Winnicott's therapeutic consultations revisited

Winnicott described in his book 'Therapeutic Consultations' (1971) how a diagnostic assessment of a referred child developed into a fruitful therapeutic intervention when he was able to discover the unconscious fantasy that underlay the child's symptoms. Because these were children who were, essentially, developing normally, he used the word 'knot' to depict the obstacle the child had met. Any conflicts the parents might have were not explored in that context. This work present cases in which child and parents are seen together for the diagnostic assessment. The child's feelings about his world and his difficulties are explored through a variety of techniques including drawings. In the same interview, an analytic enquiry into the parents' history and also their views of the child reveals how the child's fantasies and the parents' past experiences interact and create a mutually reinforcing vicious circle. In other words, the 'knot' involves all of them. If the child's unconscious fantasy can be verbalised and if the parents are able to approach the child in a manner that acknowledges the child's real needs, the 'knot' disappears and normal development can be resumed.