Psychotherapy

Volume 24/Spring 1987/Number 1

ADDICTION, AFFECTS AND SELFOBJECT THEORY

L. GUY CHELTON FACE Centers, Atlanta, Georgia Addiction represents a means of inducing certain affects and intense feelings for the purpose of reestablishing or maintaining a cohesive sense of self when that self is threatened by loss of continuity. It is a temporary reconstitutive affect system, acting as an affective prosthetic to shore up a fragile self state. The addiction system fails because it is regressive and isolates the individual from necessary current self-enhancing relationships, particularly with a peer group. The need for peer groups in treatment is essential.
As a leading cause of human misery, addiction is far more frequent than previously believed. Addiction is defined here in a new way which identifies many more addiction syndromes, other than chemical, and could provide major treatment implications. The data for the generalizations and theories expressed in this article have been derived over almost three decades of close observation and treatment of patients with psychosomatic illnesses and addictions. Individuals with an addiction use a certain behavior pattern or activity that has become socially, physically, or psychologically harmful to them, and they use it repeatedly and persistently. They seem unable to cease the behavior no matter what the risk or cost to them or others. They feel desperately in need of the activity and cling to it in an increasingly pathological way. Attempts to interfere with the addiction are frequently met by intense feelings of helplessness, hopelessness, meaninglessness, and reactions of withdrawal, denial, and rage.
Reprints may be ordered from L. Guy Chelton, M.D., 17 Dunwoody Park, Suite 113, Atlanta, GA 30338.

WARREN C. BONNEY The University of Georgia

Currently there are many treatment centers for alcohol and drug addiction (substance abuse), and many do an excellent job of helping the addicted individual give up the use of chemicals. Primarily, the centers utilize principles of the Twelve-Step approach, originated and proven effective by Alcoholics Anonymous {Alcoholics Anonymous, 1939). The peer group is the central focus of treatment, and professionals act as facilitators and guardians for the treatment. The involvement of the family in the treatment is important, and adequate aftercare with Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, and other similar self-help groups is often mandated. The Addictive Process Any behaviors of repeated use to generate diffuse sensations and intense affects and feelings which help maintain order and continuity in the sense of self (aliveness, vigor, psychic cohesion, and calmness) could be said to be potential addictions. This may be the ingestion of certain chemicals or the use of our physiological processes (and sensations). These behaviors are ubiquitous and need not become pathological (addictions) until a set pattern develops and persists even though risk and harm ensues. In these instances, the set patterns eventually exclude most other healthy means of maintenance of a cohesive, vigorous self. Most important, the addiction isolates the individual from necessary and legitimate dependence on others for healthy validating, confirming, idealizing, and calming interaction, which usually takes place in a to-and-fro manner with a group of peers. Therapeutically it is not difficult, with the use of empathy, to feel the desperation of addicts, to feel, sometimes, the nothingness within them; to experience with them their loss of aliveness and continuity of self. Kohut & Wolf (1978) refer to an understimulated self state. In this state, addicts are lacking in vigor and stimulation, having no goals or meaning in their lives. At other times, they feel fragmented and anxious and in need of

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soothing and calming. The psychic functions which have to do with the internal regulation of feelings of continuity and cohesion of self, with self-esteem and meaningful goals, with modulation of affect and maintenance of ideals are overwhelmed either because they were originally deficient for ordinary external circumstances or because external stressors have become too great. The effect of the addiction itself produces regression and further loss of function of any existing internal regulatory structures. Many physiologic processes produce changes in monoamine systems, neurochemical systems, or hormonal systems and may be used to produce intense sensations, affects, and feelings by internal biochemical manipulation of the brain and assist in the maintenance of a sense of aliveness and self-cohesion. Certain chemicals, such as alcohol, are really external sources of biochemical manipulation of the brain and produce affects and feelings of a similar nature, but it is likely that chemicals are less frequently used for this purpose than our own physiologic functions, which are always so available to us. In many individuals, for example, the use of the sensations, affects, and feelings related to the eating process, that is, tasting, chewing, smelling, swallowing, fullness, and so on is or may be helpful on days when severe blows to self-esteem are experienced. When this activity is used secondary to a relationship with others, and as only one of a number of ways to modulate affect or help with maintenance of self-esteem, it does not become an addiction. When eating or drinking is done with others and the human relationships used as legitimate sources of validation and ideals, healthy constructive dependencies may occur and not destructive, unsatisfying addiction. Eating Disorders as Addiction In developing an outpatient program for eating disorders, the author (L.G.C.) was able to observe these abovementioned processes used in an addictive manner. Bachmann & Rohr (1983) have pointed out that therapies for psychogenic eating problems have neglected to include the addictive aspect of the illness. In anorexia nervosa, bulimia, and in many cases of obesity we see the addictive use of these powerful sensations as intense, archaic stimulators and soothers in a set pattern or system on which the individual desperately attempts to rely to maintain cohesion and continuity in a fragile self. The "high" produced by anorexia nervosa by the phenomenon of starvation, probably through both biochemical and psychological change, is easily observable. The biochemical relationship to anorexia nervosa has been experimentally supported (Kaye et al., 1982). Bulimics and other addictive overeaters speak of similar intense hyperphoric states related to various aspects of the eating process, including fasting and purging. The feelings produced seem to reactivate the experience of a safe yet stimulating early relationship with parental figures, which gives hope of possible further development and provides a temporary, fleeting sense of self-cohesion and vigor. The addictive affect system comes into play because of a reactivation of an underlying intense feeling of abandonment when seeking important peer relationships. One consistently hears from patients with eating disorders and from other addicts the pain of being unable to fully share in the affairs and activities of a cohesion peer group. That important step from parent to peer group for the fulfillment of legitimate self-enhancement needs seems so difficult or impossible for addicts to make. Even in a group these patients tend to develop intense, transference-like, one-to-one relationships which may secondarily become destructive to the group. The addiction in eating disorders, as with any addiction, is ultimately a failure in its attempt to produce self-cohesion and self-development because it represents a regression. The affects and feelings alone without current direct connections with human relationships are only a stopgap measure and do not provide the human empathy and understanding needed for further self-development. Varieties of Addictive Expression Other examples of physiologic processes, which produce intense sensations, affects, and primitive feelings, include sexual activity. Sexualization for purposes of stimulation of a dead self is frequent and addictive. In general, so-called masochistic behaviors of all types are probably more often the result of the desire and need to stimulate, even through pain, affects which will counter deadness and nothingness. They can be seen as the outgrowth of a motivation to be alive (self-cohesion enhancing) rather than a desire to be dead (selfdestructive). Behaviors such as promiscuity, exhibitionism, or voyeurism, seem to be sexualized attempts to fulfill nonsexual stimulating and calming self-needs, that is, mirroring, twinship, and idealization, which are necessary to help maintain a cohesive sense of self. Intense muscular exercise is well known to produce its "high" and to counter

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feelings of fragmentation and depletion and, as is becoming clear, has an addictive aspect. Cerebral functions may be used to deal with feelings of self-depletion and emptiness, as seen in intellectualization, forced thinking, obsessive ritualistic behavior, and the creating of real or fantasized risk taking or crises. Examples of the latter are gambling, thrill seeking, and delinquency. These activities generate intense feelings and may become addictive. Consider, for example, the intense feelings of aliveness, the "rush," produced by being in a strange house, in the dead of night, with robbery in mind. Some forms of hypochondriasis appear to demonstrate the use of thinking to stimulate primitive fears and dreads regarding loss or fragmentation of self as an actual attempt to prevent depletion and deadness. We may respond to the threat of loss of the psychological self by using archaic fears of failure to survive physically, which in turn provides affective stimulation and, at least temporarily, relieves the pain of a meaningless self (self-depletion). In addition, it frequently results in the reassuring concerned attention of physicians, nurses, and other parental figures. It seems to promote an expectation of empathy (as from an early parent-child relationship). Rage, with or without physical aggression, is frequently used as another primitive affect-feeling system to maintain the sense of self and may also become an addiction. Perhaps many cases of hyperactivity in children and adults arise from the need to provide constant novel and stimulating situations to prevent the experience of a dead self, and, in this sense, is addictive. Smoking is a complicated addiction dealing with many factors other than the role of nicotine. Affects and intense feelings produced by respiratory behaviors, such as the use of sighing and deep breathing to relieve tension and to relax, is known to us all. We would like to suggest that the seeing of one's breath, that is, the proof that one is breathing by the sight of smoke, is a profound reassurance that one is alive. The awareness may be helpful to certain self states, which include feelings of intense deadness and apathy. It could be a confirming, mirroring experience. It is interesting to note that most smokers agree that smoking in the circumstance of the deprivation of light, where the smoke cannot be seen, does not appeal to them. Of course, smell, taste, and other oral stimulation must also be a part of the induction of the affect system in this behavior. Two empirical observations that have aided us in the study of addiction syndromes should also be mentioned. First, many of our patients have more than one syndrome. For example, an alcoholic may also be a gambler and have an eating-process addiction. An anorexic or bulimic is also commonly addicted to exercise, alcohol, and, frequently, to shoplifting or excessive spending as well. Obviously, the principle of cross addiction is not limited to chemicals only, as it has been understood in the past. Of course, this points in the direction of a basic underlying disease of addiction with varied manifestations. Second, many of us have observed some relationships between people which can only be described as addictions. That is, the primary purpose of the relationship itself is to produce affects which tend to shore up a fragile self, but which isolates the individual from a legitimate peer group relationship for healthy mirroring, twinship, and idealization needs. It becomes restricting and preventive of growth and development and reactivates intense feelings from early in life, as in the case of other addictions. It is clung to desperately and yet is greatly resented. This may begin in many patients in childhood with the failure of a safe transition from parents, for maintenance of a cohesive vigorous self, to the peer group as the chief helper in this process. Before going on to genetic-dynamic considerations, we would like to stress again the differences between the healthy and necessary use of certain physiologic processes mentioned above, with the abuse and overuse of them in an addiction. For example, eating for the maintenance of life and health is far different from the use of the eating process in a desperate attempt to relieve the agony of a crumbling self. Exercise for the purpose of maintenance of health and improving function is just as easily separated from the excessive use and abuse of exercise for the stimulation of a dead self. Genetic-Dynamic Considerations Many of the behaviors described above would be termed compulsions by drive-defense theorists (Freud, 1953/1974; Hartmann, 1964; Kernberg, 1976). But it seems to us that the central problem in addictive disorders is related to self cohesion and psychic order, that is, psychological survival and early psychic development (and the development of internalized regulatory functions related to mirroring, validating, and calming), not to con-

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flict pathology (drive derivatives and defenses against them). Compulsion indicates forcea drive. The driveness in an addiction is more an intense need related to the failure of a developmentally needed important relationship. It is an intense clinging rather than a force; perhaps, a pull instead of a push. The addict believes that the loss of the addiction cannot be tolerated and that survival depends on the behavior. Indeed, the addiction has been used as an attempt to substitute for, or provide, that parental relationship which failed and was needed for further psychic development to take place. The psychoanalytic psychology of the self places self-selfobject relationships at the center of the psychic development and views drives as fragmentation products resulting from failures in those relationships (Kohut, 1977). A selfobject is defined as another who is perceived as part of the self and performs important functions involved in the development and regulation of a cohesive reliable sense of self over time and in space. The basic self-needs of mirroring and idealization are seen as clustering around the two poles of a bipolar self and representing, respectively, the grandioseexhibitionistic pole (ambition and goals) and the pole of ideals. Skills and talents occupy the intermediate area, and their appropriate development and use depends on a vital energizing connection between the two poles. Selfobjects, through empathic responsiveness, supply the basic needs stated above and are necessary in one form or another throughout life. As total empathic responsiveness is never possible, selfobject empathic failures occur, and if these are not massive and traumatic the selfobject functions will be internalized and made a unique part of the self. This process is referred to as transmuting internalization (Kohut, 1977) and results in the development of psychic structure. As self-development proceeds, selfobject need becomes less archaic, less concrete and person-represented, and more abstract and idea-represented. An addiction seems to reactivate affects and positive primitive feelings from the matrix of an archaic self-selfobject relationship which pridefully validated and confirmed, yet soothingly encouraged, further progress and self-development. This seems to be an attempt to re-create the healthier selfobject matrix which existed just prior to the traumatic selfobject failure so that further psychic development could take place. The addiction may be looked at as though it affectively repairs a serious empathic break with an important developmental selfobject and brings the hope of experiencing a different, more helpful selfobject response. However, this is an illusion (a ghost selfobject), and the comforting, encouraging affects and feelings are not the result of a current relationship with a human selfobject and never can truly supply empathic responsiveness and optimal frustration. In fact, the very nature of the addictive process further isolates the individual from current relationships with others. Peer-group involvement is made even more difficult to achieve, and appropriate mirroring, twinship, and idealization needs cannot be fulfilled. At what developmental step does the consistently faulty self-selfobject relationship occur? It appears to be that stage of development when children assertively make their move to give up their parents) as their only resource for self-enhancement and selfobject needs and move to other selfobjects for a broader, more developmentally effective set or series of resources. In the new scheme, the parent is included, but never again will have the level of importance as before. Peers and peer groups become more central in the child's psychological development. If the parent's own selfneeds are counter to this and the developmental process is resisted and discouraged by the parent, the child may not have the necessary selfobject support to take the step. The connection between parental attitudes and addictions is succinctly summarized by Kohut (1978); "Thus, in asking the crucial question concerning the factors in childhood that lead to the addiction-prone personality, we will say that, in the last analysis, and within certain limits, it is less important to determine what the parents do than what they are" (p. 850). At this phase of incomplete development of internal structures for self-validation, the child feels abandonment because of the selfobject withdrawal with resultant depletion and/or fragmentation of the self and regresses back to a former relationship with parental selfobjects and the reassuring affects arising from that level of development. As this is not a healthy situation for further development and causes serious harm but is persisted in for the purpose of maintenance of a sense of self, it is an addiction. The children become addicted to their parents (and the parents to their children). The addiction may continue throughout life by transference and displacement to spouses, therapists, and others, and to chemicals

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or the use of bodily sensations and physiological processes in the attempt to produce reconstitutive affect-feeling systems. Although we spoke of a relationship with parents that is reassuring, it is far more complex than that. The healthy need is for it to be reassuring from the standpoint of calming or modulation of affect, but also it needs to be stimulating from the standpoint of the prideful but careful risk taking involved in a forward step into strange territory. The locus of difficulty varies along the continuum of the move from parental to peer-group relationships. By empathic communication with the affects, feelings, and emotions of addicts, one can identify their frustrated need for the feeling of calm risk taking and the excitement of advancing alone in their personal growth with the calmness that accrues from an encouraging, reassuring selfobject milieu. The addict has not completed the process. Emotional abandonment by the lack of soothing and encouraging responses on the part of archaic selfobjects at this point is frustrating to a traumatic degree, and transmuting internalization of these functions cannot take place. Joyfully modulated excitement and risk taking may become excessive risk taking or fear of even minor risks (phobias) and the need for excessive use of a calming affect system occurs as well. It is understandable, then, that the individual may search for a risk or stimulation to feel a sense of aliveness and create an illusion of forward movement but be unable to modulate these affects, thus increasing the already existing need for calming. This may be done by the use of certain chemicals or by the use of sensations and affects arising from the eating process or other sense organs and physiologic processes. The Role of the Transitional Object The terms transitional object and transitional phenomena were first introduced by Winnicott (1953) and elaborated upon in later publications (1971). Winnicott was fully aware of the importance of the phenomenon in the process of separation-individuation and the developing capacity of the child to distinguish between internal and external reality. Tolpin (1971) has helped to clarify many aspects of this subject, and most writers seem to feel that it is a helpful phenomenon. We would like to suggest that its use by the infant during the stages of moving away from the maternal selfobject is for the purpose of helping to make an optimally frustrating experience out of one which may be frustrating to a traumatic degree so that transmuting internalization of certain selfobject functions may take place. When observing a child using his or her transitional object, one is struck by the trance-like withdrawal from parental selfobjects that occurs and the apparent soothing and calming nature of the child's affective experience. How the parent experiences this phenomenon and responds to it must have great significance to further developmental progress. If the parent is using the child inappropriately to maintain the self, it may be felt as a competitive threat, that is, the loss of control of a needed selfobject. Also, the parent may feel, at some stages of the child's use of the transitional object, that the child should be more advanced in development. This may occur if the parent needs the child to live out and mirror the parent's own grandiose needs. For whatever reason, if the use of the transitional object is responded to by empathic failure and withdrawal on the part of the parent, the so-called separation process may become traumatic and prolonged or prevented. Winnicott (1971) reports a case history of a patient which illustrates this point exceptionally well. Owing to several traumatic separations from his mother during early childhood the patient had developed abnormal attachments to string and rope (transitional object) which continued into later childhood. After treatment of the entire family the symptoms appeared to be in remission. However, he was never able to escape his neurotic enmeshment with his mother. A decade later Winnicott reports, "In adolescence this boy developed new addictions, especially to drugs, and he could not leave home in order to receive education. . . . The question is: would an investigator making a study of this case of drug addiction pay proper respect to the psychopathology manifested in the area of transitional phenomena?" (pp. 15-20). The phenomenon of the transitional object, then, may represent the use of something which symbolizes and reactivates the affects or feelings from the matrix of a previous archaic self-selfobject relationship. This may be summoned up during a time of selfobject loss (separation from mother) to maintain optimal frustration and therefore selfcohesion and even continued transmuting internalization and psychic development. The transitional object may be one of the first examples of the use of a nonhuman substitute for a human being as an aid in self-development. In the feelings it produces, it is an inanimate substitute maternal

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selfobject. We see many examples of both nonhuman animate (pets) and inanimate objects (toys) used to modulate affect and in so doing counter depletion and loss and allow for continued psychic cohesion. The transitional object is given up when the child has developed significant self-regulating structure and has begun to establish a series of mirroring and idealized selfobjects, other than parental, in the family and with neighborhood peers. Psychic structuralization never occurs to such a degree that the individual does not need empathic peer selfobject relationships and the modulated use of the transitional selfobject as well. The initiation of relationships within a peer group is a developmental step which further defines the self and is needed for fulfullment of legitimate selfobject functions. It provides a broader, safer supply of empathic selfobjects than was available with parental relationships alone. If this step is not adequately taken or if transmuting internalization of selfobject functions is not adequate because of an overwhelmingly traumatic early selfdevelopmental process, the use of the transitional object may be excessively prolonged and take on the characteristics of an addiction. Similarly Tolpin (1971) states, "I would emphasize that phenomenologically the behavior with the blanket is like an addiction" (p. 321). By addiction, we mean it is used to produce affective stimulation and soothing to attempt to maintain a continuous, cohesive, and alive nuclear self, but producing pathological results with regression and isolation from others as with other addictions. An addiction, in many ways, may be the vain attempt to repeat the function of the transitional object to reduce current frustration to optimal levels by the induction of a certain feeling state. "When the process of effective internalization of maternal regulatory functions is impaired, fixations on the transitional form of mental structure of regressions to earlier autoerotic mechanisms are the result" (Tolpin, 1971, p. 329). One might conclude that the transitional object and its affective prosthetic function may change in appearance tofitthe context of each succeeding developmental stage, but the function remains the same (i.e., the blanket in infancy may be replaced in later years by food, alcohol, sex, etc.). From the varied clinical pictures seen in addiction, it seems evident that the defects in selfdevelopment are also quite varied, from severe to mild. As the addiction progresses with its destructive effect on physical health, social interactions, personal goals, and self-esteem, further regression occurs. Internal regulatory structures, even if present, are overwhelmed. However, it must be realized that children who experience an early failure in parental empathy in regard to their need to develop further autonomy from parents persist in having a basic motivation to continue their self-development. Therefore, if the circumstances with their parental selfobjects change, they may totally or partially complete that developmental step or, at least, build compensatory structures with the help of later selfobjects. If there is a basic drive, perhaps it is a drive toward a greater and more elaborate self-developmenta higher sense of order to life and a greater use of talents. However, as stated by Kohut & Wolf (1978), "To begin with, it seems safe to assume that, strictly speaking, the neonate is still without a self. The newborn infant arrives physiologically pre-adapted for a specific physical environment . . . outside of which he cannot survive. Similarly, psychological survival requires a specific psychological environmentthe presence of responsive-empathic selfobjects" (p. 416). The process is begun by an intense self-selfobject relationship with parents and then, we believe, later must shift to an intense selfobject relationship with peer groups (peer selfobjects). Although, the development of the self is never complete, the major shift seems important to prevent the later development of addictions. The presence or absence and the relative strength of the internalized regulatory structure obtained from archaic parental selfobjects which supports self-cohesion enough to make and maintain that transition to an appropriate selfobject group is where the varied clinical pictures of addiction may arise. The use of the peer group, then, in addiction treatment is necessary. In order to provide the quality of empathic communication and optimal frustration so desperately needed by the severely addicted person, a group of peers with similar problems must become an integral part of that individual's daily life, with full commitment and involvement. This is especially important during the early stages of recovery. The importance of the peer group (self help) as a component in the treatment of addictions and other disorders of the self is also noted by Larke (1985). Individual therapy may be helpful, but only if it promotes and supports peer-group interaction. If it does not, it may cause the patient to experience the same trauma he or she experienced

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in childhood, and the addiction will continue and will include the therapist. Several further comments regarding addicted individuals in peer groups are in order. Individuals whose development has not included the move to a solid position in peer groups are peer-group hungry and in this condition are vulnerable to the slightest peer pressure. This may be helpful early in treatment because in order to feel accepted patients will respond to whatever they perceive the group wishes, but it must be kept in mind that these patients are likely to react to the slightest criticism as rejection and quickly withdraw. We agree with Bacal (1985) that it is important for the therapist to consider the interactions within the group in relation to their effect on the sense of self of the individual. Bacal also states that "the individual's frustrated reactions to others are not interpreted as distorted and/or maladaptive, but as understandable reactions to the patient's experience of thwarted developmental needs for selfobject responsiveness which are repeated in the here-and-now interactions within the group" (p. 483). The patient entering a group of others with similar problems is likely to receive empathic understanding more rapidly, and a common realizable set of goals will be established more easily. Group cohesion may begin quickly, and if group leaders maintain principles and guidelines appropriately, a more solid group self (Kohut, 1976) will develop with idealization needs supplied as well as mirroring needs. It is our view that, just as is required of an individual self, the group self must make that important developmental step from the parent group selfobjects (group leaders) to a peer selfobject group by way of relationships with other similar groups in order to receive and maintain dependable selfobjects for continued cohesion. In the treatment of addictions the inclusion of Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous and similar multigroup organizations provides that needed selfobject group. Professionally led isolated groups are effective in the initiation of treatment but cannot go far enough by themselves. References
Alcoholics Anonymous (1939). New York: Works Publishing Inc. BACAL, H. A. (1985). Object-relations in the group from the perspective of self psychology. International Journal of Group Psychotherapy, 35, 483-501. BACHMANN, M. & ROHR, H.-P. (1983). A speculative illness model of over-eating and anorexia nervosa. Psychological Reports, 53, 831-838. FREUD, S. (1953/1974). The Complete Psychological Works of Sigmund Freud, Standard Edition, vols. 1-24. J. Strachey (Ed). London: Hogarth. HARTMANN, H. (1964). Essays on Ego Psychology. New York: International Universities Press.
KAYE, W. H., PICKAR, D., DIETER, N. & EBERT, M. H.

(1982). Cerebralspinal fluid opioid activity in anorexia nervosa. American Journal of Psychiatry, 139, 643-645. KERNBERG, 0 . (1976). Object Relations Theory and Clinical Psychoanalysis. New York: Jason Aronson. KOHUT, H. (1976). Creativeness, charisma, group psychology. In P. Ornstein (Ed.), The Search for the Self, Vol. II (pp. 547-562). New York: International Universities Press. KOHUT, H. (1977). The Restoration of the Self. New York: International Universities Press. KOHUT, H. (1978). Preface to Der flasche weg zum selbst, studien zur drogenkarriere, by J. vom Scheidt (1976). In P. Ornstein (Ed.), The Search for the Self, vol. 2 (Chap. 49, pp. 845-850). New York: International Universities Press. KOHUT, H. (1984). How Does Analysis Cure? Chicago: University of Chicago Press. KOHUT, H. & WOLF, E. S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psychoanalysis, 59, 413-425. LARKE, J. (1985). Compulsive treatment: Some practical methods of treating the mandated client. Psychotherapy, 22, 262-268. TOLPIN, M. (1971). On the beginnings of a cohesive self, an application of the concept of transmuting internalization to the study of the transitional object and signal anxiety. Psychoanalytic Study of the Child, 26, 316-352. WINNICOTT, D. W. (1953). Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34, 89-97. WINNICOTT, D. W. (1971). Playing and Reality. London: Tavistock.

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