The Collected Works of D. W. Winnicott: Volume 10. Therapeutic Consultations in Child Psychiatry

Two Cases

The third case of this volume (Part 1) introduces Eliza, a seven-year-old girl brought by her mother for consultation. The mother had seen Winnicott several months earlier for a concern of her own, but in the course of her interview realized that her daughter would benefit from a consultation as well. Winnicott tells the reader nothing of the “strain” or problem of this little girl, letting the emerging play speak for itself. Following his description of the interview, with a sequence of twenty-eight squiggle drawings, Winnicott invites the reader to “examine what has been presented without help” (p. 110). As noted above, this book is a teaching volume, and it offers the unusual opportunity to think and play with Winnicott as the nature of the child’s difficulty emerges. He offers a carefully considered conclusion, but perhaps it would be interesting here to follow Winnicott’s lead and experience his process by describing the play without further preamble.

Winnicott introduced the squiggle game to Eliza and started by drawing a curling line of his own. Although we cannot offer the actual squiggle pictures that wonderfully grace this volume, we will briefly describe some of them in order to convey the lively movement of engagement in the session. Eliza took this squiggle and “put another leg on it, leaving a space between the legs” (p. 84). In the figure a line connects the two legs (“the tummy”), but this was added by Eliza later in the session. Winnicott asked Eliza, “What is it meant to be?” She said: “Something gone wrong” (p. 84). Winnicott notes to the reader at this point that it is not unusual “for a child to plunge immediately into deep matters” (p. 84). He thought to himself that the combination of the space where a belly might be and the “something gone wrong” suggested a little girl who was aware of a problem, and that it could have to do with the belly, perhaps “where do babies come from?” (p. 84).

Winnicott notes with emphasis that he did not say anything and went on with the game. What follows is a delightful series of drawings. He made Eliza’s squiggle into an expressive face. Eliza followed with a bird, and Winnicott drew laundry hanging on a line, leading Eliza to mention her life at home. There is a deep pleasure for the reader in turning the pages as the drawings progress; the freedom of an unfolding process, play in its most simple and profound form. Eliza continued, turning the next squiggle into someone with a long hat. At this point, Winnicott interjects for the reader that in the mother’s earlier interview she described a critical early incident with Eliza concerning a hat. At the end of his case report, Winnicott relates the mother’s story of having departed for several days, returning to her ten-month-old daughter without removing her hat. Eliza had frozen, and for a period of time had a phobia of hats. Here Winnicott asserts, “I always take my cue from the child” (p. 88). He could have followed the mother’s story as suggesting a main theme, but, as we will see, Eliza took Winnicott on a different path.

Eliza made a squiggle that she described as a kangaroo with a hat on; knees bent up, hiding the belly. Winnicott said nothing but noticed the pouch as a visible rather than hidden pregnancy. Several drawings later, Eliza turned Winnicott’s squiggle into “a dog or something” (p. 92). This drawing also has a space between tail and legs; something registered by Eliza because it was at this point that she went back to her first drawing to give that figure a tummy. She followed by making Winnicott’s next squiggle “a fierce dog . . . ready to punch somebody” (p. 94). We see a figure with a forcefully drawn black eye, indeed pugilistic with its squashed nose, and yet there is the same kind of gap between the legs found in the earlier figures. Winnicott remarks to the reader that “this was evidence of Eliza’s ability to get to something in her nature which does not show in her usual behavior” (p. 94). As she contemplated her next squiggle, Winnicott silently linked “punching” with the absent belly and made a mental note that she must have witnessed the development of the two pregnancies after her.

This is followed by a series of whimsical, quite beautiful drawing exchanges. Eliza lined up their many drawings on the floor of the consulting room such that they stretched into the next room. As she carried one and yet another picture off, Winnicott would say “Goodbye” and, when she returned, “Hallo,” with Eliza “vitally interested in what was going on, and we were both enjoying ourselves playing together” (p. 97). Winnicott asked Eliza about her dreams as they drew, and she “ventured the comment that her dreams were horrid”; he pointed out to her that “there was evidently something horrid that is part of herself but which she does not know what to do with” (p. 97). Winnicott remarks to the reader that this reminded him of the fierce dog. At this point, the tone shifted as Eliza made the next squiggle into “a fierce something” (p. 99). She elaborated: “a fierce something that has claws and big ears and one curious big eye so it can see in the dark” (p. 99). Indeed, Eliza drew a figure in dark pressured lines, an ominous animal with teeth and claws, a deeply scrawled eye and large ear. Winnicott remarked: “things would fall out of the inside if there was no tummy; perhaps something fierce would fall out” (p. 99), as she had drawn. Winnicott noted to Eliza that with the claws perhaps she had “ideas of getting at whatever was inside mummy’s tummy” (p. 100).

After several more exchanges, Eliza drew on a large quarto sheet a “frightening dream . . . a thing,” a kangaroo-like creature plunging down on her in bed, “as horrid as possible” (p. 103). Winnicott gently queried Eliza about the idea of sexual stimulation by masturbation or seduction, and he tells the reader that she looked as if this was the first time she had thought about such things. He offered her the choice of doing something else, but Eliza preferred to continue their squiggles, drawing another kangaroo, this time where the pouch was visible and holding a baby kangaroo. Winnicott suggested to Eliza that the horrid thing was her feelings about the baby inside her mother’s belly. It was a “return of something of her own that she could feel to be horrid but which she could not allow to be part of her own self” (p. 104). The play continued without further comment but with greater levity and ease, and a final squiggle that Eliza turned into a man’s head with glasses, a fairly obvious portrait of Winnicott. He notes to the reader that “she was very free at this point, and in fact, she could now see whatever she likes to see into her own squiggles” (p. 109).

The simple sequence of drawings in this case takes us deep into Eliza’s troubles. With “something gone wrong,” we enter into the immediacy of the “alimentary-tract fantasy system” (p. 110) and gradually discover that this was related to the “horrid” or destructive ideas and feelings regarding “things” in mother’s belly. Central in this consultation is, first, the creation of a setting that bridges the child’s expectation or fantasy with the reality of the doctor being there responding to the child’s belief in the possibility of being understood. Second, the case demonstrates the importance of following the arc of experience in transitional play and not a history separate from the potential space of the session. Much like the play in the session, Winnicott shows us what unfolds without direct elucidation. He allows the drawing-exchange to speak for itself, inviting our own experiential intuition of its meaning. Winnicott relates his interpretive inferences from the start, and we see the logic of his eventual interpretation, and the result in this little girl’s delight and increasing freedom in play. Third, Winnicott indicates in his summation that it was the child’s own sequence of discoveries and not interpretation that produced the result. It was Eliza’s capacity to use her dream as her own discovery, being “able to produce it and to draw it for my benefit” (p. 112), that led to change.

In Part 2, the case of twelve-year-old Ashton highlights Winnicott’s use of play, potential space, and aspects of his developmental theory. Ashton, who was referred by his general practitioner, is described as “exceptionally intelligent but unfortunately with most of the snags of the people who approach genius” (p. 214). Winnicott mentions at the outset that there was possibly an incipient schizophrenia but advises caution when using such labels, especially when a child like Ashton is approaching puberty and early adolescence.

The squiggle game began as Ashton turned Winnicott’s curving line into a fish, a shark-like creature swimming down toward the lower corner of the page. Ashton offered his own squiggle, whichWinnicott then made into a snake and snake charmer. The reader gets to appreciate Winnicott’s artistic gifts. The charmer has a little smile, the spiral of the snake complemented by the swirl of the charmer’s turban. As with Eliza, we can see the value Winnicott ascribes to play itself, the amusement and joy of play, its intersubjective nature in which the minds of analyst and patient converge in a collaborative process. Winnicott does not have a preconceived destination. Instead the emphasis is on creating something together, uncertain of what will evolve. Winnicott notes that their play “carried itself forward by its own momentum, and the boy and I reached surprising places” (p. 213), interweaving squiggles, dreams, and fantasy.

As the game developed, aggressive and oedipal themes made their way into the play. Ashton drew “a fish swallowing a turtle or a large jellyfish” (p. 217) and, after a few more iterations, squiggled an image from a “weird” dream: “It tied me up with pieces of string. When I broke the string it looked at me rather nastily” (p. 225). The detail of this description outstrips the simplicity of the curvy lines of the actual squiggle. At this point, Winnicott describes to the reader how Ashton took over the interview, speaking “through the intellect” in a highly sophisticated, rather stilted way suggesting a much older, erudite person. Ashton described a sensory dream: “I was listening to music, that is to say, going through a Beethoven symphony in my mind. I must have been half asleep because when there was a break in the music, the next bit came as a weird noise instead of as the bit of music that was due” (p. 226). As Winnicott listened to the young man, he noted the significance of music to Ashton, the importance of the sensory surround, and how Ashton used music to deal with the frightening, chaotic, and unorganized noise of his hallucinations. Rather than make a content-based interpretation or use the dream material to reconstruct an early childhood memory, Winnicott appreciated the ambiguity of the dream and talked with Ashton about his use of music and painting “as a way of getting control over hallucinations” (p. 226).

Next Ashton drew a detail from a larger abstract painting he had completed earlier, and then decided to show Winnicott the full painting. The piece resembles a black and white Kandinsky. Spherical and “lava lamp”–like shapes balance in an aesthetic whole. Winnicott remarks to the reader that Ashton had trusted him with something “sacred,” a production from his “secret hiding place” (p. 228)—a place of privacy that he brought forth into the daylight. We can hear the role of “potential space” as Winnicott conveys that this privacy and sense of separateness was offered alongside a point of relational contact. For Winnicott, the painting captures the overlapping areas of experience the two of them engaged, discovered, and created at the same time.

In response to the painting, Winnicott interpreted, “It could be a representation of simultaneous acceptance and refusal” (p. 228). This concise interpretation respects Ashton’s “I-ness” by noting what the painting “could be” rather than handing down a declaration of “what it in fact is.” With “simultaneous acceptance and refusal,” Winnicott offered his sense of Ashton’s capacity to contain conflict, and this had a mutative effect. Ashton was “excited” by this and replied, “When I drew this picture I had no idea it could mean anything. I know it had to do with a picture I had seen the day before, of a monster with a lady on the tip of its tongue” (p. 228). Winnicott’s interpretation lent meaning to Ashton’s painting, but then Ashton took it a step further, a verbal game of squiggle taking up the two-dimensional themes drawn on the page.

Winnicott’s further interpretation shows the influence of Klein on his theory in reference to oral sadism and primitive aggression: “This painting that was the stimulus for the dream had a meaning for you, which includes primitive features like eating her. The monster in fact is yourself” (p. 228). Here Winnicott notes to the reader that the “object” in the abstract painting could be the breast or the nipple and that the simultaneous acceptance and refusal could be a conflict in Ashton, “protecting his mother from being eaten and destroyed, because of his primitive love for her” (p. 228). While this fits the predominant psychoanalytic language of the time, it also reads as a forced departure from the emphasis on creativity and meaning embedded in the squiggle game up until this point. The interpretation feels a bit contrived, imposing meaning from a theoretical schema instead of allowing it to emerge unbidden in the play. Interestingly, Winnicott notes to the reader, in his self-effacing way, that this interpretation was rather “long” and that he did not expect Ashton to understand it.

Yet, to his surprise, Ashton responded: “I understand perfectly what you are saying, but it is new to me”; he then described “watching his baby nephew taking the bottle.” Ashton told Winnicott, “That reminds me of a story Father told some people, and I could not see why it was thought to be funny. This was of a small child who had said, ‘If I like something I eat it.’” While it is unclear to what extent Ashton was going along with Winnicott’s ideas in order to gain his approval, Winnicott notes to the reader that Ashton seemed to have a sophisticated grasp of his ideas and was interested in his “little lecture” about “oral sadism” and “guilt arising out of the ruthlessness of primitive love feelings” (p. 229).

Ashton next reported two dreams. Winnicott relates to the reader that the first is about “a ghost in the house. To get rid of the ghost [Ashton] used a magic formula which he was able to tell me exactly. Some of the words were familiar (‘invisible,’ ‘spurious,’ ‘matured’), others were invented words” (p. 229). In the second dream Ashton reported, “There was a car travelling along with a man in it. There was another man in the car, either in front or behind, and one man attacked the other. I rushed to his aid. The frightening thing was that I realized that both men were myself” (p. 229). In these dreams, we not only see the overlapping areas of fantasy and reality, but also, with Winnicott’s guidance, Ashton’s mental agility, being able to play with and think about objects both in dreaming and in waking life. Responding to the second dream, Winnicott pointed out to Ashton, “That nicely gets you out of the clash between you and father when you both love mother. You are father, and he is you. You each lose your separate identities, but you don’t have to kill each other” (p. 229).

Reading Ashton’s dream and Winnicott’s response about self and identity, it seems that both are playing with the traditional characters of the oedipal drama, configuring and reconfiguring the triangulation as Ashton wrestled with his oral sadism, love, and guilt, all embedded in this drama. Similarly, when Ashton next talked about a train running over an animal and remembering that it was the noise of the train that stood out, Winnicott and Ashton “together” linked up the noise with Ashton’s having heard his father’s “labored breathing in intercourse” (p. 230). Winnicott and Ashton went on to play with the theme of father-son rivalry and jealousy, with Ashton precociously asking, “Is the son jealous of the father’s adult relationship to the woman or is the father jealous of the infant’s infantile possession of the mother and his intimacy with her?” (p. 230).

It is compelling to see how the literal squiggle game comprising drawings at the start of the consultation shifted into a verbal psychoanalytic squiggle game. Ashton and Winnicott each worked from the other’s material and developed it further. Potential space is the context in which mutual free association took place between them, allowing for an ambiguity of form and formlessness. This took hold as Ashton’s imagination, fueled by curiosity and a creative mind, made these oedipal themes his own. He rediscovered the object (e.g., father) where his own sense of “I-ness,” with Winnicott’s backing, could occupy center stage.

Conclusion

In his introduction to this teaching volume, Winnicott suggests that if one simply listens to the story of the person sitting next to one on a bus journey, with sufficient privacy, the story will evolve revealing the “patterns of strain” that are the ingredients of a clinical consultation. The conversation goes nowhere because you the listener are not giving yourself fully to use the material presented and thus it becomes diffuse or boring. “In the therapeutic consultation, the material becomes specific and acutely interesting since the client soon begins to feel that understanding may perhaps be available and that communication at a deep level may become possible” (p. 32). In both of the cases described here, as well as throughout the other consultations in this volume, we experience Winnicott creating a process of living and becoming with his patients. For the most part, Winnicott does not impose a prescriptive clinical theory. Rather, something evolves. The play and mutuality that spark the contact between him and the child lead to psychic destinations that are neither predicted nor preconceived. By privileging emotional communication through play in all its danger and wonder, the freedom and imagination that spring from the child’s discoveries become the central ingredients of change.

We find in these consultations a good enough doctor, “a human being not exactly like any other human being” (p. 31), who offers results that are never omniscient, who is modest in his achievements, honest in his foibles. Although Winnicott uses interpretation and relies on his deep formation and knowledge as an analyst in the institute of Klein, Riviere, Strachey, and others, interpretation functions as a probe rather than as an imposition of meaning. Meaning is generated through the play, a mutual process that arrives through the back-and-forth between Winnicott and his patients. Unlike some psychoanalytic theories, his working theory relies on the wonder of play as a process of becoming and a conviction in the inherent drive to create as the child gradually makes his or her way into the world. We see in these intimate encounters the formation of a new paradigm of theory and treatment in which the emphasis shifts from understanding to being and becoming, where the role of the analyst is to work in the paradoxical realm between imagined/expected/illusion and a facilitating reality, something Winnicott elucidates as “creative apperception” (1971, p. 65), the experience of being fully alive.

Winnicott notes about this volume that the “case descriptions hang on the word enjoyment” (p. 31; emphasis added). If they are a labor, they are too clever, displaying technique and not the music. He offers these consultations to “communicate” (his term for the deep engagement that is our work) with us still “slogging away at technique” with the hope that comes from playing music; “but,” he says, “there is little satisfaction to be gained from giving a virtuoso performance from a written score” (p. 31). Over the forty years since its first publication, this enduring volume of consultations offers an experience of improvisation that continues to excite and enrich our experience of our craft in a contemporary way.