106. Бессознательное и острые неврозы у ребенка. А. Сольнит (106. The Unconscious and Acute Neurosis in a Young Child. Albert J. Solnit)

Child Study Center, Yale University, USA

Introduction

Although there has been a good deal of skepticism that one can find evidence of unconscious functioning in young children, over the years child specialists have accumulated persuasive evidence about these unconscious phenomena. This interest has also been part of the study about infantile neuroses, a concept that deserves recognition. This interest reflects not only our increasingly refined understanding of psychoanalytic observations and theory, but also suggests an uneasy effort to relate child analysis findings to the childhood experiences reconstructed in the psychoanalytic treatment of adults. Although these efforts at validating the reconstructions are a sufficient basis for our unsatisfied curiosity, there are other significant reasons for clarifying the continuum of human development from childhood to old age.

One obvious reason is the need and urge to be able to predict outcomes in adulthood from an understanding of childhood. Related to this is the quest for preventive influences that will safeguard the healthy development from childhood into adulthood. However, there is yet another reason for these efforts; namely, to deepen our understanding of the relationship between earlier and later development and to more fully penetrate into the powerful ways in which adolescent and adult development activate past experiences as a persistent or altered influence on the appearance and functioning of the adolescent and adult personality.

Freud's classical studies of Little Hans (1909) and of the Wolfman (1909) have had a continuing resonance with subsequent developments in psychoanalytic practice and theory.

In this presentation, I shall focus on clarifying the definition of the infantile neurosis in childhood. I wish to raise questions about the significance of the childhood infantile neurosis as evidence of unconscious conflicts and as a marker of past developmental achievements and difficulties and as an indicator of the child's strengths and vulnerabilities in future development. This window of past and future development is a limited, but useful one, since it offers an assessment of unconscious functioning in terms of the ego's mediating, compromising, synthesizing and defending functions and capacities.

The infantile neurosis was clearly delineated by Freud in his discussion of Little Hans (S. Freud, 1909):

"Let me say in Hans' favor... that he is not the only child who has been overtaken by a phobia at some time or other in his childhood. Troubles of that kind... are extraordinarily frequent... In later life these children either become neurotic or remain healthy. Their phobias are shouted down in the Nurseries... In the course of months or years they diminish and the child seems to recover; but no one can tell what psychological changes are necessitated by such a recovery, or what alterations in character are involved in it. When, however, an adult neurotic patient comes to us for psychoanalytic treatment, we find regularly that his neurosis has as its point of departure an infantile anxiety..." In other words Freud was pointing out:

1) the universality of the infantile neurosis - almost like a phase of development

2) the child's unconscious motives and conflicts are discernable in the infantile neurosis

3) that the infantile neurosis is more frequent than its adult counterpart

4) that not every infantile neurosis is followed by neurotic illness in later life

5) that many infantile neuroses are open to a spontaneuos cure, usually between the phallic-oedipal and latency period

6) that it depends on the experiences of adult life whether the childhood conflicts will be re-activated, i.e. whether a new neurosis will be precipitated.

Anna Freud more recently (1965) has said, "in spite of all the links between infantile and adult neuroses, there is no certainty that a particular type of infantile neurosis will prove to be the forerunner of the same type of adult neurosis".

As described by Anna Freud in her 1970 paper the infantile neurosis can be characterized by the process involved in the formation of neuroses, generally, i.e., "conflict, followed by regression; regressive aims arousing anxiety; anxiety warded off by means of defense; conflict solution via compromise; symptom formation" (A. Freud, 1970). For many analysts this process of the formation of the infantile neurosis is regarded as reaching a level of crystallization in the phallic-oedipal phase when the unfolding of the personality has reached a level of structuralization and dynamic functioning that characterizes the neurosis, at least as it is conceptualized in its adult form. To put it somewhat more pointedly, until the oedipal period, the degree of identification that is necessary for internalizing conflicts (i. e. unconscious conflicts) is not considered sufficient by many psychoanalysts to infer that the conflicts are intrapsychic rather than between the child and the outside world. In this view, struggles between instinctual wishes and opposing forces are not considered pathogenic until the child has entered into the phallic phase of infantile sexuality. I believe the patient I will describe today will raise serious questions about the validity of this assumption about crystallization.

Before presenting the case it may be helpful to again point out thatl am exploring the concepts of the child's unconscious and the infantile neurosis for the understanding it sheds on normal and abnormal child development - not as a model for adult neuroses.

Cases from the Journal of the American Psychoanalytic Association

We regularly expect that aggression in the second year of life is in advance of the dawning ego's capacities to transform or curb this maturational unfolding or influx of aggressive energies. Temper tantrums, independent motility, and the reluctance to go to sleep are empirically noted as regular features of this period.

A 16-month-old girl, Sara, the second child of affectionate sophisticated parents, had an excellent, steady development. She was walking, talking in phrases, teased a good deal, and had shortlived temper outbursts when she was frustrated. Her mother was pregnant during the period being described. Despite her father's usual gentle admonishments as he held her, she would often not let go of his spectacles, which she pulled and dropped. On one occasion she gleefully threw his glasses to the floor and the father became irritated. He spoke to her sharply and tapped her wrist to make his point. She let go of the spectacles and cried in a heartbroken fashion. That evening she refused to lie down and go to sleep. The next day she and the parents were exhausted. The father recognized the likelihood that his response to his daughter's teasing had precipitated this anxiety state. He consulted with a child analyst and under her supervision helped his daughter overcome her acute neurotic reaction.

This illness, its structure and dynamics, could best be understood and analyzed through the analysis of a dream that our charming little patient, Sara, told her father one day after the teasing encounter. In the dream a big black bird hurt her in the tummy. She told him and her mother that a big black bird would hurt her if she lay down to sleep. Over the next few weeks, it became clear as she played and talked about the big black bird that she felt overwhelmed by her father's aggressive outburst and by her own angry response and aggressive feelings toward her beloved father. She feared going to sleep manifestly because of her fear that he would attack her, but even more because of her impulse to attack and destroy her beloved father, with the notion that such a feeling would magically become realized if she did not remain awake and vigilant. The fear of retaliation was also involved. This can be seen most clearly about two months after her "psychoanalytic" treatment began, when she told her father that he was a big, black bird. She giggled and playfully began to attack him with her hands clawed and with a grimacing chewing movement of her mouth and face. Then she told him he was all right and hugged him. He told her that he was all right and wouldn't let the big, black bird hurt him or her. She was pleased and relieved, and for the first time since the outbreak of her anxiety she was able to go to bed and fall asleep without being in her mother's or father's arms.

It became a family joke that the father was a friendly, protective, big, black bird who was very attentive to his daughter's interests. She treated him playfully, at times, as though he were her powerful servant, to do as she ordered. As Anna Freud said "-experience has taught us that the beginning of treatment, immediately after the appearance of trouble will shorten the duration of treatment by several months" (Anna Freud, 1958, p. 99).

I shall present one more brief clinical illustration. Tommy, three-and three-quarters-years old, was referred for psychoanalytic treatment because of depressed behavior, stuttering, bowel retention, and persistent thumb sucking in the treatment, it became evident that his mother's inability to limit or regulate Tommy's aggressive strivings had reached the danger point when she had a spontaneous abortion at home in Tommy's presence. His inhibited, regressive behavior was his reaction to the fear that his angry destructive impulses toward his mother had culminated in her bleeding away a new baby into the toilet. In the psychoanalytic treatment this notion was played out and discussed, as Tommy perceived and experienced it when he was three- and-a-half years of age. The context for these reactions included Tommy's devoted parents , who tacitly encouraged the child to do whatever he liked by treasuring his impulsive behavior and expecting him to set his own limits. He became anxious and precociously obsessional as a result of this background.

In the treatment and through discussions with the parents it became clear that Tommy's fear of the magic power of his unconscious, sadistic impulses had evolved into his strong feeling that any aggressiveness on his part would result in the permanent loss of his beloved mother. As this was worked through in his psychoanalytic treatment, he showed the first evidence of recovery in his nursery school, where he built enormous block structures and experimented with crashing them (much excitement) and rebuilding them (sober, hard-working).

There is increasing evidence in the psychoanalytic treatment of children with severe learning difficulties that these are conflicts involving aggressive impulses. There is a preoccupation with fantasies representing unacceptable or dangerous impulses and wishes, especially angry and aggressive representations, that are associated with the block to learning, to studying. In the school- age child the continuation of the feelings of magic potency attributed to anger or aggressive strivings, as illustrated in Tommy's case, commonly leads to the fear of knowing. Such children are afraid that they will not be able to separate one kind of knowledge (the safe kind) from the other kind of knowledge (the dangerous aggressive stirrings, etc.). All knowlege and learning are then equated with the fearful realization of unacceptable aggressive impulses; therefore, aggression is warded off by regressive and inhibitory mechanisms, leading to a massive inhibition against all formal learning.

Discussion

The observations and treatment of these two children can be used to examine one aspect of child development as viewed through psychoanalytic constructs and treatment. The impetus for this presentation stems from certain formulations of Ernst Kris about child development. In 1950, Ernst Kris stated:

"There seems to be wide agreement that the psychoanalytic study of child development would fill an urgent need, might usefully function as the center of integration of various approaches, and promises the only way to answer the questions with which we are all occupied, questions in which the problem of prevention is omnipresent. Let me here list some of them: How soon can we, from observational data, predict that pathology exists in a given child; how soon can we spot it from the child's behavior, from that of the family unit, or from the history of mother and child? Which therapeutic steps are appropriate to each age level and its disturbances, or to each typical group of disturbances? The problem of diagnosis and indication requires constant refinement; the severity of one isolated symptom does not lend itself as indication for therapy (ubiquity of infantile neurosis). The self-healing qualities of further development are little knoun. How much can latency, prepuberty, or adolescence do to mitigate earlier deviation or to make the predisposition to such disturbances manifest?"

In the past 15-20 years, we have had opportunities to examine characteristics and effects of psychological trauma in early childhood and its unconscious reverberations. In this report I focus on vicissitudes of infantile neurosis, which can be described as a stage of unconscious consolidation of a symptom or reaction pattern that can be resolved or which may be difficult to influence by treatment or/and education. This is one way of stating explicitly what experienced clinicians consider or question when they try to gauge the impact of neurotic reactions on and the urgency of treatment for a young child. A crucial indicator of seriousness and need for special treatment or education is the degree to which the unconscious conflicts and motivations are dominant in determining the child's attitudes, moods and behavior.

It is generally agreed that therapeutic assistance immediately after the appearance of the neurosis is most effective in preventing a continuing disturbance. However, once a pathological reaction or reaction-pattern, such as stuttering, is established in early childhood there is a consolidation period, during which time the symptoms and reaction-patterns become increasingly un-consciously linked with aspects of the instinctual and ego development that were originally relatively conflict-free. During the pre-oedipal period, depending on the child's constitutional equipment and on the characteristics of his experiences, the pathological unconscious reactions may invade various aspects of ego functioning, or may be restricted to a particular area such as speech, motility, bowel activity, or impairment of the capacity to play. However, the main pathological reaction pattern maybe quite plastic and can still be influenced by treatment, education and by changes in the environment, depending on the degree to which the neurotic reactions to trauma have become fixed.

When the child reaches a point in his development where one can speak of the resolution of the oedipal conflict, there is a consolidation of the personality in terms of ego development. It is a consolidation associated with the emerging infantile amnesia, i. e. when repression leads to the conscious memories becoming unconscious. At this time, certain patterns of reaction, normal and pathological, tend to become well established regardless of whether they arose out of unconscious conflict or were conflict-free in their inception. Clinical experience suggests the question, do many symptoms and pathological reaction patterns become consolidated at the time of the resolution of the oedipal conflict and in a certain sense become unconscious and "autonomous", (i. e. independent to some extent of the conflict out of which they arose)?

It is very likely that this formulation is especially pertinent for the distortions or disturbances of certain ego functions that have been impaired by trauma or deprivations at the time of their emergence in the pre-oedipal period (e. g. Tommy's speech). These disturbed functions become temporarily or partly linked to other aspects of the developing ego and its functions and may secondarily attract conflictual reactions other than those from which the symptoms arose. For example, in Tommy's case it appeared that thinking and remembering could be significantly influenced by a continuing speech difficulty. In fact, his continued social passivity and school learning problems that were noted when he was 8 and 11 years of age became the basis for having further treatment. Thus, at the time of the resolution of the oedipal conflict the pathological ego functions that have not yielded to development, education, or treatment will tend to become consolidated and repetitive, no longer being as fluid and as responsive to education, therapy or "developmental healing" (This refers to the compensatory and mitigating mechanisms that progressive develop ment ordinarily makes available to children) as during the pre-oedipal period. This seems particularly true of certain psychosomatic reactions in which the child utilizes the body as an essential tool for the expression of neurotic reactions.

It would appear that stuttering, bowel retention, tics, enuresis, certain types of physical awkwardness or poor athletic skill and certain inhibitions of the aggressive strivings that stem from the unresolved unconscious conflicts and trauma in the second year of life are likely to provide examples of this concept.

In Freud's "Inhibitions, Symptoms and Anxiety" (1925), he attributes neurosis to three factors - biological, phylogenetic and purely psychological. The biological factor is described as the long period of dependency and helplessness of the human infant which "is sent into the world in a less finished state", intensifying the "influence of the real external world" upon the infant and thereby promoting an early differentiation between ego and id. The pervasive psychological need for the protecting maternal object rises out of this biological condition which is magnified by risks or potential dangers of the external world when one is born into it in a helpless state.

The phylogenetic factor develops out of the biphasic characteristics of psychosexuality. Due to the eariy differentiation of ego and id most instinctual demands of infantile sexuality are treated by the ego (representing the demands of the external world, especially those of the parents), as internal dangers to be fended off. Later sexual drive derivatives are at risk of "following these infantile prototypes into repression", of not being ego-syntonic.

The psychological factor consists of that "imperfection of our mental apparatus", the differentiation into an id and an ego, ultimately due to the influence of the external world. The pressure or demands of the external reality make the ego guard against certain drive derivatives and it treats them as dangers or trends to be avoided or warded off into the unconscious.

Following Freud's assumptions of three factors that tend to lead toward the inevitability of neurotic development in early childhood, and assuming that this does not make inevitable the adult outcome, we can view the ubiquity of inner, i. e. unconscious, psychic conflict in early childhood as characteristic of the species. This enables us to analyze and understand the large varieties and degrees of neurotic development in early childhood - from the relatively silent ones to those that become deeply patterned, as in Tommy's case. With these assumptions to organize our observations and to sharpen understanding of nodal points in the life history of each child, especially in interaction with his or her parents we are better able to identify vulnerability in the child, risks in the environment and immediate future and the likelihood of neurotic development and functioning in later life.

References

1. Freud, A. (1958), Child observation and prediction of development: A memorial lecture in honor of Ernst Kris, The Psychoanalytic Study of the Child, 13:92-116. New York: International Universities Press.

2. Freud, A. (1971), The infantile neuroses, The Psychoanalytic Study of the Child, 26:79-90. New York: International Universities Press.

3. Freud, A., H. Nagera, and W. E. Freud (1965), Metapsychological assessment of the adult personality, The Psychoanalytic Study of the Child, 20 9-41. New York: International Universities Press.

4. Freud, S. (1909), Little Hans, Standard Edition of Complete Psychological Works of Sigmund Freud, Vol. X. London: Hogarth Press, 1953.

5. Freud, S. (1925), Inhibitions, Symptoms and Anxiety, Standard Edition, 20:77-175. London: Hogarth, 1959.

6. Kris, E. (1950), Notes on the development and on some current problems of psychoanalytic child psychology, The Psychoanalytic Study of the Child, 5:24-46. New York: International Universities Press.