During the 1980s, three critically ill patients from my private practice forced me to acknowledge, to my dismay, that traditional psychoanalytic theory did not provide sufficient support for their cases. They were an anorexic girl whose lack of hope prevented anything from flourishing in her life; a professionally successful woman, who nevertheless saw no meaning in life and whose brilliant mental performance, I later realized, was split off from psycho-somatic living; and a 23-year-old man, who presented the greatest psychic devastation I had ever witnessed, a mixture of dread, despair, and violence.
Searching for some new light to guide me, I came across Winnicott’s writings. I learned that as he was beginning his career in the middle of 1920s, he also started his training in traditional psychoanalysis. He was taught to pay attention to what happened in the sexual life of his patients as children aged between two and five, the reason being that this period was dominated by Oedipal conflicts. In his own paediatric clinic, however, Winnicott found that some babies still only a few weeks old were already emotionally very ill: for instance, they were excessively scared or agitated, or developed anorexia without any signs of physical problems. Given the extreme immaturity of Winnicott’s baby-patients, it was not possible to apply the central hypothesis of traditional psychoanalysis to understand and treat their difficulties. Indeed, Oedipal conflicts presuppose a high degree of development, including mental development. Winnicott concluded that “something was wrong somewhere” and that there might be very primitive problems with later manifestations that escaped the Freudian Oedipal paradigm.
Reading more of Winnicott, I found that he directed a sizable part of his clinical and theoretical research precisely towards clarifying the development of babies at the very outset of life. In doing so, he gave great importance to the absolute dependence of infants on the mother’s care, in particular, the “magic of intimacy” and the communication that unfolds between a baby with an inherited tendency towards integration and his mother when she is facilitating her baby’s integration in a good-enough way.
Winnicott also enquired into the origin and nature of the disturbances affecting the maturational processes of babies at this primitive period of their development and into the corresponding defences. Another important insight by Winnicott was to link the disturbances which infants may suffer when the maternal environment is not good-enough to those difficulties which psychotics have with regard to feeling real and relating to the external world. Studying this pre-verbal, pre-symbolic, and pre-representational period of the integration processes, Winnicott found both the unconscious roots of psycho-somatic health and the unconscious origins of the hindrances to feeling alive, of the hovering between living and not living which afflicts psychotics and other patients but which actually affects all human beings.
This new concept of the unconscious was related to the successful realization or failure of realization of the integration tendency. In addition to the standard traditional “talking-cure”, modified in the light of his clinical experience and his theory of maturational processes, Winnicott introduced a new way of treating psychoses and other early emotional disorders or character disorders such as the anti-social tendency. He called it “care-cure”, i.e. cure by management and, more generally, by what he called “total response” to the patient’s needs. Moreover, Winnicott extended his theory of disturbances to all later periods and stages of the maturational process, even those in which internal conflicts are also present as pathogenic factors, specifying appropriate treatment procedures. Some of them still belong to psychoanalysis since they can be used to deal with the unconscious, whether Freudian or Winnicottian, while others are meant to be used in different medical and non-medical fields, such as paediatrics, child psychiatry, psychiatric social work and education.
This is a short summary of what I found in Winnicott and what made me a Winnicottian psychoanalyst, as well as an occasional practitioner of his other clinical procedures. I started teaching what I learned, first in Brazil, within the Brazilian Society (now Institute) for Winnicottian Psychoanalysis, which I founded in 2005 together with other Brazilian colleagues who shared the same understanding of Winnicott’s contribution, and later internationally in Argentina, China, Portugal, France, etc. Our teaching of Winnicott at this level was greatly facilitated by the creation of the International Winnicott Association (IWA) in São Paulo in 2013.
I had reached this stage in my professional life by a circuitous route. I started to practice psychotherapy in 1976 in outpatient healthcare and mental health centres in São Paulo, where I was brought into contact with psychotic patients at a very early stage. I subsequently developed a private practice but also worked in a very poor neighbourhood of São Paulo as a counsellor for mothers whose social and emotional circumstances were extremely precarious. My clinical work was initially based on the existential therapy of the Daseinsanalytic School elaborated within the framework of Martin Heidegger’s existential analytic proposed in Being and Time.
It seemed to me that the existential therapeutic view of clinical phenomena and Heidegger’s philosophical perspective genuinely illuminated the human condition and I valued the unconventional ethical perspective that it included (caring for one’s own and others people’s true self). Technically, however, it soon proved inadequate since there was no clear definition or classification of pathologies, or of corresponding treatment procedures. I gave up ‘dasein’-analysis and sought help and training in Freudian psychoanalysis, but the paradigm shift that I had experienced did not bring any significant clinical gain. It was impossible to see any trace of the Oedipal complex considered as the core issue by Freud and traditional psychoanalysis in the difficulties that most of my patients brought to me.
In these circumstances, Winnicott’s views were both a relief and a revelation. I started to realize that the troubles of my apparently untreatable patients, such as the three mentioned above, could be understood and treated if I considered their extreme lack of emotional maturity, which was a burden they carried round hidden in their Winnicottian unconscious. I devoured any works by Winnicott that I could lay my hands on. As I deepened my studies and at the same time allowed my clinical work to be guided by Winnicott’s theory of the maturational processes, I realized that I was undergoing yet another profound paradigm shift, which provided me with entirely new theoretical perspectives and, most significantly, new clinical tools which now revealed themselves to be effective.
Indeed, Winnicott’s thesis that psychic disorders are defensive reactions to interruptions of the individual’s integration process and personal development which can be particularly severe during the period of initial absolute dependence has clinical implications that radically alter the analytical setting, the task of the analyst, and what is meant by healing in traditional psychoanalysis. As is well known, the “ordinary” setting and corresponding clinical practice were established on the basis of the study and treatment of neuroses, troubles resulting from conflicts related to the repression of sexual functions. In particular, it is assumed that the patient is an individual with a unitary personality, containing the repressed unconscious and capable of relating to the analyst in the external world by transferring elements of his or her troublesome, symptom-generating repressed unconscious. The task of the analyst is to mirror and to interpret this material. Healing consists in reaching the repressed unconscious, making it conscious and thereby halting symptom formation.
A whole new perspective unfolds when the setting, the analyst’s task, and the healing process are guided by Winnicott’s theory of the maturational processes. In this context, we admit that the patient may not have a unitary personality and hence may not contain the repressed unconscious or be able to relate to the external world at all. In such cases, transference as defined by Freud does not and cannot take place. What may instead happen is that the patient hands over to the analyst the care of the blockages inflicted on his integration process in the remote past and to his very self, a risky move which makes him or her defenceless in one aspect or other of his going-on-being.
The task of the analyst is not to interpret what has happened, or rather, what should have happened but did not, but to accept the responsibility of caring for the unattended needs of the patient. This is done by playing appropriate roles, which in many cases are similar to those of good-enough mothers and parents, by adopting attitudes and by being present in a reliable way. In such cases, the setting, as a place for trust, is more important than interpretation. What is more, interpretation, by creating distance between the analyst and the patient as it appeals to mental process, may repeat the original trauma and result in loss of trust and, as a consequence, be interruptive of the treatment and dangerous for the very existence of the defenceless patient. Healing means helping the maturational process to re-start from a point before it was interrupted, regardless of possible remnants of symptom formation.
Throughout his work, Winnicott insisted on the central place of the theory of the maturational processes in his understanding of human beings, to the point of declaring it to be the “backbone” of his theoretical and clinical efforts. This is not surprising, since in his view, phenomena arising both in health and illness can only be understood against the background of the actualization of the tendency towards integration. In the case of a disorder, awareness of the maturational processes makes it possible to identify the stage at which the disorder originated, i.e. the task in which the individual was involved but did not accomplish when the maturational process was interrupted by repeated reactions to a pattern of environmental failures. For Winnicott, the classification of psychic disorders is primarily maturational and only secondarily symptomatological.
I evidently became interested in seeing how Winnicott’s revolutionary ideas were received by other people and searched the secondary literature, reading everything written about him by his contemporaries that I could find. To my great surprise, I realized that many contemporary readers of Winnicott, even those who admitted that he was an insightful clinician, maintained that he was theoretically poor, if not incapable of conceptual thought, lacking a consistent or unified theory of human development, pathology and clinical procedures. As I had observed the exact opposite, I decided to do something to render Winnicott’s theoretical views more readily accessible. This research resulted in my doctoral thesis, Winnicott’s Theory of Psychoses (1998), which I defended in the Post-Graduate Studies in Clinical Psychology Program at the Pontifical Catholic University of São Paulo (PUC-SP). This book is a corrected and expanded version of the first introductory part of the thesis.
In writing my thesis, I was not merely addressing my fellow analysts but all professionals involved in psychotherapeutic work, since Winnicott’s theses encompassed many areas related to healthcare as well as psychoanalysis. Indeed, Winnicott’s psychopathology may not only be used in the treatment of so-called difficult cases which were intractable to traditional psychoanalysis, but also allows us to formulate therapeutic procedures in other fields of healthcare, such as paediatrics, child psychiatry, speech therapy, nursing and occupational therapy. It can also guide people involved in social work and education by suggesting forms of care which favour the processes of socialization. It is invaluable for anyone involved in prevention policies.
Although Winnicott continued elaborating the central elements of the theory of maturational processes over the years, he did not go so far as to make a unified and organized presentation of it, with the exception of Human Nature (1988). This book nevertheless remained unfinished and was not published during his lifetime. As it stands, it is only a partial presentation of the maturational processes, limiting itself to the triangular family relationship (Oedipus), as traditional psychoanalysis commonly does, leaving out essential parts of the socialization process described elsewhere by Winnicott (adolescence, social maturity, old age). Furthermore, it follows the maturational process in reverse order, going from Freud’s later Oedipal stage (Part II) back to much earlier Winnicottian stages (Part IV), instead of describing this process by starting with its very beginning.
My aim in my thesis was to remedy this situation and to present in due order all periods and stages, indeed, the whole circle of life, from its opening at the beginning to its closure at the end. I also dedicated due attention to Winnicott’s views on human inherited potential, in particular, on the tendency towards integration, which is the main component of the maturational processes, as well as to all major achievements attained during the establishment of a human being as a time-sample of human nature. As in Winnicott’s writings, the principal focus in my study is on the initial stages, since it is during this period that the bases of personality and psychic health are established and if this does not occur, the individual suffers consequences for the whole of his or her life. In particular, he or she may not be able to reach the natural closure of the life circle, that is to say, become able to have a self which, as Winnicott puts it, “can eventually even afford to sacrifice spontaneity, even to die”, the natural death being “the final seal of health”.
In the Introduction to my book, I emphasize Winnicott’s interest in the study of human nature, as well as the central place of the maturational processes in his paradigm. I use Thomas Kuhn’s concept of scientific revolution to show in what sense Winnicott’s proposals can be seen as revolutionary steps in establishing a new paradigm for psychoanalysis and other psychotherapeutic practices. I then provide a brief overview of the commentators available to me at the time (I completed the first edition of this book in 2003), examining some divergent readings. Finally, I present my general view of Winnicott’s writings as a whole, highlighting their particular nature and the originality of his approach to human phenomena.
Chapter 1 tries to locate Winnicott with regard to the other areas of healthcare which concerned him, some still in their infancy. Keeping my analyses in due proportion, I point out aspects of his dialogue with paediatrics, academic psychology, adult and child psychiatry and especially with traditional psychoanalytic theory.
Chapter 2 explains what I regard as the basic concepts of the theory of the maturational processes: the innate tendency towards integration and the facilitating environment; periods and stages; psycho-somatic existence; integration via personal rather than mental experience; the state of unintegration and absolute dependency of early life; the mother/infant relationship; the good-enough mother and the baby’s father; the concepts of ego, self and I; the philosophical and epistemological characteristics of the theory of the maturational processes and the language in which this theory was formulated.
Chapter 3 presents and integrates everything that I was able to assemble regarding the most primitive stage of absolute dependence, including the prenatal stage; the experience of birth; the stage of the theoretical first feed; primary creativity; excited states, quiet states and the alternating movement between them. I also present the fundamental tasks of this most primitive stage: integration in time and space; the indwelling of the psyche in the body; the beginning of contact with reality and the establishment of the primary self.
Chapter 4 discusses the different stages during the periods of relative dependence leading towards independence and of relative independence: the beginning of the process of disillusionment, which includes weaning and the early activation of mental functions; the stage of transitional phenomena; the stage of object use; the stage of I AM; the stage of concern; the stage of triangular (Oedipal) relations; puberty and adolescence; adulthood; old age and return to origin. I conclude the study with a brief comparison between Winnicott’s theory of the maturational processes and the theory of the development of sexual functions of traditional psychoanalysis.
In summary, Winnicott’s theory of the maturational processes can be used as a practical guide for understanding essential aspects of human psycho-somatic health and ill-health, for promoting the first and for treating the latter. Psychoanalysts and psychotherapists may find it useful, as may professionals whose work is to help with difficulties in emotional development of babies, children, adolescents and adults, not to mention parents who are concerned with facilitating the personal development of their children. Anyone investigating preventive action and policies in the field of psychic health may also find useful material here. As the theoretical background for the understanding of psychic disorders, the theory of the maturational processes is an intrinsic part of all kinds of psychotherapeutic action and can and should be used in training professionals in these fields. Winnicott himself has practiced it as he learned it from his patients, who, as he says, paid to teach him: “The only companion that I have in exploring the unknown territory of the new case is the theory I carry around with me and that has become part of me. I do not even have to think about it in a deliberate way. This is the theory of the emotional development of the individual which includes for me the total history of the individual child’s relationship to the child’s specific environment.”
Elsa Oliveira Dias, PhD, is a clinical psychologist, psychoanalyst, and co-founder of the Brazilian Society of Winnicottian Psychoanalysis. She is also deputy chairperson of the International Winnicottian Association (IWA), and author of a number of books in Portuguese.
Her latest book, Winnicott’s Theory of the Maturational Processes, was published by Karnac in 2016.