Forensic Psychotherapy and Psychopathology

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This exceptional book adds to the fast growing area of forensic psychotherapy and shows the relevance of Winnicott's work to therapy with some of the most deprived in our society.Contributors:Brett Kahr; Jennifer Johns; Estela Welldon; Joan Raphael-Leff; Valerie Sinason; Jeannie Milligan; Donald Campbell; Em Farrell; Peter Giovacchini; Charles Socarides; Murray Cox.

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1. Winnicott: a beginning

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Jennifer Johns

It would require more than a single chapter to do any justice at all to Donald Winnicott’s life and his contributions to the understanding of the developing inner world of the baby and child, his view of the importance of relationships in that development, and the continuing story of the vicissitudes of human life both as they affect and are affected by the developing individual. Winnicott’s biography can be studied in the books about his work by Adam Phillips (1988) and Michael Jacobs (1995). Recently, Brett Kahr (1996a) has produced impressive details of his life. To summarize: Winnicott came from a stable English background that existed one hundred years ago, before the earthquakes of this century that were to affect both him and his work later.

Winnicott was the youngest child, the only boy, of a prosperous Methodist middle-class family with a strong sense of civic responsibility, living in Plymouth. He was sent to school in Cambridge, and then he later went to the University of Cambridge and studied biological sciences, before going to London to become a doctor. The son was special in a rather feminine family—his earnest father is described as being absent much of the time—with both the rewards and the burdens of specialness and responsibility. Going away to school seems to have been something of a relief and perhaps allowed room for his playfulness and the music that he loved all his life.

 

2. Babies as transitional objects

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Estela Welldon

I saw a man who had requested a consultation with a female psychiatrist. The first time he came, he asked me directly and emphatically: “Are you Jewish or Catholic?” Although the question did not take me by surprise, since patients or prospective patients would like to know all sorts of information regarding -their psychotherapists, the tone of this man’s question conveyed a sense of urgency and despair that made me feel that it was necessary to take into account its deeper, unconscious layers. As usual, I explained that, though the factual information could be easily imparted, this would immediately pre-empt access to other immensely significant areas unknown to himself that could give us important clues to his present predicament.

This patient was a married man in his mid-40s with four children who had referred himself with the following letter:

“I have lived with a condition for most of my life which manifests itself in the form of transvestial [sic] or transsexual behaviour and feelings. Whilst I am able to suppress these feelings for a good deal of the time, there nevertheless comes a moment when I can cope no longer—has happened now […] and for the first time self-mutilation seems to be logical. […] f desperately need someone to help me decide upon the best way in which I could free myself of my now unremitting torment. […] The symptoms that I am experiencing at the moment fall into two quite distinct categories, i.e. mental and physical. Mentally, I feel that I am a woman in the cliche situation of having to masquerade my way through life simply because I am not as perfect as I want to be. […] I can quite see the clear possibilities of a “change”. To this end I have now almost cut myself off emotionally from those around me—and so the conflict rages, as I question: to whom does my first loyalty lie, my family, all of whom are and will be able to make lives of their own, or to myself, with one precious life only? […] On the physical side, the tension can only be relieved by wearing anything other than men’s clothes. […] More obvious symptoms, physical side that is, are: morning sickness, vomiting through the day, loss of appetite, feeling shivery, aching in the small of the back and the most obvious sign that tells me when I am about to “go under” again—that my breasts become tender and sore—and it is at these times that the sensation of my nipples touching against my woolly jumper makes me just want to scream. […]”

 

3. Primary maternal persecution

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Joan Raphael-Leff

Winnicott backs up his much-quoted aphorism that “there is no such thing as a baby” by quoting Freud’s footnote referring to a psychical system of infant and maternal care (Freud, 1911b). In his theory of the parent-infant relationship, Winnicott (1960b) focuses on early emotional development within the psychic system and the impact of maternal care in facilitating or failing a baby’s journey from absolute dependence. In this chapter, I examine this mother-infant psychic system from the other point of view—that of the emotional impact on the woman of being in close contact with a dependent newborn who has come out of her body and for whom she is responsible. I propose to treat this system as a prenatal rather than postnatal one, and, furthermore, I consider the possibility that within this interactive system, far from experiencing benevolent “primary maternal preoccupation” (Winnicott, 1956a), some mothers may be caught up with what I have termed “primary maternal persecution” (Raphael-Leff, 1986).

 

4. Children who kill their teddy bears

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Valerie Sinason

“And they smiled so sweetly as they ate her dolls and bears she knew no toy could hold her”

Valerie Sinason, “The Re Naming”, 1982

In 1903, Rainer Maria Rilke, anticipating Donald Winnicott’s (1953a) paper on transitional objects by nearly fifty years, understood many of the emotional uses to which a toy, a “thing”, could be put in the service of the child’s developmental needs. In being the first not-me possession, it must survive loving and hating; it can be cuddled, attacked, and mutilated; it has to appear to have some life of its own, to not be an hallucination; it must be able to contain in its actuality the longings, needs, and projections of the child; and finally, it is neither forgotten nor mourned, but eventually loses meanings. It stands for the first relationship, largely that with the mother.

With loving, good-enough parenthood, the child can negotiate the ordinary painful difficulties of life and achieve the disillusionment that comes from having been allowed the state of illusion previously. The child can move from magical control to muscular control, and finally let go. The thumb, the corner of the blanket, the teddy bear, the doll, can all finally be put aside but not disappear. At times of adult difficulty, they can return as cigarettes, as drink, as executive toys, or even as transitional people. Where there are greater difficulties, they are transformed into fetishes where they continue their life in various forms of adult sexuality.

 

5. Deprivation and delinquency in the treatment of the adolescent forensic patient

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Winnicott (1968) saw delinquency as a sign of hope, because it is essentially object-related. He compared it with the infant’s milk-seeking behaviour, whereby a fundamental need may be satisfactorily met by the provision of external resources. He viewed the origins of delinquency as rooted in a sense of deprivation. By this he meant that the infant, having discovered that the desired supplies exist and aire accessible, develops the sense of possessing them. However, if the infant then perceives the supplies as disappearing, it suffers the traumatic experience of the loss of a right. Winnicott argued that what underpins the delinquent act is the wish of the infant self to repossess that to which we believed we had a right. The essential characteristic of a delinquent act is that it affects some other person or thing, and it is this quality that allows the possibility of a response. Winnicott argued that it is this active direction in delinquent behaviour that may be understood as the deprived infant-self displacing the search for its rightful possession onto other resources, which may be appropriated by theft. In this way, hopelessness and despair can be avoided. If the delinquent’s search can be correctly identified, it may become acceptable for the taking-in of a good substitute for the painfully lost previous response. Winnicott suggested this may take the form of an emotional relationship, or may come about by management of the delinquent’s environment.

 

6. On pseudo-normality: a contribution to the psychopathology of adolescence

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Donald Campbell

Over the years I have been struck by the way children and especially adolescents seek reassurance for their anxieties about lagging behind their peers, or feeling strange and abnormal, by trying to achieve what they consider to be a developmental milestone, such as having a girlfriend, passing an important set of exams, or going off to university. The appeal of the achievement of a developmental milestone for the child or adolescent is that it provides a sense that they must be normal after all, because they have been able to do something that is expected of them and, in some cases, that their peers have already accomplished. Parents, teachers, and peers tend to support the fantasy that normality is defined exclusively by the achievement of developmental milestones.

I have found this a very powerful resistance in treatment with adolescents who use their work towards these milestones to avoid the more painful and disturbing regressive pulls in analysis with accompanying passive and infantile longings. I often find it difficult to resist my own wishes for them to progress and, more important, to be seen to be improving. The resistance may also manifest itself as an unspoken termination date which is in the adolescent’s mind from the beginning of his or her analysis—a termination date that coincides with the achievement of their developmental milestone (Novick, 1976).

 

7. Vomit as a transitional object

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Em Farrell

In this chapter I want to look at one particular aspect of the bulimic ritual—vomit—and its meaning for normal-weight bulimics in relation to the bulimic ritual, as well as its link to early mother-baby experiences and its relevance in the dynamics of the transference and countertransference. The baby, its vomit, the clearing and cleaning-up after vomiting, the baby’s faeces— and also material in sessions—may all be seen as attempts to create transitional objects and so construct a bridge towards whole-object relationships and reality.

In the United Kingdom, eating disorders have been understood as being primarily narcissistic in nature, the central problems being the differentiation of self from other, the use of introjective and projective mechanisms, and the move to symbolization. Reiser (1990) describes it thus: “The ultimate roots of bulimic behaviour reach into the earliest stages of life when the mental and the physiological aspects of experience are virtually inseparable” (p. 246).

 

8. Transitional objects in the treatment of primitive mental states

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Peter Ciovacchini

The field of mental health is in a state of transition, a fact that makes Wmnicott’s works even more relevant. Winnicott (1953a) was the first to introduce the concepts of the transitional object and transitional space, which helped pave the pathway from the world of the intrapsychic to that of object relationships.

Freud acknowledged but did not particularly emphasize the role of the external milieu in the production of psychopathology. Discussing severe psychopathology, he did not rely exclusively on an intrapsychic focus but stressed conflicts between the ego and the outer world (Freud, 1924b [1923], 1924e). Previously, he had formulated childhood seductions as aetiologic traumas in the causation of obsessive compulsive and hysterical neuroses (Freud, 1894a, 1896b), but later he returned to the intrapsychic perspective in that he believed most of these alleged seductions were, in fact, fantasies (Freud, 1906c).

Melanie Klein purported to be more Freudian than Freud. Though she recognized that there was an external world and caregivers, most of her explorations and formulations concerned the internal world and internal objects as they are subjected to introjective and projective mechanisms. The most attention given to an interaction that is not exclusively confined to the boundaries of the mind was based on projective identification (Klein, 1946), which referred to the temporary relinquishment of an impulse or part of the mind as it is projected into the analyst. This can be, among other things, a developmental experience, in which case it would highlight the participation of the external world in intrapsychic integration and maturation. This was about the only attention she gave to interpersonal experiences.

 

9. D. W. Winnicott and the understanding of sexual perversions

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Charles Socarides

Winnicott’s clinical work with infants and children in the pre-oedipal phase of development, and his observations on the dynamic relationship between mother and child have proven to be an important source of information for the elucidation of the origins of those ineluctable conditions, the sexual perversions. His concepts of good-enough mothering and of the true self and false self, his idea that there is no such thing as a baby, only a nursing couple, as well as his important discovery of the concept of the transitional object, all shed much light on the development of the perversions.

While I have utilized primarily the theoretical framework suggested by Margaret Mahler and her associates (cf. Mahler, 1966, 1974; Mahler & Furer, 1968; Mahler, Pine, & Bergman, 1975) on the theory of separation-individuation, as well as the work of Rene Spitz (1959) and the writings of object relations theorists, notably Otto Kernberg (1975), in support of my clinical findings, my writings over four decades on sexual perversions have been greatly enriched by Winnicott’s theories, observations, and conclusions.

 

10. On the capacity for being inside enough

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Murray Cox

Most patients in Broadmoor Hospital are legally detained “without limit of time”, so that the phrase “being inside enough” could carry an ironic connotation. It can also refer to the depths of the personality reached during prolonged forensic psychotherapy. Furthermore, the therapist’s auto-audit constantly questions whether the patient’s defensive organization, which precipitated the “criminal act”, has been adequately relinquished. In other words, in that complex mutuality between therapist and patient, which is a sine qua non of effective psychotherapy, the question hovering over both therapist and patient has to do with their reciprocal “capacity for being inside enough”. Such modified mutuality—which is partial, reversible, and at the therapist’s discretion—is exemplified in the simplicity of the squiggle that the psychotherapist starts and then invites the patient to continue.

Donald Winnicott’s influence is so pervasive and powerful that he is an ever-present prompter to those attempting to write about dynamic psychotherapy. Even within the relatively circumscribed field of adult forensic psychotherapy, with which he had some direct contact as a paediatrician and as a psychoanalyst, phrases of his are constantly at the ready, as we shall shortly see. Having an interest in those metaphors that change things—mutative metaphors (Cox & Theilgaard, 1987)—it seems appropriate to launch these reflections with Goldman’s words:

 

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