Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Winnicott’ Category

Nature or Nurture: Will The Debate Ever End?

Posted by Dr. Vollmer on February 8, 2012

   Daniel is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

Posted in Aggression, Anger, Child Development, Child Psychotherapy, Mother/Child Relationships, Neurobiology of Behavior, Parenting, Winnicott | 6 Comments »

The Aggressive Child

Posted by Dr. Vollmer on February 7, 2012

Daniel, six, with a two-year old brother, Jonathan, knew that Jonathan was the favorite. He was angry when Jonathan was born, very angry. Daniel acted out his anger with aggression, which further confirmed to Daniel’s parents, that he was the “bad child.” This was my theory as to why Daniel was so violent, both at school and at home. Many teachers, family members, and other professionals saw his aggression as either part of a “spectrum” disorder or an impulse-control disorder such as ADHD. In my office, Daniel was indeed quite aggressive. He would take off his shoes so that he could throw them at me. Yet, I saw his aggression as a way that he communicated that his emotional needs were not getting met, and he needed me to understand that. I explained to Daniel that throwing his shoes was unacceptable in that I did not want to get hurt and I  did not want him to hurt others. We could use my pillows to “play” in a way which might get out some of his aggression, but we could not use the pillows to hurt each other. He understood the fine line between physical play and aggression. Eventually, Daniel calmed down in my office, but he continued his aggression at school and at home. With that in mind, I began seeing his parents on a monthly basis. Both the mother and father agreed that Jonathan was a “much easier child,” suggesting that they did favor him at home. Jonathan made them feel like competent parents, whereas Daniel, partly because he was the first-born, and partly because he was more prone to acting out, made them feel like they were “parental failures”. I worked with the parents to help them see that as they felt like “parental failures”  where it came to Daniel, they then unconsciously encouraged Daniel to be aggressive as a way of denying their role in his behavior. As Daniel got into more trouble at school, the parents felt more relief that Daniel had “issues,” thereby taking away their feeling of “parental failure”. The cycle of parental inadequacy leading to the unconscious wish for Daniel to show that his issues are “organic” and not environmental caused the downward spiral of increasingly difficult behaviors. However, I pointed out to them that although Daniel’s behavior is getting worse, in my office, his behavior is getting better, suggesting that with appropriate limits, Daniel can calm down. Winnicott’s idea of a holding environment comes alive again. Daniel felt “held” in my office, so he did not need to be aggressive in order to feel understood that his emotional needs were not getting met. Daniel’s parents, for complicated reasons, were not able to create this “holding” environment at home. Violence is often a communication tool; a tool to wake up those around that the aggressor needs attention. Sometimes people do not want to be woken up. My work is to find a way to gently nudge a “wake-up” in these parents. I suspect that when I do arouse these parents, Daniel will be “cured”. We will see.

Posted in Aggression, Attachment, Child Psychiatry, Child Psychotherapy, Parenting, Play, Winnicott | 4 Comments »

Holding: Winnicott Comes Alive

Posted by Dr. Vollmer on February 2, 2012

   The psychoanalytic situation, as developed by Sigmund Freud, is notable for its constant setting, its regular hours, its ritualized trappings, which provide the patient with a feeling of safety, a sense of being held. D. W. Winnicott, a British pediatrician/psychoanalyst, gave a special importance to this aspect of psychoanalysis. He introduced the term “holding environment” as a metaphor for certain aspects of the analytic situation and the analytic process. The term derives from the maternal function of holding the infant, but, taken as a metaphor, it has a much broader application and extends beyond the infantile period to the broader care-taking function of the patient. Winnicott transferred this concept to an aspect of the analyst’s function, with full awareness of the analyst’s capacity to exercise a care-taking role. But for Winnicott, this care-taking was more than simple support and the provision of a reliable and reassuring presence. As he once remarked, it “often takes the form of conveying in words, at the appropriate moment, something that shows that the analyst knows and understands the deepest anxiety that is being experienced.”

   Nell, sixty-five, was suddenly widowed. “You are scared of being alone,” I said, thinking about Winnicott’s notion that articulating the anxiety can make someone feel understood and therefore contained. This kind of articulation often represents the difference between a friend and a psychotherapist. A friend might say “you are going to be OK,”  with the best of intentions, but  the “OK” is vague since it does not convey an understanding of how Nell might fear not being “OK.” Nell looked visibly relieved when I spoke about her fear. The sudden death of her husband forced her in a position of feeling that she had to take care of everyone else’s shock. She did not have a place to feel her anxiety, so she sought out psychotherapy. She was not aware that she went to psychotherapy to feel her fear, but once I said that, she understood why she found a good place to work through her grief. Winnicott is one of my heroes.

Posted in Psychoanalysis, Psychotherapy, Relationships, Winnicott | 5 Comments »

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