Book Review: "Face-to-Face with Children", Joel Kanter (Editor), Karnac Books, 2004

Reviewer: Lynn Taylor, M.D., Division of Child and Adolescent Psychiatry, University of Arkansas College of Medicine

Journal of American Academy of Child and Adolescent Psychiatry, July 2006

Looking back, my earliest interest in child psychiatry started with my fascination in the richness and depth of childhood experiences. I still have deep impressions of the earnestness and contentment of the jump rope group on the second grade playground. Since I completed my training, child psychiatry has changed a great deal and we have learned much about the relationships between the architecture and functioning of the central nervous system and adaptive behavior and emotional regulation. Still, it seems important that we maintain the connection to the world of children as we integrate newer information into the biological "hows" and "whys" that may well govern them. Face to Face With Children, the Life and Work of Clare Winnicott can help us to that end. Edited by Joel Kanter, this book contains a memoir of this fascinating woman as well as a collection of her works.

Clare Winnicott was a wife, colleague, collaborator, and playmate to Donald Winnicott, the famous pediatrician turned child analyst. Many people will be drawn to this book by their interest in Donald (as I was), only to find their encounter with Clare rewarding and thought provoking in its own right. The memoir provides a fascinating look at the story of these two perceptive and talented individuals, with the good fortune to find each other, set against the uncertainty of Britain before and during World War II. These golden years also saw the intense development of child analytic theory in London, through the works of Anna Freud, Melanie Klein, and Donald Winnicott.

After graduation from the London School of Economics’ course in psychiatric social work, Clare sought work in the "hurly burly of what’s going on in the world" (p. 15). She became involved in the evacuation of children from London during the Blitz, work that changed her life as well as Donald’s:

"Clare’s work with evacuated children in Oxfordshire was the defining experience of her life: not only did she meet Donald Winnicott, her future husband there, but her talents as social worker emerged at a time when Britain was undergoing a change in its child welfare policies and programmes. The work of Clare and others during the war established precedents that altered the course of children’s services for the half century" (p. 14).

However, over the years, Clare’s contributions in the fields of social work and psychoanalysis have been largely subsumed into her identity as Donald’s wife and editor. Kanter believes that at least part of this is because of the straightforward quality of Clare’s writings and lectures. Clare expressed complex analytic ideas in the context of her experiences with children and in plainspoken English, a "clarity that can, unfortunately, be dismissed as common sense" (p. 62). Personally, I found this refreshing and in keeping with the idea of relating to children simply and directly, without sentimentality or the burdens of professional jargon.

Two thirds of the book contains Clare’s collected writings, starting with the problem of homeless children and her experiences in Oxfordshire. Much of the content is relevant today in terms of how to help large numbers of suffering children, often displaced, and with scarce resources. Clare and Donald evolve a system of working together that is reminiscent of today’s treatment team concept. The social environment was conceived of as a potential therapeutic space, a "holding environment" of direct caregivers (foster parents or hostel workers) acting as the "therapists" and treatment team members. Clare put much thought into the fit of the relationship between a child and the primary caregiver working with that child, recognizing that not all caregivers work equally well with all children. She put much importance on the ability of the caregiver to be authentic and mature enough to listen and hear the real communications of the children, going beyond the obvious content. In her way of thinking, when caring for a child, educational background was not as important as the ability to let the child be himself or herself, with all that this implies. This requires a caregiver who can be himself or herself as well. These thoughts are just as relevant today as we grapple with state departments of children and families trying to ensure that children receive the services they need and that the staff receive enough work satisfaction to continue on with their hard work.

Clare Winnicott directs a significant amount of her writing to the qualities and professionalism that allow people to work in these areas successfully. One problem she identifies is the problem of suffering in children and our response to that suffering. In her 1963 essay "Face to Face With Children" (p. 166), she directly addresses our roles and responsibilities to the children we serve. She states that the expression "face to face with children" gives us "no possible loophole for escape from facing the nature of our responsibilities for the children who are our clients. And if I am not mistaken, brings us face to face with our own uncertainties, not only about our techniques but about our role in relation to children" (p. 167).

She suggests that one of the most important things we can do is enter their inner worlds, accept their suffering, and respond in a way that "conveys our willingness to understand" (p. 172):

"It seems to me that in work with children we are really trying to reach the suffering in them arising out of their deprivations and handicaps. Obviously we cannot force children to suffer, and some will not be able to reach this point; all we can do is give them an opportunity to reach it by being able to stand it ourselves and by believing in it. If we do not do this nobody else will and the child will either be left with the burden of it or will develop defences against all real feelings" (p. 173).

With all of our current-day pressures of managed care, brief therapies, and briefer residential and acute treatments, it is easy to lose track of the inner child, solely focusing instead on behavioral problems and outward family conflict. These essays serve as reminders that suffering is real, at times unavoidable, and that human relationships are complex and messy and do not readily fit into neat categories.

Other essays in the book include reflections on Donald Winnicott, his childhood, his life, and his work, as well as the relationship between Clare and Donald. Clare describes Donald as a man of playfulness and vitality. Despite the war and their commitment to their work, their joyfulness and celebration of life is apparent. Her love and respect for him shine through in all of her writings about Donald and his family. Donald grew up in a large active family. His home was safe and secure with much space for play and exploration. The family was financially prosperous. Again, understanding Donald Winnicott’s own relational history deepens our ability to understand his theories and their evolution. In short, the Winnicotts sound like fascinating people one would like to know and have over for dinner.

There are essays on more psychoanalytic topics and specific case material. Examples of these include a description of the treatment of a musician illustrating Winnicott’s theory of the fear of breakdown; a child reunified with a large, possibly overwhelmed family after a prolonged hospitalization for the treatment of polio; a 17-year-old girl in foster care disturbing hostel staff by taking a baby bottle filled with milk to bed with her. Finally, there are essays on understanding the possible motivations for taking on this type of work with children and the professionals’ need for increasing self-awareness to be truly present for the child. This book should be interesting to child and adolescent psychiatrists, developmental psychologists, psychoanalysts, and social workers, as well as readers interested in the response to the problem of displaced children in Europe following World War II. It is well written and organized. The memoir is helpful in truly understanding the context of the original writings. Reading this book inspired me to order several volumes of Donald Winnicott’s writings as well. I truly enjoyed reading it and strongly recommend it.