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Comments by Anna Freud

Unveiling of Commemorative Plaque

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In a recent paper on “The Role of Bodily Illness in the Mental De­velopment of Children” (1952), I stated with regret that professional workers have hale opportunity to follow without interruption what hap­pens in a child’s mind during the complete course of an illness. I attrib­uted this to our present conditions in child care when doctors and nurses lose touch with their patients when they recover, while teachers, child-therapists or analysts do not meet their charges when they are ill. There remain only the mothers who see their children in both health and illness and in the transitional states between them. But mothers, as I said then, are bad observers at such times, preoccupied as they are with their own anxieties and with the task of nursing.

It is this latter statement, which I want to withdraw after reading Joyce Robertson’s account of her four-year-old daughter’s tonsillectomy. This mother’s outlook on her daughter’s inner experience remained objective during all the intricacies of the child’s disturbed, occasionally negative, at all times highly exacting behaviour. She never lost touch with the underlying trend of affect by which the child’s reactions were deter­mined and to which her own responses were directed. In following her account we are presented therefore not only with an interesting descrip­tion of a small girl’s behaviour under the stresses of operation and hospitalisation but also with a convincing and consistent report on the inner struggle between the anxieties which were aroused by the expe­rience and the infantile ego’s attempt at dealing with them.

From the first part of the diary, which covers the preparatory period we learn that Jean confirmed almost all our theoretical expectations of what operation and hospitalisation may mean to children of her age. There was, in the first instance, the threat of the anaesthetic, conceived by the child as an oral attack against which she defended herself by a refusal of oral intake. Only the quick understanding and interpretation from the mother’s side interfered with more permanent displacement of this phobic attitude onto food, prevented symptom formation and rendered the child amenable to a rational discussion of the danger situation. Separation anxiety arose next with which the mother could deal by reassurance since she had permission to accompany the child to hospital. Next came castration fears, centred around the frightening image of a body hole. Again, Jean had recourse to a phobic defence which made her reject temporarily the use of knife and fork and eat with her hands, an attitude which changed almost immediately to the active use of knives. Jean placed herself in the role of surgeon and operated tentatively on herself. Alternating with this identification with the aggressor, she turned aggression outwards, against members of the family, furniture, etc. Death fears and the fantasy of being robbed of body content (blood) were mobilised next on the id side. To these the superego added an equally frightening moral version of the impending dangers in which the hospital took on the aspect of a prison, the surgeon that of a policeman, and the operation was turned into a major punishment. The anxieties from these sources which flooded the child’s mind produced in manifest behaviour an increased demandingness, irritability, uncooperativeness and indiscrim­inate aggressions toward the environment (cutting and shooting). Conversely there appeared also a certain measure of accident proneness and self-injury, the defences regressing increasingly toward primitive types (psychosomatic symptoms, temper tantrums) as the date of the operation drew near. In the last days of waiting, denials of external reality and internal feelings were most prominent: children are not killed, they have not gone to hospital, hospitals are nice places where children wear their party dresses, where they want to stay for ever. Jean’s final protest against going to hospital may be regarded as belonging to the same defence, i.e., less as a refusal to cooperate than as a vehement denial of her sense of helplessness and impotence to do so.

With the operation accomplished the diary presents a very different picture of Jean’s state of mind. We find the diffuse anticipatory anxieties swept away and the child more concerned with the reality aspects of the situation. Even the actual sight of her own blood did not revive her former fantastic anxieties and left her unafraid. What disturbed her most at this time was the interruption in conscious experience caused by the anaesthetic. Apparently this connected with some unconscious fantasy of passive surrender to attack. She reacted with a “barrage of questions,” i.e., an insatiable demand for reassuring details which might serve to fill the gap. One can well imagine another child answering to the same expe­rience with a phobic attitude toward sleep as the state of unawareness in which “anything might happen.” Further, there were the indications of a proprietory and positive attitude toward the hospital and staff which so many children manifest after medical or surgical interventions; in Jean’s case this well-known passive-masochistic trend was tempered by an ag­gressive retaliating wish (hurting the nurse who had hurt her). A heightened impatient irritability on the morning before leaving hospital may well have been due to the child’s disbelief in the promise of release.

In the three weeks after their return home, the diary shows how mother and child dealt with the emotional aftermath of the operation. Unlike children who have been to hospital on their own, Jean showed no excessive clinging to the mother. An exception to this was bedtime when —contrary to former habits—she refused to be left alone. We may ascribe this difficulty to the prolonged fear of the passive experience of anaesthesia, which leaves her suspicious of sleep and increases—at this time only—her infantile dependence on the mother’s presence.

There is, further, the interesting incident when Jean decided to dis. card her cut-out tonsils. Here, the reader is reminded of similar infantile behaviour during toilet training when children find it easier to be active themselves in throwing out their own highly cathected body products than to be deprived of them passively. One concludes that Jean’s mother had used the device in earlier years of allowing the child to empty her own pot.

Another interesting characteristic of the postoperative period was the marked increase in Jean’s ambivalence toward her mother which reminds us of an infant’s primitive distinction between the “good” and the “bad” mother.⁴ At this time Jean saw her mother actually in a double role, as her protector against danger as well as the person responsible for delivering her to danger. Accordingly, gratitude and anger, love and hate, appeared in quick succession in her conscious feelings, causing difficult and unpredictable behaviour. This regression in the relationship to the mother also reawakened the primitive anxieties and, with them, some of the defensive behaviour of the preparatory period.

On the other hand, with the operation safely behind her, Jean showed herself less overwhelmed by her anxieties than she had been before and better able to cope reasonably with some of the undigested memories of her hospital experience. She returned gradually to more cooperative and independent attitudes with the need for constant reassurance markedly diminished. The emotional relapse after an interval of two months, although bearing witness to her prolonged vulnerability, also provided an added opportunity for working over and assimilating the experience.

While following the sequence of happenings in Jean’s mind, we cannot help speculating how she would have dealt with the events if— as happens to most children—she had been less well understood, or among strangers, and deprived of help and support at the critical time. As it was, her battle between id anxieties and ego defences was played out against the background of her mother’s reassuring presence. There was in the child a constant urge to distort and magnify external danger situations and use them as representations of internal threats. This was met by the mother’s equally constant, tolerant and understanding be­haviour, which served to undo the distortions, to separate fantasy from reality and, thereby, to reduce the quality and quantity of anxiety to levels with which the child could deal. That she accomplished this with­out falsifying the unpleasurable aspects of reality is greatly to the mother’s credit.

Mrs. Robertson’s account of Jean’s tonsillectomy seems to me an in­structive contribution to our psychoanalytic studies of small children, not diminished in value by the fact that her observations were carried out in the original setting of the child’s life and relationships instead of in the analytic setting as we construct it artificially to provoke the repetition of internal events before the analyst’s eyes and in the transference rela­tionship.

In her role as mother, Mrs. Robertson kept her account strictly within the limits of her own child’s experience and refrained from generaliza­tions. As analytic readers, we may permit ourselves to go a step further and extract from her study some points of general validity. There are, in my opinion, two main respects in which the foregoing description con­firms and illustrates our knowledge of the working of a child’s mind.

First is the fact that a young child’s emotional balance is shown here to be no more than a matter of quantities, i.e., a function of the relation of strength between the id and ego forces. Anxieties are mastered by the ego while they remain below a specific threshold. They become patho­genic, creating neurotic symptoms or behaviour problems when they rise above that level, that is, when the defences are overtaxed or overthrown. If the ego is successful in its mastery of anxiety, the child feels encour­aged and relieved. Progress within the province of the ego has been achieved and a potentially traumatic event has been transformed into beneficial and constructive experience, as it has happened in Jean’s case.

Second, there is ample confirmation in Mrs. Robertson’s account that it is not the external danger, real and serious as it may be, which accounts for the traumatic value of an experience. Injections, loss of blood, sur­gical interventions, etc., are shown to remain manageable events unless they touch on and merge with id material which transforms them into experiences of being assaulted, emptied out, castrated or condemned.

When looking at the two aspects of Jean’s fears, one is tempted to reopen an old theoretical controversy, which has been neglected by analysts in recent years; I mean the question whether the phenomenon of “real” anxiety exists at all. Most analytic authors insist that, by the working of our mind, external danger is inevitably and automatically transformed into internal threats, i.e., that all fear is in the last resort anxiety with regard to Id events. Personally, I find it difficult to subscribe to this sweep­ing statement. I believe in a sliding scale between external and internal threats and fears. What we call “courage” in ordinary language is, I be­lieve, no more than the individual’s ability to deal with external threats on their own ground and prevent the bulk of them from joining forces with the manifold dangers lurking in the id.

It is this last consideration, which may help us also to assess the nature of the mother’s achievement in Jean’s case. Mrs. Robertson helped her child precisely in this way: to meet the operation on the level of reality, to keep the external danger in consciousness to be dealt with by the reasonable ego instead of allowing it to slip to those depths in which the rational powers of the ego become ineffective and primitive methods of defence are brought into action.

Child analysts and therapists may wonder where, with a mother of such rare insight, her province ends and theirs begins. I suggest the fol­lowing answer. Mothers—unless specially instructed and guided to do otherwise—should, as Mrs. Robertson has done, limit themselves to assisting the child’s ego in its task of mastery, lend it their strength and help to guard it against irruptions from the id. Analysts work in the opposite direction. Under carefully controlled conditions, they induce the child to lower his defences and to accept the Id derivatives in con­sciousness. The contact with the Id impulses, which is obtained thereby is used then to effect a gradual transformation of these strivings to which all neurotic anxieties and symptoms owe their origin.

4 See Melanie Klein.

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