treatment. But if he sustains your interest, no matter how grave his distress and conflict, then you can help him alright.’ (Winnicott 1986: 1) For Masud Khan this was not a light hearted anecdote. He knew that, ‘behind all the naïve and wayward innocence and spontaneity of Winnicott's behaviour there is a complex mind guiding the manoeuvres and constantly checking its own abstractions.’ He was well aware that Winnicott's clinical practice ‘was anchored in a growing and intricate theory costing him, as he used to say quoting Eliot's verse, ‘not less than everything’. (Winnicott1978: xii)

Contrary to popular belief, Winnicott spent a great deal of his time attempting to formulate elaborate psychoanalytic theories about what he thought was wrong with his patients—children and adults alike—what brought about their suffering and what might be the best analytic technique for dealing with their problems. He gave serious consideration to the desired analytic stance, clinical set-up, the nature and frequency of interpretations, what precisely needed interpreting and what kind of personal and professional level of psychic health and development was necessary in the patient and analyst for a treatment of this kind to take place.

There is little doubt that Winnicott impressed those who knew him, including his patients, as an exceptional practitioner and human being. ‘Winnicott was one such the like of whom I shall not meet again’ as Khan concludes in his introduction to Through Paediatrics to Psycho-Analysis. (Winnicott 1958: xlviii) However, since The Site is in the business of learning, teaching and the transmission of psychoanalysis, and if we refuse to believe that this practice is done through a process of internalising ones analyst's unconscious via the apostolic succession, then it is to Winnicott the theoretician that we must direct our attention.

My aim in this paper is to arrive at an understanding of the origin and meaning of Winnicott's statement and to show its relevance to the advent of a regulatory framework. In the history of the impossible profession, theoretical conflicts and disagreements have led at best to fruitful

collaboration and revisions and at worst to splitting into multiple trainings; the conflicts have never amounted to more than a ‘domestic’. This is no longer the case and the proposed drafts of The Health Professions Council's National Occupational Standards for psychotherapy (most easily found on the British Psychological Society's website) are a clear instance of this. (British Psychological Society website )

As you may know, in order to regulate ‘psychoanalysis and the like’ the powers-that-be require schools to have a coherent and consistent body of theory. This body of theory must include a theory of mind, a theory of pathology and as a direct and rational step, a theory of effective predefined therapeutic interventions culminating in a preset aim of therapy and the means by which this aim can be achieved. A necessary consequence of this viewpoint is the detailed spelling-out of competencies required by all practitioners in order to enable the latter to carry out the task. Furthermore, an elaborate safety net must be put in place to demonstrate that they and their patients are as safe as can be expected whilst engaging with the process.

Failure by an institution to demonstrate that it can provide the above could result in its licence to authorise practitioners being revoked. Failure to demonstrate fitness to practice by the individual along the required lines would become public business with details of complaints posted on the Health Professions Council website.

So, let us go back to the starting point, Winnicott's theory of mind and more specifically, of his theory of psychosis; I shall return later to its relevance to the regulatory process. The ever-admiring Khan describes Winnicott as having been ‘reared in the tradition of his people, the English. For him facts were the reality, theories were the human stammer towards grasping the facts’ (Winnicott 1958: xii). This is a polite way of saying that like most philosophy departments, the medical establishment and the Institute of Psycho-Analysis in the UK at the time, Winnicott's education was deeply rooted in the Logical Positivist tradition. Following in Freud's footsteps, Winnicott assumed an ‘objective’ or ‘external’ reality' outside the individual; one which was capable of objective testing through the senses and other scientific means. The individual would be able to perceive this reality either correctly or incorrectly

with varying degrees of distortion leading to a mirroring of the external by an internal or subjective world; this would be achieved through transitional phenomena capable of straddling the two, the capacity to create illusion or the necessity to invent delusions.

Winnicott embarked on a training analysis with James Strachey when he undertook his classical Freudian training. At the same time, he became a consultant paediatrician and found the combination most gratifying. In a talk given in 1962 to trainees in Los Angeles he recalled:

You can imagine how exciting it was to be taking innumerable case histories and to be getting from uninstructed hospital-class parents all the confirmation that anyone could need for the psycho-analytic theories that were beginning to have meaning for me through my own analysis… (Winnicott 1965: 172)

But what are these theories which are beginning to make sense to him? We need to remember that Winnicott started as a Freudian; his practice was informed by the prevailing wisdom of his generation which he sums up beautifully:

At the time, in the 1920's, everything had the Oedipus complex at its core. The analysis of the psycho-neurosis led the analyst over and over again to the anxieties belonging to the instinctual life at the 4–5 year period in the child's relationship to the two parents. Earlier difficulties that came to light were treated in analysis as regressions to pre-genital fixation points, but the dynamics came from conflict at the full blown genital Oedipus complex of the toddler or late toddler age… (Winnicott 1965: 172)

Leaving neurosis on one side, it is clear to see why Freud found it difficult to fit cases of psychosis into this formulation. Freud had already defined psychosis as an economical withdrawal of libido from external objects thereby leading to the impossibility of transference as he understood it. He theorised the cause of psychosis as a structural failure of the Ego to prevent Id impulses from flooding consciousness, thus rendering

the notion of making the unconscious conscious futile. According to Freud, in essence the unconscious and conscious processes of psychosis are one and the same. However, in a later attempt to find for psychosis an equivalent psychodynamic mechanism to that of repression in hysteria, Freud came to the conclusion that the psychotic simply refused to accept the facts of a traumatic reality; more specifically, the reality of the absence of a penis in the female. He termed this process ‘disavowal’. From this formulation of psychosis it follows that the psychotic is out of touch with reality, incapable of transference and as a result, outside the remits of a classical Freudian analysis. (Those who are familiar with Lacan will see the origins of the concept of ‘foreclosure’ and the role of castration).

Winnicott is beginning to struggle. Owing to his habit of painstaking case history note-taking, he can see in his work that some of the psychological problems of his young patients have their origins long before the age of four or five and that the form their pathology sometimes takes, can not be explained as a pre-Oedipal fixation. He is happy enough to accept that neurosis can be explained as having its origins in the Oedipal conflict but notices that some children:

[S]howed difficulties in their emotional development in infancy, even as babies. Paranoid hypersensitive children could even have started to be in that pattern in the first weeks or even days of life. Something was wrong somewhere… I knew that troubles started earlier [than the Oedipus complex]… Babies could be emotionally ill. (Winnicott 1965: 172 my italics)

There was nothing in the existing theories at his disposal to make sense of his observations. Winnicott took his problems to his analyst. Strachey made an unprecedented intervention; he broke into the analysis and told Winnicott a woman called Melanie Klein who was also interested in the analysis of children. Strachey qualified his recommendation with, ‘She is saying some things that may or may not be true, and you must find out for yourself for you will not get what Melanie Klein teaches in my analysis of you.’ (Winnicott 1965:173)

Winnicott found an inspiring teacher in Klein with whom he entered into what we now call supervision. He considered other teachers rigid by comparison and at first accepted wholeheartedly most of her ideas since, for the first time, they seemed to provide him with the tools to understand and work with his very young pre-Oedipal patients.

In his paper, ‘A Personal View of the Kleinian Contribution’ (Winnicott 1965: 171–178), Winnicott lists thirteen of what he considers to be Klein's most valuables contributions to psychoanalysis and recommends that all Freudians should adopt them in addition to what they had learned from Freud and his followers. These contributions included the use of classical psychoanalysis with children by means of using small toys, acceptance of Klein's formulations regarding projection and introjection, the depressive position, manic defences, talion fears and the splitting of the object.

Winnicott objected to some of the terminology used by Klein; for example he preferred his formulation ‘the development of the capacity for concern’ to the term ‘the depressive position’ but took no real issue with the concept itself. However, as far as concepts go, he did not accept Klein's theory of the life and death instinct as clinical phenomena and did not believe that, ultimately, the child's destructiveness could be explained by heredity and envy.

Winnicott and Klein eventually grew apart. One reason for their falling-out was Winnicott's insistence on taking environmental provisions into account—something which psychoanalysis is still struggling with. ‘She [Klein] paid lip-service to environmental provisions… [she] claimed to have paid full attention to environmental factors, but it is my opinion that she was temperamentally incapable of this’ (Winnicott 1965: 177).

The most relevant concept for the purposes of this paper is Klein's notion of a paranoid-schizoid position. In Klein's view, every individual passed in the normal course of events through phases in which psychotic anxieties or mechanisms predominated — first the paranoid position and then the depressive position.

As we have seen already, Winnicott was well aware before he met Klein that some babies are overtaken with persecutory anxieties very early on; he agrees with her that both talion dread and the splitting of the object into ‘good’ and ‘bad’ are present but does not like the term

paranoid-schizoid. He objected to Klein's claim that infants start life in this fashion. Although Klein claimed that she investigated the unconscious minds of her adult patients more and more deeply in order to arrive at a picture of their ‘infantile’ mind, Winnicott claimed that she confused depth with chronology and therefore kept moving the age goal-posts further and further backwards. What Klein seems to ignore, he claims, is ‘That with good-enough mothering the two mechanisms may be relatively unimportant until the ego-organisation has made the baby capable of using projection and introjection mechanisms in gaining control over objects. If there is not good–enough mothering, (Winnicott insists) then the result is chaos rather than talion dread and a splitting of the object into “good” and “bad”’ (Winnicott 1965:177).

In short, it is all the mother's fault!

This takes us back to the question of psychosis which, for Winnicott, was firmly bound up with the question of the failure of the maternal provision in the developmental timescale, a timescale which he uses as his main diagnostic tool when it comes to defining psychosis. Winnicott believed that ‘Psychosis takes origin at a stage at which the immature human being is truly dependent on environmental provision.’ (Winnicott 1965: 124) He thought that it came about as a result of a failure in maternal provision in the area of infant-care. Good-enough infant care would consist of a mother who, from pregnancy onwards, anticipated and welcomed primary maternal preoccupation, who perceived her infant's gestures and responded to them in a good–enough manner. ‘The good-enough mother meets the omnipotence of the infant and to some extent makes sense of it. She does this repeatedly. A True Self begins to have life [as a result of this] through the strength given to the infant's weak ego by the mother's implementation of the infant's omnipotent expressions.’ (Winnicott 1965: 145)

The ‘not a good–enough mother’ does not do this. Instead, she ignores her infant's gestures replacing these with her own. She does this repeatedly thus creating compliance and the creation of a false self.

Winnicott placed the onset of psychosis,

[At] the stage prior to that at which the developing individual has the equipment to be aware of either the environmental provisions or its failure… In attempting to date the

Page 62

onset of psychosis I am referring to the degree of the individual's dependence and not to the individual's pregenital instinctual life, nor to the individual's erotogenic zone primacy. (Winnicott 1965: 136)

In psychosis, Winnicott suggested, it is very primitive defences that are brought into play and organised, because of environmental abnormalities. Winnicott can of course see the problem in this assertion because, as he goes on to say, the very same primitive mechanisms are present in other forms of pathology—so what is the difference? ‘None’, he says—which is why he suggests that:

We cannot diagnose psychotic illness by finding primitive mental mechanisms. Of course, in psychotic illness it is the primitive defences that we meet with, defences which do not have to be organized if in the earliest stages of near-absolute dependence the good enough environmental provision does in fact exist. Justice can be done to all the factors by the statement that the individual's maturational processes (including all that is inherited) require a facilitating environment, especially in the very early stages. Failure of the facilitating environment results in developmental faults in the individual's personality environment and in the establishment of the individual's self, and the result is called schizophrenia. Schizophrenic breakdown is the reversal of the maturational processes of earliest infancy. (Winnicott 1965: 135)

It is hard to continue without at least mentioning that this diagnostic definition of psychosis not as a structure in its own right but as relying on psychological ‘carbon dating’ to differentiate it from other forms of pathology has met with fierce resistance from psychiatrists and from a great many psychoanalysts and the like but, for now, let us stay with his argument and see what Winnicott proposes as suitable psychoanalytic treatment.

In the case of the neurotic patient, Winnicott tells us that:

[T]he analyst is prepared to wait till the patient becomes able to present the environmental factors in terms that allow of their interpretation as projections. In the well chosen case this result comes from the patient's capacity for confidence, which is rediscovered in the reliability of the analyst and the professional setting… in the case that is badly chosen for classical psycho-analysis it is likely that the reliability of the analyst is the most important factor (or more important than the interpretations) because the patient did not experience such reliability in the maternal care of infancy, and… he will need to find it for the first time in the analyst's behaviour. This would seem to be the basis for research… into the treatment of schizophrenia and other psychoses. (Winnicott 1965: 38)

Winnicott clearly believed that the transference is structured like a mother-infant relationship. In any analysis, he claimed, ‘The analyst will need to be able to play the part of mother to the patient's infant’ (Winnicott 1965: 163) and never more so than in instances of regression which in psychosis, by definition reigns supreme. It follows that the nature of the transference and countertransference in the case of a psychotic patient would be overwhelming. The analyst would be on the receiving end of organised primitive defences, and extreme dependency on the part of the patient. He or she would be called upon to symbolically provide for the privations which took place at a very early age including infant-care, implementation of the patient's omnipotent expressions, to be able to give strength to the weak ego of the patient and generally provide a corrective emotional experience whilst unable for the most part to make the necessary transference interpretations. The analyst, he claims, would inevitably experience hate towards his/her patient and find the experience ‘Irksome as compared with that of a neurotic and inherently so.’ (Winnicott 1958: 194)) The same analyst would have to have been very well analysed and achieved a so-called ‘truly objective countertransference.’ (Winnicott 1958: 195)

Such a treatment can give rise to ‘Problems of management which can easily take the analyst beyond his resources… If the analyst is going to have crude feelings imputed to him he is best forewarned and so forearmed’

(Winnicott 1958: ) and if management is the best that can be done for the most part, then we are in real trouble.

It is hardly surprising then that Winnicott wishes to protect the trainee from such unbearable and difficult tasks. ‘The important effect of the analyst's own analysis in this context is that it has strengthened his own ego so that he can remain professionally involved, and this is without strain’ (Winnicott 1965: 162) Your ‘average’ trainee, he assumed, has yet to avail themselves of the full strength of their ego as a result of the training analysis and so could not gain much from the experience nor be able to contribute to it in any way.

Let us now return to the prescriptions of the National Occupational Standards for psychotherapy. Before qualifying a trainee we must make sure that they are able to:

6. Respond to unproductive levels of anxiety or other feelings in therapy by adapting technique flexibly

7. Sustain the relationship in the face of primitive states of mind and intense emotion. (British Psychological Society website )

How is one supposed to achieve this if trainees are to be protected from so-called primitive states and intense emotion?

Before readers misunderstand the aim of the paper, I am not advocating that trainees be made to work with psychotic patient. Indeed, they should certainly not be forced to work with anyone of whom they are afraid. In the history of the profession within the UK, there has always been a collusion between psychiatry and the Freudian contingency that psychotic patients are outside the remit of psychoanalysis and should therefore be treated only by psychiatrists or, at best, be the subject of a so-called ‘research analysis’. Kleinian and other followers of the Object Relations tradition have, on the one hand, opened the door for such patients to be included in the analytic endeavour but on the other have adopted a contradictory protective approach to the question of trainees and psychosis as outlined in my paper. The problem of so-called ‘management’ is a serious one, not for the reasons given by Winnicott, but

because of the reality of working with psychotic patients; some degree of cooperation and support from the patient's environment may be needed.

The current draft of the National Occupational Standards does not include a single instruction which is remotely relevant to working analytically with psychosis. Very few analytic schools really prepare trainees to understand or work with psychosis. In-patient placements, originally designed to familiarise trainees with severely-ill patients, have turned into placements for outpatient work with neurotic patients in exchange for free supervision.

There are at least two fundamentally different psychoanalytic readings of psychosis and the proposed ways to approach the teaching and training of would-be suitable analysts about what constitutes a so-called ‘good’ or ‘bad’ case choice. In some instances the different approaches are fundamentally opposed to one another; in others, they are talking about closely-related phenomena. For example, for Lacan, the fault, as it were, in psychosis, is not in the Object relation but in the nature of the Intersubjective relation. He addresses the fact that in psychosis there is no subject. Winnicott is also aware of the same phenomenon but expresses it somewhat differently: ‘We make more headway by recognition of the patient's non-existence than by a long-continued working with a patient on the basis of ego–defence mechanisms’ (true and false) (Winnicott 1965: 152).

A ‘Standard Edition’ which produces one manual for all is bound to outlaw rather than to encourage dialogue. It is bound to enshrine one story amongst stories and make it look like a truth.

To sum up, my answer to the question, ‘Why Winnicott?’ must be:

Because he took the question of differentiating psychosis from neurosis seriously and tried to make sense of Freud's exclusion of the psychotic to an ‘out of reality’ out of analysis status, Klein's inclusion of psychosis as a normal phase of development and his interest in the influence of actual childrearing. This, and his other pioneering ideas observed Masud Khan, caused him ‘to run into a special sort of difficulty with his analytic colleagues, from the start—that of being politely disregarded’ (Winnicott 1958: xiv).

Because his thinking is firmly rooted in his clinical work. Although he did not consider himself an intellectual and ‘had a militant incapacity to accept dogma (and) was a non-conformist by upbringing’ (Winnicott 1958: xi), he always demanded of himself a clear and erudite theoretical explanation of everything he did, an explanation which he revised constantly in the face of clinical evidence and other people's ideas.

Because, for the sake of his patients, he was not afraid to seek answers to his questions wherever he could find them. Deeply troubled by the fierce fighting which took place between Melanie Klein and Anna Freud, and which almost tore his beloved organisation apart, he nonetheless had the courage to learn openly from both of them. As he tells the trainees in Los Angeles, ‘You see, there developed a Melanie Klein—Anna Freud controversy, and this has not yet resolved itself. But this was not important for me in my early years, and it is only important to me now in so far as it hampers free thought’ (Winnicott : 171).

Because he struggled endlessly with psychoanalytic notions of reality, inside and outside, fantasy, nature and nurture, psyche and soma. Although his metapsychological attempts to address these ideas are often highly problematic, like Klein, his clinical observation and comprehension of the phenomena themselves are invaluable, compassionate and compelling.

Because I like to imagine that up there, in a psychoanalytic section of Heaven or Hell, he might be having a cup of tea with a certain French gentlemen who might, over the crumbs of his croissant, say to him, ‘Mon cher Winnicott, you know, I loved it when you said: “early infancy is truly a period in which it is not possible to describe an infant without describing the mother whom the infant has not yet become able to separate from a self” (Winnicott 1965: 177). Did you ever consider that it is not possible to describe a mother who has not been impregnated and “contaminated”? Isn't your dyad really a triad from the very start?’ And that Winnicott would reply, ‘Now that's an intriguing thought—this might just throw some light on some of the blind alleys I have come up against. I can't wait to go over my papers and try out your ideas.’ For Winnicott was always prepared to take the chance that by so doing it might indeed cost him ‘not less than everything’.