Kim J. Masters, M.D
D.W. Winnicott, M.D. and Melanie Klein pioneered an affect psychology that explained the origins of guilt and the wish to make amends. They described how we come to feel guilty about hurting those we love, and how these feelings are lessened when we do something that the injured person accepts as a repayment.
Winnicott proposed that breastfeeding and weaning provided an early opportunity for experiencing affects. In this case, the infant is dependent on his mother for breastfeeding. When she stops, puts the child down for a nap and leaves, if the child wanted to continue feeding, he could scream with frustration and fear—frustration at being denied supplies and fears that he would not get any more and that she would not come back. After many repeated experiences of his mother returning and resuming feeding, he would learn to modify these fears and learn that while he could not make his mother be there when he wanted, her leaving would not result in his abandonment. This made her a “good enough mother” because in part it allowed the development of trust.
Later, the child would learn that by doing what his mother wanted, he could have her smiles and approval, but with other behaviors, he could bring out her anger. Toilet training is an example of both. If he messed all over the crib, she might be angry, but if he went in his diapers, she would smile and praise him. Thus he could experience feeling loved for toileting himself. This is an early example of restitution or reparations, fixing a mess to make a caretaker happy and thereby encouraging her in her caretaking efforts.
Many examples of similar experiences occur throughout life: being angry at being sent to bed and being reassured by a good night kiss and helping to clean up the house to make up for abusive or belligerent behavior. These acts become integrated with coping styles of managing frustration, or fear of getting out of control, or of being abandoned, on the one hand and reparative works to assuage personal guilt and maintain ties with loved ones. A teenage peer example would be a boy, who feeling sad after a fight with his girlfriend, and fearing the end of the relationship, brings her a gift bought from his wages.
Some children have failed to develop these controls for biologic reasons such as cognitive delays, attention problems, or mood disorders. In some families, the attachments are unsuccessful due to temperament mismatches or environmental failures. The resultant problems in residual anger control and empathy lead children into treatment. In the more severe cases, the therapy is carried out in hospitals and residential treatment centers. Anger outbursts and attacks on staff and peers lead to deescalation efforts and when they fail, to seclusion or restraint. In the processing of these events, restitution can be used as a way of repairing damage to the staff or peer or treatment. Nancy Cotton has described a Winnicott type approach to child induced staff injury in Lessons From the Lion’s Den. This book was written at a time when inpatient length of stays were a lot longer than five days, and when a child had been with a staff member long enough to see him or her as caretaker on whom maternal and paternal power conflicts could be projected. What is useful about it now? Several things.
During an initial evaluation, a child who reports feeling no guilt when he loses his temper with his caretakers may be at risk to injure others if a similar episode occurs. A parent who reports the lack of guilt in an aggressive child may be describing the failure of parenting to bring about control of frustration, or limit assaults.
These diagnostic discoveries lead to several predictions and treatment options. A child can be taught that anger control is improved, if it is part of a wish to preserve the relationship to caretakers, and that restitution is one avenue to cope with lapses. A very strong selling point in driving a child to work on these controls is that they are necessary to prevent assaults on future loves, namely future girlfriends and boyfriends. Since most children and adolescents have dreams about future peer loves, the thought that rages would harm these yet to be discovered amours, brings immediacy to them and helps to remove the barriers that come from repeated failures of self control in the past. That is to say, if a child has kicked his mother or father many times, he might feel that it was unlikely that working with feelings could help stop these outbursts. However, the prospect that it could prevent a break up of a future relationship could be motivating, because in this effort, he has not had a chance to fail.
A child can also learn to use CBT (cognitive behavioral therapy) cognitive exercises, such as: when you feel angry with your mother, you could think, “She deserves it.“ But you could also think, “Well, if I work this out so I don’t hurt anyone, it may make me happier tomorrow…” If you think of someone you would like to date, and you think, “I wouldn’t want my anger to get to them, and this time I am learning how to control it… maybe guilt is a good thing, because it could help me stop and control myself, before I wreck things with those whom I need and love.”
These discussions can be introduced both to the child and the family in a crisis inpatient stay and may have more power because inpatient care is intense, and more confining than other treatment. Practice self talk dialogs can then be incorporated in discharge plans.
Affect management and restitution also offer up a new way to conceptualize anger control, casting it a part of “good enough parenting“ with “good enough frustration tolerance” to avoid injury to caretakers and loved ones.
On a personal note, I would especially like to thank Dr. Eugene Beresin for the many hours he spent teaching me Winnicott theory.
Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, Georgia. He is also co-author of AACAP’s Practice Parameter on the Prevention of Aggressive behavior.
References
Cotton, N (1993), The interpersonal context of therapeutic management: Discipline, in Lessons from the Lion’s Den Jossey-Bass, San Francisco 130- 159.
Klein, M (1940) Mourning and its relation to Manic Depressive States, in the Selected Melanie Klein, ed: J. Mitchell, Free Press, New York 146 – 174.
Winnicott, DW (1955) The Depressive Position in Normal Emotional Development, British Journal of Medical Psychology, xxviii, parts ii and iii 90 – 99.
Winnicott, DW (1963) The Development of the Capacity for Concern, Bulletin of the Menninger Clinic 27, 4 167- 176.
