I once risked the remark, “There is no such thing as a baby”—meaning that if you set out to describe a baby, you will find you are describing a baby and someone. A baby cannot exist alone, but is essentially part of a relationship.1 — D. W. Winnicott
The modern inpatient psychiatrist lives in an era in which justifications for continued psychiatric hospitalization are exactingly assessed by third-party reviewers, documentation needs to be both litigation-proof and detailed enough to ensure insurance reimbursement, clinicians are expected to be psychopharmacologically savvy and to keep apace of a panoply of new drugs, and an ongoing quest for diagnostic precision has come to dominate both clinical psychiatry and the design of research projects. What could Donald Winnicott, a pediatrician and psychoanalyst from the early twentieth century, have to communicate across the generations to today’s psychiatric attendings and residents? The answer is, a lot. Winnicott’s writings explore treatment attitudes and therapeutic elements that make for humane and healing relationships with patients. His writings would support the idea that the psychiatric patient does not exist. There is only the dyad of patient and doctor—a dyad that can be extended to patient and psychiatric unit, with all its component parts and staff. Winnicott’s concepts enrich our understanding of a unit staff’s interactions with acutely ill psychiatric patients, including the accompanying transferences and countertransferences. His therapeutic posture of attunement and adaptation to the patient’s deficits provides a model of treatment engagement that is readily applicable to the modern inpatient setting with its population of psychotic, mood-disordered, and Axis II–disordered patients.
Winnicott’s fundamental ideas are highly applicable, in general, to rehabilitation settings, with their interplay of disability and the need for a responsive, restorative environment.2 The patient’s adaptation to illness is a central problem in physical/rehabilitative medicine, and Winnicott’s object relations theory provides a valuable perspective on evaluation and treatment in occupational therapy.3 In both respects, the parallels to the work of inpatient psychiatric units is readily apparent; my goal here is to explore more fully out how Winnicott’s unique concepts and terminology can be used to understand the problems and processes of inpatient psychiatry. Although some may argue that Winnicott’s language merely articulates what inpatient units and clinicians are already doing (presumably with their own non-Winnicottian concepts and therapeutic principles), the view presented here is that inpatient care can be enhanced if clinicians are explicitly aware of Winnicott’s ideas and use them to understand the therapeutic unfoldings that he describes. Several clinical vignettes will be used as illustrations.
Modern inpatient units, with their increasingly restricted lengths of stay, are organized around a set of fundamental principles and goals: the review and integration of historical and current psychiatric/psychological/medical data leading to diagnosis and treatment; continuity of care and coordination with outpatient treatment; a multidisciplinary team approach; and attention to the patient’s support system.4 The actual clinical environment, along with the day-to-day clinical interactions with the patient that occur in that environment, might be described more concretely, and more evocatively, as follows:
* Refuge, asylum, and respite. Removal from a stressful or chaotic environment into a structured setting is itself therapeutic.
* Care and nurturing. Meals are provided for; nurses and others tend to patient’s daily comfort and physical well-being; and staff are available around-the-clock for advice and emotional support.
* Safety, stability, and containment. These elements, which are especially important with acutely psychotic, suicidally depressed, or highly agitated patients, are achieved and reinforced in various ways—namely, through the secure physical setting, staff monitoring, behavioral management, pharmacologic treatment, and the regular structure of the unit’s programmatic activities.
* Activity and engagement. Activities therapists (including recreational, occupational, art, and music therapists), nursing staff, social workers, and others all play crucial roles in defining the day-to-day environment of a unit and in mobilizing patients toward recovery. Engagement also includes the patient’s affective involvement in sessions with his or her psychiatrist.
The above list serves to remind the reader that the inpatient psychiatric setting contains elements that augment and support the psychiatrist’s evidence-based body of knowledge in diagnosing and treating serious mental illness. Winnicott’s concepts add clarity and nuance to the notion of a hospital patient as a person in crisis, temporarily residing in a highly structured therapeutic environment and embedded in a matrix of therapeutic relationships with unit staff, including his or her psychiatrist, the assigned nurse, the social worker working with the patient and family, and other inpatient staff.
WHO WAS DONALD WINNICOTT?5,6
Most psychiatrists and psychiatry residents know that the term transitional object refers to the teddy bears and security blankets that children use to comfort themselves, and that holding environment denotes the quality of the special relationship of a good-enough mother with an infant. These highlighted terms were coined by Donald Woods Winnicott (1896–1971), a British pediatrician with psychoanalytic training who worked for many years at Paddington Green Children’s Hospital in London, where he saw thousands of children and their mothers. This background formed the basis for his large body of writings in the field of object relations, most of which deal with the nature of the early interaction between mother and child. His reconciliatory temperament and intellectual flexibility allowed him to play a large role in establishing a “Middle Group “of British psychoanalysis that straddled the polarized and warring camps led by two formidable women—Melanie Klein, with her emphasis on deep id interpretation, and Anna Freud, who, as heir to her father’s mantel and guardian of his classical legacy, focused on defense mechanisms and ego adaptation. In the post–World War II period, Winnicott was also heavily involved in what would now be deemed psychoeducation, and provided a series of BBC radio lectures directed at young mothers. Winnicott’s vast clinical experience and body of work lent credence to his reassurances to these mothers that they knew what was best for their infants. He encouraged them to trust their motherly instincts and the natural unfolding process of the dyadic relationship.
Reading Winnicott is a great pleasure, especially if one attunes to his style, which can be quirkily idiosyncratic and ambiguous, yet also elegant, poetic, and richly metaphorical. The articles listed in Winnicott’s biographical timeline (Text box 1) provide a good starting point to introduce the reader to Winnicott’s central concepts and his uniquely playful discourse. Although Winnicott’s body of writings lacks the kind of rigid systematic exposition that founds a strict doctrine and followers, it is this very elasticity that has allowed for the extension of his work beyond psychiatry and into other fields such as art and literary criticism, anthropology, and family systems theory.
In addition to his work with child patients, Winnicott concerned himself with adults who would be classified as psychotic, borderline, or narcissistic. He was less focused on “worried well” neurotics, whom he saw as benefiting from classical analytic approaches. His own brand of therapy, which paid more attention to attachment and early self-differentiation, better suited patients with deficits in relatedness and ego functioning. Winnicott recognized the biological/hereditary contribution to schizophrenia but, like many other psychoanalysts of his era, saw severe personality psychopathology and psychosis primarily as consequences of environmental failures. His view of illness is not entirely concordant with that of today’s psychiatrists, who judiciously weigh the relative etiologic contributions of genetics, constitution, trauma and loss, and—especially with borderline personality disorder—invalidating responses by the family. Nonetheless, even with modern psychiatry’s new tools and knowledge, Winnicott’s emphasis on the environment’s empathic responsiveness to a patient’s needs continues to bear relevance to the therapeutic milieu of an inpatient unit and the therapeutic interactions with individual inpatients.
WINNICOTT’S FUNDAMENTAL CONCEPTS AND THEIR RELATION TO INPATIENT WORK
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Winnicott uses the terms holding, holding function, and holding environment to refer to an infant’s stage of total dependence on the environment.1,6 In particular, Winnicott is focused on the mother and her attentive attunement to the needs of a small child, which include not only feeding and bathing, but also the consistent manner in which the child is handled, soothed, and comforted. It is not difficult to extrapolate this concept to the inpatient setting, where patients admitted with psychosis, severe depression, and other regressive states are—particularly in the initial portion of their stays—in a position of heightened dependency upon the staff. In a questionnaire study of patients in a Swedish university hospital’s acute inpatient psychiatric unit, Johannsen and Elkin7 looked at which of the unit’s atmosphere factors (as perceived by patients) correlated with measures of treatment alliance. They found that the factors relating to support, encouragement by staff, and program clarity were “dominant components” in establishing the alliance. Futhermore, in discussing their findings, the authors offered that “theoretical considerations derived from our results lead in the direction of the psychotherapeutic and psychodynamic concept of holding” and likened the inpatient unit to Winnicott’s holding environment.7 Many of the factors in the categories of refuge, care, structure, and containment—listed earlier in this article—can be thought of as analogous to this holding function.
Winnicott saw holding as part of a sequence that ultimately leads to the presentation of the outside world to the child, culminating in an integrated sense of self and the ability to relate to others.8 A short-term acute inpatient stay is certainly not sufficient to repair a damaged sense of self. Nonetheless, even with a relatively brief hospitalization, regressed or psychotic patients with a previous level of adequate functioning may utilize the hospital’s holding environment as a respite from stress and may proceed through this Winnicottian sequence as they improve. The following vignette illustrates how a typical patient may benefit from attention to the need for initial holding and for a subsequent, gradual exposure to the outside world:
A 19-year-old college student was transferred to the acute psychiatric unit from the medical unit, where she had required treatment for a significant overdose that occurred in the context of psychosocial stressors that included poor grades, a recent breakup, and conflict with her parents. Her initial presentation on the psychiatric unit was one of extreme regression, with childlike dependency, limited investment in activities, and difficulty carrying out her activities of daily living. Nonetheless, with much support of staff, toleration of her need for regrouping, medications to help with sleep, and allowance of several days of limited responsibilities, the patient began to pull out of this reactively depressed state. At that point she was able to begin to process the meaning of her suicide attempt and could work with her psychiatrist and social worker on modifying her course load, discussing her recent loss, and meeting with her parents in several family meetings on the unit.
In the initial portion of her stay, this patient was able to utilize and benefit from the unit’s holding functions. This safe and secure base of holding and handling allowed gradual introduction of issues from the outside world. This patient, like others with similar short-term inpatient stays, improved remarkably within several days. Though she left the hospital with a diagnosis of depression, her change in mood was too quick to attribute to antidepressant medication. Myriad nonpharmacologic factors, including the holding environment of the unit, were likely instrumental in her recovery. The vital role of the unit’s holding function in patient improvement can also become evident when patients relapse and require readmission soon after discharge. Awareness of this phenomenon should be incorporated into discharge planning—for example, making sure that at least some of the unit’s holding functions are replicated outside the hospital.
While much has been written about the good-enough mother—a term that presages Kohut’s self-psychology with its concept of a parent as a mirroring selfobject9—perhaps the most succinct definition is Winnicott’s own: “The good enough ‘mother’ (not necessarily the infant’s own mother) is one who makes active adaptation to the infant’s needs, an active adaptation that gradually lessens, according to the infant’s growing ability to account for failure of adaptation and to tolerate the results of frustration.”10
As many (Winnicott himself included) have pointed out, an exegetical expansion of this definition allows substitution of the word “therapist” for mother and application of the concept to the psychotherapeutic situation. For instance, Kohut’s original mirroring selfobjects are replicated in the transference, especially when the original selfobjects have faltered in their availability or responsiveness. Winnicott’s good-enough mother’s initial laser-focus on her infant’s wants gradually gives way to structure-building withdrawal of this symbiotic attention. Similarly, in the psychotherapeutic situation, the patient’s processing of the therapist’s inevitable failure to provide perfect empathy can promote self-structure through transmuting internalizations.11 Is it too far-fetched to stretch even further from good-enough mother to “good-enough hospital unit”? Here are some of the similarities:
* Patients commonly perceive the unit as a temporary substitute caregiver and as a place where fundamental needs are addressed. The link between good-enough mothering and good-enough unit care is particularly salient for the large group of our patients who have experienced early developmental deficits in maternal care.
* The good-enough mother, in Winnicottian terms, “meets the infant’s gesture”6—that is, in a seemingly magical fashion, she presents herself to satisfy the infant’s need without demanding an integrated response beyond the infant’s capability. Similarly, in the early part of a psychotic or otherwise regressed patient’s inpatient stay, the unit staff must meet the patient’s gesture in the form of a heightened responsiveness to the patient’s—often nonverbally expressed—needs at the time. The unit may need to provide appropriate calming medications, physical redirection, or even frank containment. Staff must be careful not to overwhelm the patient in this regressed state and must gauge the patient’s capability to understand and comply with the treatment plan.
* The good-enough mother, through her administration of care, supports the infant’s developmentally appropriate illusion of omnipotence, but this illusion cannot be sustained in the face of graded frustration experiences. Likewise, acutely ill and deeply regressed inpatients may perceive the initial care that they receive as appearing magically in response to their acute distress. This level of attunement, however, should be seen as the unit’s temporary compensation for the severity of the patient’s illness. As patients progress and improve with their stay, the good-enough unit will gradually expect more of them, and patients’ illusory relationship with the unit is replaced by a more reality-oriented focus on understanding their illness and dealing with precipitating life issues. One-to-one attention may be withdrawn, replaced with a progressive expectation that patients engage in unit programming and therapy, build coping skills, and interact with others.
Gabbard offers an encompassing definition of Winnicott’s transitional object: “An inanimate object (e.g., a blanket, teddy bear, tune) discovered in the environment by the child and invested with powers under the child’s omnipotent control. For the child, the object exists in a third space, which incorporates both REALITY and FANTASY.”12(p586)
In his classic article “Transitional Objects and Transitional Phenomena,13 Winnicott lays out his far-reaching and innovative insights into young children’s first “not-me” possessions: their existence at the interface of inner and external reality (“third space”), and the associated developmental line that involves illusion and its ultimate transformation into the whole cultural sphere of art, music, play, religion, and, indeed, the entire creative enterprise. Transitional objects/phenomena are woven into the very fabric of the inpatient unit experience in multiple ways:
* Music therapy, art therapy, occupational therapy, and recreational therapy on an inpatient psychiatric unit can be seen as operating in Winnicott’s transitional space. As such they offer alternatives to pure regression and acting out, and serve as a bridge from the patient’s initial acute state of self-absorption to an engagement with the outside world. Winnicott makes much of the importance of play—a response to Freud, who famously saw the endpoint of treatment to be the abilities to love and to work. In this regard Winnicott is similar to Sullivan, who thought that a person’s hobbies and avocations are closer markers of the patient’s real self—and less contaminated perhaps by parental or societal expectations—than vocation or profession might be.14 Winnicott saw play itself as occupying a transitional space created by a good-enough mother who can respond in a graceful and timely way to the child in mutual excursions into a playful realm (peek-a-boo, for example). In the hospital setting, the unit activities can act in part as adult versions of such play. Activities on the unit serve to address the inherent need for fantasy, while also aiding in rebuilding coping skills and reality orientation during a period in which the patient’s play function and reality testing may both be compromised. Thus the play on the unit assumes more than ancillary importance; it represents the space in which patients can reemerge from illness-related regression into the safety of the transitional space and then into the more fully individuated space of real-world responsibilities and relationships.
* Transitional objects may have an especially important soothing role for certain patients who are under stress. Patients with defects in object constancy—which includes many patients with borderline personality disorder15—may become suicidal in the setting of perceived or actual abandonment. Many hospital patients have ego deficits that render them unable to transform early transitional-object experiences into the capacity for evocative memory. For such patients, the failure of transitional substitutions may have played a role in the need for hospitalization in the setting of a break-up or outpatient-therapist vacation. This deficit in the “evocative trace”16 leading to a compensatory turn toward transitional objects for soothing may account for the finding that the presence of stuffed animals on the bed is a fairly reliable marker for borderline personality disorder in inpatients.17 Awareness of the soothing function of transitional objects may lessen staff’s annoyance with the patient who brings in a quilt and pictures from home and appears to be settling in too comfortably on the unit. In fact, toleration of a patient’s temporary use of these transitional objects might prevent the overuse of pharmacologic agents as transitional objects (“med-seeking behavior”). In addition, much acting out by patients around discharge day could also be conceptualized as difficulty relinquishing the comforting properties of an inpatient unit that has itself become a “transitional space.” This same dynamic may explain the importance that many patients attach to the items that they have created in craft groups; these pieces may serve as transitional objects to bridge the separation from unit to home.
True and False Self
Winnicott placed great value on the ability to be authentic, with this high premium embodied in his notion of the true and false self. Gabbard defines the concept as follows: The “TRUE SELF” is “an experience of the SELF that emerges in response to one’s own needs and wishes (as opposed to the FALSE SELF experience, which emerges in response to another’s needs, expectations, and demands).”12(p586)
Although Gabbard does not affix any particular developmental period to his definition, Winnicott viewed the splitting off into true and false self as most pathologic when it represents the failure of the early holding environment to prevent threats to the embryonic self-structure (impingements is Winnicott’s term for such threats).6 Impingements can take the form of premature or mistimed presentations of the outside world or of failures to recognize the infant’s “gesture” and to meet it with an appropriate responsiveness. By protecting the infant against impingements, the good-enough mother contributes to the development of a confident, calm, and nondefensive child. But factors such as poor dyadic fit, lack of resilience, and an adverse environment can lead to a false self that is marked by compliance and lack of spontaneity, with “imitation as its specialty.”18 At the furthest end, such patients would be considered to have major core identity issues and would likely fall into such categories as borderline or narcissistic. The psychoanalytic concept of the “as-if personality” would also fit many of the most disturbed examples of false self.
Winnicott also allows that gradations of true and false self can occur—with virtually all well-functioning persons able to adjust their behavior in social situations and compromise their core true self in an adaptive way if necessary. The false self may emerge on the inpatient psychiatric unit in various ways. One common example is that of the depressed patient who quickly reconstitutes after a serious suicide attempt and claims improvement and readiness for discharge. The flight into health may actually describe the group of such patients, many of whom are Axis II–disordered, who do not experience a sufficient “holding” on the unit that could allow them to talk about the events and feelings that led up to a suicide attempt. Astute staff may discern a blasé attitude, a subtle lack of investment in the program, or a lack of true-self vitality in these patients, who may seem to superficially comply with supportive therapies. In addition, the inpatient setting’s various impingements, including length-of-stay pressures from third-party reviewers, may lead a clinician to collude with the patient’s inauthentic self in a quest for a quick fix and rapid discharge. The following vignette illustrates the virtue in resisting entreaties engendered by a patient’s false self:
A 19-year-old female university student was transferred to the inpatient psychiatric unit from the medical unit after treatment for an intentional overdose. This was her second suicide attempt in as many months. The patient was anxious to return to school and was abetted in her wish for another short stay by her parents, who feared that her hospitalizations would cause her to be “off track” in her educational progress. Although she expressed some guilt that she had put her roommate through the ordeal of taking her to the emergency room, she insisted that she was no longer depressed and was out of suicidal danger. Various staff saw her as isolating herself and as just going through the motions in the inpatient program’s groups and activities.
The psychiatric resident persisted in trying to get to know her better, and after several days the patient began to open up about her mood and the fights with her roommate that had precipitated her suicide attempts. She confided that she is very quick to become attached to people, and prone to interpret minor misunderstandings as a sign that someone may no longer wish to be her friend. The resident began working with her on recognizing the connection between her emotions and her actions. The patient was aided in this work by attendance in dialectical behavior therapy groups on the unit. When she ultimately was discharged to outpatient treatment and to a reduced university course load, the resident and other staff had the sense that her level of engagement was more genuine.
Sadly, this young woman’s predicament is like that of so many of our patients. It is not difficult to see how both the internal and external pressures to be well and to prematurely resume full functioning can lead to the emergence of the false self, especially in patients with Axis II vulnerability. The dynamics of these suicidal patients can be very complex, and unit staff needs to be careful not to get caught up in splitting. Nonetheless, the psychiatric resident, responding to the superficiality of the patient’s improvement, decided to take some time with this patient and thus avoided aligning with demands for conformity and a simulacrum of wellness. Aspects of the patient’s hidden true self could then surface for a true therapeutic encounter.6 For many such patients, the concept of a false self may have more usefulness than “flight into health” in describing the patient’s response to internal and external pressures that oppose authenticity.
By way of contrast, it is important to remember that the adaptive persona of the healthier patient—which Winnicott calls the “normal equivalent of the False Self”18—may allow that patient to conform to the culture of the inpatient psychiatric unit, to understand and abide by the temporary restrictions necessary in an acute setting, and to tolerate having a stranger as a roommate.
“There’s no such thing as a baby”
Like a Japanese kōan, Winnicott’s aphoristic emphasis on the unity and indivisibility of the mother-child dyad invites contemplation and extension. Can this maxim speak to the inpatient setting? If one encounters a person who says “I am a patient,” the logical question would be of whom or at what hospital. And while the early derivation of the word patient is “one who suffers,” a more complete description would be “one who suffers and is treated.” In Winnicott’s world, the image of a hospital patient has no meaning in isolation, without its counterpart in the caregivers on the inpatient staff.
But likening an adult psychiatric inpatient to a young child works well in the metaphorical abstract only if we consider that severe illness (i.e., major depression, schizophrenia, and bipolar states) fosters regression. Furthermore, Winnicott would not support an ongoing infantilizing of our adult patients. His end goal with his patients was always one of self-integration and differentiation from early objects, culminating in what he called “the capacity to be alone.”19 We could view our inpatient treatment goals in similar terms: the patient’s internalization of the holding qualities of the good-enough unit to a point that supports and permits a safe discharge from the hospital.
The Squiggle Game
Winnicott utilized the squiggle game—a technique of reciprocal doodling with young children—to establish rapport and to access their inner world. He describes it as “a game in which first I make a squiggle and he turns it into something, and then he makes a squiggle and I turn it into something.”20 In Winnicott’s terms, the squiggle game creates a transitional space between the child and the clinician, an arena in which the clinician is playfully offering a “gesture” that invites a creative response. Although Winnicott confined this game to his child patients, his general style with adult patients was in full accord with the metaphorical sense of squiggling. That is, a Winnicottian approach is light, playful, reciprocal, responsive, and respectful of boundaries. On the inpatient unit, these “squiggle moments” are likely to occur in the activity therapy groups, especially those that draw upon the patient’s creative potential. Psychiatrists are not likely to spend much time doodling in sessions with patients. Nonetheless, such Winnicottian junctures can also occur in patient interviews in which clinicians allow themselves to veer from the necessary, templated review of the patient’s progress regarding target symptoms toward a more improvisational give-and-take conversation.
Hate in the Countertransference
Inpatient psychiatric staffs confront the severe illness states of their patients on an unrelentingly daily basis. Justifiably, various psychological defenses come into play to deal with the onslaught of strong emotions that are stirred up in the process. For surgeons to operate calmly and confidently, humor, intellectualization, and isolation of affect are just as important as a clean surgical field.21 Likewise, for psychiatrists and the unit as a whole to function therapeutically, they must utilize higher-level coping strategies. What may distinguish those in the mental health field from other medical fields is their learned capacity to recognize and process negative emotional states that can compromise attunement to the patient. In Winnicott’s “Hate in the Countertransference”22 (which has become familiar to a past generation of psychiatrists through its frequent references in another classic, Groves’s “Taking Care of the Hateful Patient”),23 the therapeutic relationship is compared to that of a mother with her infant. Winnicott provides a detailed and powerful description of all the reasons a mother might—despite ample love for her infant—intensely dislike her role and her baby, at times to the point of sheer hatred. His list of the infant’s demands and improprieties that precipitate such loathing is insightful and exhaustive. In his inimitable way, Winnicott offers, among other causes for complaint, that the infant “is ruthless, treats her like scum, an unpaid servant, a slave.” Though a mother’s sacrifice for her baby goes well beyond what inpatient staff do for their jobs, taking care of deeply regressed inpatients can be very taxing. Nurses and psychiatric aides, who have to contend with day-to-day patient management, are especially burdened in this respect. Winnicott’s cataloguing of the indignities that mothers (and caregivers) endure, along with his implied permission to have strong negative feelings in response, should be required reading for inpatient psychiatric staff.
Regardless of whether Winnicott’s ideas, terms, and clinical approach can be precisely tailored to the inpatient arena, there is no arguing against the simple fact that patients do not exist in a vacuum. A review of Winnicott’s concepts and their adaptability to the modern inpatient psychiatric unit serves to reiterate that even today, amidst hyper-concern for diagnostic precision, evidence-based treatments, air-tight documentation, and economically sustainable lengths of stay, Winnicott’s ideas can serve as a reminder to modern psychiatrists, nurses, and inpatient staff that they need to remain aware of the complexities of their relationships to patients. Furthermore, it is reasonable to suggest that despite an already crowded list of mandated competencies for psychiatry residents, residency training directors and faculty may wish to incorporate several of Winnicott’s classic articles into their programs’ formal curricula or into the informal teaching on the inpatient unit.
Dr. Casher gratefully thanks Kyra Sutton, BA, for her editorial assistance.
Declaration of interest
Dr. Casher is currently a consultant to Sunovion Pharmaceuticals and has previously been a consultant to AstraZeneca.