Community-based Management
of Psychotic Clients:
The Contributions of D. W. and Clare Winnicott
(Originally published in the Clinical Social
Work Journal, 18(1):23-41, Spring 1990. Joel Kanter is a Senior Therapist at
Fairfax County (Virginia) Mental Health Services and is in clinical social work
practice in Silver Spring, Maryland. His edited volume “Face to Face with
Children: The Life and Legacy of Clare Winnicott” will be published by
Karnac Books in 2004.)
As the burgeoning
field of "case management" has focused attention on the environmental needs of
psychotic clients, the lack of direct practice models has created a disturbing
conceptual vacuum which has been filled by bureaucratic attempts to define this
work. Reflecting an all-too-common perspective, one author defined case
management as:
the process of planning
for individuals or families who require the organization of services to effect
desired outcomes by assuring that all aspects of that outcome are controlled by
reducing harmful effects.
... case
management is carried out by case managers, who in turn maintain a complete
record of interactions by timely notations in the case record" (Sullivan,
1981, p.120).
Reacting to such
perspectives, many concerned clinicians have come to view case management as an
impersonal service more concerned with bureaucratic systemization than providing
help to persons in need. While several authors have recognized that addressing
the environmental needs of the mentally ill requires a personal relationship and
a high level of clinical skill (Lamb, 1980; Kanter, 1985, 1987, 1989; Harris and
Bergman, 1987; Harris and Bachrach, 1988), most case management literature
reflects an administrative perspective (Sanborn, 1983, Levine and Fleming, 1984;
Weil, Karls and associates, 1985).
However,
well before the field of "case management" was defined and implemented in the
United States, D. W. Winnicott, the British psychoanalyst and pediatrician most
noted for his concepts of the "transitional object" and the "holding
environment" was stressing the importance of "management" in the treatment of
severely disturbed children and adults. As I will outline, he used the term
"management" to describe direct interventions with the environment which
facilitate the healing and maturation of very troubled individuals, a usage
clearly compatible with contemporary case management practice. Drawing from his
years of pediatric experience, his usage of "management" reflected the very
personal manner by which all "good-enough" parents help their infants and
children adapt to the larger environment. In doing so, Winnicott moved beyond
the classical Freudian and Kleinian focus on the instinctual components of the
parent-child relationship, examining instead the less dramatic regulatory
functions of everyday parenting.
In his
discussions of management, Winnicott frequently referred to his wife Clare's
writings for further elaboration. A social worker who worked closely with
Winnicott during the war, Clare Winnicott was one of the last analysands of
Melanie Klein and was awarded the Order of the British Empire for her leadership
in the child welfare field (Grosskurth, 1986). Described by a British social
work journal as "a well known team in social work and psychotherapy" (C.
Winnicott, 1970), the Winnicotts collaborated closely with one another and
according to one colleague, E. James Anthony (1989), there is "no way of
separating their contributions in (the management)
area."
In this paper, I will outline D. W.
Winnicott's perspectives on "management" with the psychotic client, reviewing
both practice and theoretical considerations. As his clinical observations were
always integrated with developmental psychology, I will also examine some of his
ideas on the role of environment in facilitating personality growth. Finally,
after presenting a case vignette and reviewing the writings of both D. W. and
Clare Winnicott, I will describe in greater detail how their approach to
management can be implemented in clinical practice. As their ideas on management
are scattered throughout their papers, I will be quoting their remarks at length
to accurately convey the spirit of their thinking.(For purposes of simplicity, I
will refer to D. W. Winnicott as Winnicott and refer to Clare Winnicott by her
full name.)
Winnicott's Approach to Management
Winnicott's approach to management emerged from
his experience as the Consultant Psychiatrist to the program, which relocated
urban children in England to the countryside during the bombings of World War
Two. Working closely with Clare Britton, his future wife, he explored ways of
establishing and maintaining environments, both familial and institutional, that
facilitated the survival and development of troubled and homeless children
(Winnicott and Britton, 1947). This perspective continued throughout his career
as he searched for ways to apply psychoanalytic theory to difficult situations
where psychoanalysis would involve "wasting our time and someone else's money" (Winnicott,
1961).
In his classic 1947 paper "Hate in the Countertransference," Winnicott applied his experiences with normal
and disturbed children to both the psychoanalysis and management of adult
psychotic patients. Concerned with the abuse of lobotomies and ECT, he examined
the hatred that both children and psychotic patients inevitably evoke in their
caregivers, including parents, therapists, psychiatrists and nurses. This was
perhaps the first of many papers where he integrated observations from
psychoanalytic treatment, social casework and his "well-baby" pediatric
experience to emphasize the common ingredients of care giving relationships with
children and developmentally arrested
adults.
In his introduction to a collection of
Winnicott's papers (Winnicott, 1975), M. Masud Khan outlined Winnicott's
perspective on "management.” Stating that Winnicott viewed regressed
patients as "inevitably" requiring management, Khan outlined three basic types
of management in Winnicott's thinking and
practice:
1) The quality of the analytic
setting: its quiet and freedom from impingement on the patient;
2) The provision by the analyst of what is
required by the patient: be it abstention from intrusion by interpretation,
and/or a sensitive body-presence in this person, and/or letting the patient move
around and just be and do what he needs to;
3)
The management that can only be provided by the social and familial environment:
here the range is from hospitalization to care by family and
friends.
Khan goes on to note that Winnicott
viewed management as:
neither
indulging the patients' whims and wishes nor avoiding meeting the demand for
help by reassurance. Management, in fact, is the provision of that environmental
adaptation, in the clinical situation and outside it, which the patient had
lacked in his developmental process... It is only when management has been
effective that interpretative work can have clinical value (p.
xxvi-xxvii).
As Khan's remarks are
directed toward his fellow psychoanalysts, they place equal stress on management
inside and outside of psychoanalytic treatment. Unquestionably, Winnicott was
very concerned with both the psychic and physical dimensions of the symbolic
environment he created in his consulting room. As Margaret Little (1985) noted,
he saw to it she was "warm and comfortable" and regularly ended their sessions
with coffee and biscuits.
However, when
Winnicott discussed management in his writings, he almost invariably was
referring to environmental interventions outside of the office. For example, in
1953, Winnicott wrote several scathing letters in response to a meeting which
discussed a paper Herbert Rosenfeld (1952) had written on the psychoanalytic
treatment of a schizophrenic man. Winnicott wrote Rosenfeld that another analyst
told him that:
the whole work of the
management (of this case) was a very specialized business and that as far as
could be seen the bit of work you did by analysis made no appreciable
difference...(p. 44)
In response to
this discussion, Winnicott also wrote Hanna Segal on the same day to argue with
her assertion that the management needs of disturbed patients are recognized by
all psychoanalysts:
you mentioned the
fact that no-one would analyze somebody who had not had food for five days.
Presumably they would give food. You went on to imply that there is no essential
difference between the management needs of a psychotic and a neurotic patient.
If you really mean this, heaven help your psychotic patients, and until you
recover from this point of view I am afraid you will not make a very interesting
contribution to the theory of
psychosis.
If you really believe... that
the psychotic patient is in an infantile state... then what you are really
saying is that there is no essential difference between the management needs of
an infant and those of a grownup. Yet... I am sure that you would admit that
whereas a mature person can take part in his own management, a child can only
take part to some extent and an infant... is absolutely dependent on an
environment which can either chose to adapt (or fail to adapt) to the infant's
needs... As management problems are essentially different according to the level
of development... then (they) must be different in the analysis of psychotics
and neurotics. As you know, I am one of those... who say that in the analysis of
psychotics we must actually study what we do when we take part, as we always
must do, in management (Rodman, 1987, p.
47)
A year later, Winnicott wrote Sir
David Henderson, a Scottish psychiatrist about the treatment of "borderline
cases," commenting that "it is merely a matter of time before psycho-analysis as
a whole concerns itself with the whole aspect of the management problem...
without abandoning the main principles of psycho-analytic technique" (Rodman,
1987, p. 69).
Although Margaret Little (1985)
writes that Winnicott's concerns about the confidentiality of his adult patients
inhibited him from presenting case reports of adult patients, he published two
case studies, which illustrate how he used management as a primary treatment
technique with severely disturbed children. In one paper, titled "A Case Managed
at Home", Winnicott (1955) reported on his work with a six year-old psychotic
girl. After carefully assessing the child and family, he empowered the mother to
turn the home into what he termed a "mental hospital" and help nurse the child
back to health over a 15 month period. Winnicott assisted the family in this
task by asking the local school and clinic to leave the family alone. He also
had "very brief" weekly contacts with mother and child where he consulted with
mother on the home situation and "gave the child the opportunity to be
negativistic" (p. 124).
However, Winnicott was
quite clear that it was the "management rather than direct psychotherapy which
(returned) the child to normal. (While) some direct work was done with the child
in the weekly visits...(these) brief contacts (were) not the main part... of the
treatment, but (were) in fact a useful addition" (p.119).
In a second case he entitled "Peter",
Winnicott (1971) was consulted by the parents of a troubled 13 year old boy who
had engaged in a series of bizarre thefts and destructive acts at a boarding
school. Again, after evaluating the boy and his parents, he recommends that the
child return home to be nursed back to health by his parents. After an initial
series of office consultations, Winnicott supported the parents' efforts at
managing their son at home with a series of phone calls and letters. He payed
close attention to the process of choosing a new school which could which would
facilitate the progress that Peter had made at home. In this case, three
individual contacts with the patient had no psychotherapeutic impact; they only
provided Winnicott with information, which could guide his managerial
interventions.
Margaret Little's (1985) report
of her own treatment provides one of the only case reports of how Winnicott
managed a psychotic illness in an adult patient. During her psychotic
regressions, he took an active role in arranging for hospitalizations,
negotiating the ground rules for her treatment with the attending psychiatrist
and checking with her frequently to assess her subjective experience of the
hospital. In one instance, he even arranged for friends to take her on a
vacation.
Little describes Winnicott's "'holding', of which management was always a part" is
reflecting his assumption of: full responsibility, supplying whatever ego strength
a patient could not find in himself and withdrawing it gradually as the patient
could take over on his own. In other words, providing the 'facilitating environment',
where it was safe to be. Only rarely did 'holding' mean literally restraining
or controlling. He was compassionate, but consistently firm, sometimes to the
point of ruthlessness where he felt it necessary for the safety of his patient.
Short of bodily intervention he could 'forbid' action. (p.21)
Little continues by observing
that:
sometimes the holding had to be
delegated, handing over a dependent patient temporarily to someone else so that
he could get a rest or a holiday, but always keeping in close touch.... when he
feared I might kill myself while he was away, he arranged for hospitalization...
At one time I was liable to rush out of his room in a fury and drive away
dangerously. He took charge of my car keys until the end of the session, and
then allowed me to lie quietly alone... til I could be safe (p.
22).
Both Winnicott's and Little's
reports clearly illustrate that he viewed direct intervention in the patients'
environment as an essential component of effective treatment. In a classic paper
on therapeutic regression with psychotic patients, he explicitly commented that
the "accent is more surely on management... sometimes ordinary analytic work has
to be in abeyance over long periods (with) management being the whole thing" (1954,
p.279).
Management: A Theoretical Perspective
Winnicott's approach to management was firmly
grounded in his developmental theories of how social environments facilitate
personality development. His pediatric experience with thousands of normal
mothers and infants gave him a unique perspective on the essential everyday
interactions between the "ordinary devoted" or "good-enough" mother and her
child. In exploring these commonplace phenomena, Winnicott moved beyond the
instinctual relationships so central to classical and Kleinian psychoanalysis
and instead focused on the parental provision of ego support. He commented that:
a source of misunderstanding here is
the idea that the term 'adaptation toneed' in treatment of schizoid patients and
in infant care means meeting (orfrustrating) id-drives. There are more important
things going on, and these are of the nature of giving ego support to ego
processes (1963c, p. 241).
Along
these lines, Winnicott (1963a) believed that:
it is helpful to postulate the
existence for the immature child of two mothers... (an) 'object-mother' and (an)
'environment-mother".(These terms) describe the vast difference... for
the infant between the two aspects of infant-care, the mother as object... that
may satisfy the infant's urgent needs, and the mother as the person who wards
off the unpredictable and who actively provides care in handling and in general
management (p. 75).
Winnicott (1961)
viewed infant nurture as "an ever widening interpretation of the word holding,"
a term including "all physical management... done in adaptation to an infant's
needs" (p. 237). By this he meant much more than breast feeding, including
regulation of temperature, stimulation, frustration and
activity.
Foreshadowing Kohut's work (1971),
Winnicott suggests that the "individual introjects the ego-supportive mother"
(1958, p. 32) as "de-adaptation" occurs in "graduated doses" as "part of the
gradual change toward independence" (1963c, p. 239). Later, the family unit as a
whole continues this process, providing both "opportunities for regression to
dependence of a high order" (1961, p. 237) as well as a "graduated failure of
adaptation that is an essential part of the healthy environment" (1965a). This
titration of environmental support in response to the child's needs is the core
of the process of management.
Etiological Considerations
Given his interest in the environmental
influences on development, it is unsurprising that Winnicott generally viewed
psychotic disorders as largely caused by environmental forces. In a typical
comment, he stated that psychosis is "etiologically linked with environmental
failure, failure to facilitate the maturational processes at the stage of
(infantile) dependence" (1963b, p. 226). However, rather than focusing on the
pathogenic factors in the parent-child relationship, Winnicott more typically
focused on its positive characteristics.
For
example, he wrote Herbert Rosenfeld that:
if it is possible for an analyst
or... a mental hospital to cure a schizophrenic patient it must certainly be
possible for a mother to do so... (with her) infant...(The) logical conclusion
is that the mother often prevents schizophrenia by ordinary good management
(Rodman, 1987, p. 45).
In an unpublished
manuscript, Winnicott elaborates on this theme, noting that
the:
average family is all the time
preventing and clearing up the disturbances in this and that child, usually
without professional help. It is a mistake for a psychotherapist to usurp the
total family functioning except where this functioning is doomed to failure
because of some inherent defect
(1965a).
This emphasis on the therapeutic
capacity of ordinary "good-enough" families was operationalized in the case
reports mentioned earlier. Both reports describe how Winnicott empowered parents
to assume the primary role in treating severely disturbed children. Also,
neither report contains any suggestion that deficient parenting was responsible
for the child's illness.
This emphasis on the
positive elements in family life extends to Winnicott's empathic appreciation
for the inevitable psychopathology in the normal parenting experience, including
the postnatal near-psychotic maternal preoccupation (Winnicott, 1956) and the
hatred and rage evoked by children of all ages (Winnicott,
1947).
Reconciling this appreciation and
respect for ordinary family life with his belief in an environmental etiology
was not always an easy matter. In 1964, Winnicott published a letter in the
London Observer which stated that a lack of maternal devotion predisposed the
infant to become autistic. This letter elicited a barrage of criticism, as both
parents of autistic children
and leaders of The
Society for Autistic Children (of which Winnicott was a board member) and The
Association of Parents and Friends of Autistic Children publicly argued that he
had blamed parents for their children's tragic conditions while ignoring
biological factors.
Winnicott was genuinely
stung by this criticism and attempted to repair the damage by writing the
parents, the organizations and the newspaper to clarify his viewpoint and
assuage the feelings of those he had offended. Acknowledging that "autism has a
complex aetiology", he nonetheless wondered how he could express his deep
conviction that the "infant is fortunate if, at the very beginning, he or she
can have 'all of mother'" without inadvertently evoking guilt in some parents
(Winnicott, 1964b).
Over the next two years,
he reworked his thinking about the etiology of severe mental disorders in a
series of unpublished manuscripts. In one paper, he attempted to demonstrate his
appreciation of biological factors by describing the case of a boy whose
behavior problems were caused by a brain cyst and alleviated by its removal
(Winnicott, 1965c). Later in the same paper, he acknowledged that there are
"powerful inherited factors in some cases
of
schizophrenia," although he argued that environmental considerations were also
important. In a lecture given that year, he also remarked that biological
research on schizophrenia deserves "full support" (Winnicott,
1965b).
In an unpublished paper the following
year entitled "Social Aspects of Autism", Winnicott (1966) discussed the impact
of etiological theories on parents of autistic children. Acknowledging the many
mistakes professionals have made in differentiating the biological and
psychological factors in this complex disorder, he discussed the varieties of
guilt experienced by the parents of abnormal children. Aware that environmental
theories evoke guilt in parents, he nonetheless associated these theories with a
therapeutic optimism absent among many biological psychiatrists of his
era.
Case Vignette
To illustrate Winnicott's approach to the
management of a psychotic client, I will present a vignette of two and half
years work with a severely impaired homeless
woman:
Sharon, a 35 year old widowed
mother with a diagnosis of paranoid schizophrenia, has been a patient at the
mental health clinic for the past two and a half years. Because she is reluctant
to talk about her past and has no family nearby or social network, we still do
not have a good history of her illness and life. We do know that she came to the
United States with her husband and child ten years ago. Her husband died
suddenly at age 30 two years later, leaving her in custody of a 6 year old
son.
Although Sharon had a well-paying position
in a technical field, her incipient psychosis rendered her unable to care for
this child. Ultimately, he was legally removed from her custody and sent to live
with paternal grandparents in another city. After creating a public disturbance,
Sharon was hospitalized three years ago at a state hospital. She was discharged
to our clinic's shelter outreach program, which, at that time, served homeless
persons who were housed by the Department of Social Services in inexpensive
motels. The outreach worker helped connect her with our medication clinic and
case management unit. She also linked her with a community agency that helped
her obtain a job in a restaurant kitchen.
Stabilized, though still very guarded and
schizoid, she met with me in my office on a weekly basis for about two months.
Although she consented to take 200 mg of Thorazine daily, she did not openly
acknowledge any difficulties beyond her wish to reestablish contact with her
son. At her request, I contacted the grandparents who indicated that they did
not want Sharon having any direct contact with her son, now 13. As they had no
objection to correspondence, I helped Sharon draft a letter to
him.
Soon after, she received a devastating
reply in which her son indicated that she had ruined his life and that he wanted
nothing to do with her. Sharon reacted to this letter by expressing pride in its
compositional skill, acknowledging no shame, grief or anger. Soon after, she
discontinued our meetings. As she was steadily employed and had moved into a
rooming house, I did not see how I could persuade her to continue our meetings,
especially as she reacted with irritation to any expressions of interest or
support.
About 5 months after my last session
with her, I heard from a worker at another community agency that Sharon had
relapsed, becoming paranoid and delusional. She lost her job and room, and soon
moved into a local homeless shelter. Our clinic's shelter outreach workers
reported that they had been unable to persuade her to accept treatment. I
visited Sharon in the shelter for about six weeks. These visits appeared to have
little positive value and sometimes seemed to increase Sharon's agitation.
Initially, she acknowledged a need for housing assistance, but refused to accept
the medication that was a prerequisite for admission to the appropriate
programs. Later, she denied any problem with housing, claiming that she owned a
home, which had been illegally confiscated by her native country's secret
police. She also accused me of being an agent of this police force.
Alternatively withdrawn and argumentative, she did not exhibit behavior, which
would have permitted an involuntary commitment. Finally, after spending four
months in a shelter with a 6O day limit, the shelter staff expelled
her.
Within 24 hours, she was arrested for
disorderly conduct and imprisoned. The jail psychologist contacted me for
information, reporting that Sharon refused to answer any questions or cooperate
with treatment. After a month in jail, Sharon's attorney successfully petitioned
for transfer to a psychiatric hospital for a competency evaluation. Soon after
Sharon's admission, I bumped into her while visiting another patient at the
hospital. She barely acknowledged my presence and indicated that she had no wish
to speak with me.
Three more visits produced a
similar result. Finally, on a fifth visit, I found her crocheting in the day
room and she greeted me politely as if nothing had happened. I continued to meet
with her on a weekly basis and we discussed options for
discharge.
I also spoke intermittently with her
hospital social worker. She surprised me one Friday afternoon by informing me
that Sharon was being returned to jail the following Monday to stand trial on
Tuesday. As the patient was a forensic case, the social worker had no formal
responsibility for discharge planning and had no idea what would happen to
Sharon. Unable to attend the trial, I frantically arranged for a social services
worker stationed near the courthouse to assist with emergency housing after her
expected release from custody. Although Sharon's attorney had assured me that he
would assist her after her release, Sharon called me from outside the jail,
frightened and homeless. I found a jail psychologist to transport her to the
social services department.
When I didn't hear
from Sharon that evening, I became concerned and contacted the social services
worker early the next day. I learned that they were not able to locate any local
shelter beds and had sent her downtown to a large, chaotic shelter with
instructions to return to their suburban office the following morning. I worried
that she would not return and that I would not be able to locate her in a
thousand bed shelter. After losing my temper with several social services
workers for abandoning this patient, a social services supervisor called me a
week after her release to inform me that Sharon had been in one of our county
shelters for the past four days.
I visited
Sharon at the shelter and found her more responsive and communicative than she
had been in the hospital. She had continued taking her medication and had even
worked several days for a temporary agency. I recommended a transfer to a small
shelter near our clinic, a move which would facilitate planning for a long-term
placement. Sharon agreed to this move. Over the next 6 weeks, I helped Sharon
obtain temporary financial relief and a placement in a supervised apartment
program. With the help of a job counselor from another community agency, she
secured a fulltime restaurant job. Of course, none of these developments would
have been possible without Sharon's clinical improvement and energetic
collaboration. For example, when the coordinator of the apartment program told
her that injectible medication would help maintain her community tenure, Sharon
promptly initiated negotiations with her psychiatrist to administer IM
Prolixin.
As Sharon's remained very isolated
four months after discharge, I found a volunteer from her native country who
could meet with her socially on a biweekly basis. As she had not spoken her
native language for almost eight years, she anticipated her initial contact with
this volunteer with uncharacteristic excitement. Introducing them in a
neighborhood restaurant, I had to keep excusing myself to use the bathroom or
make phone calls so they would not feel compelled to converse in
English.
Around this time, Sharon kept
expressing an interest in returning to the technical work she had abandoned
seven years earlier. As her thinking was still quite concrete and her social
skills were limited, I feared she might fail if she returned to this work.
Furthermore, computers had revolutionized the practice of her specialty in the
intervening years, a fact she was reluctant to acknowledge. I arranged for an
instructor at a local college to review her work history and credentials and
counsel her on the best way to update her skills. However, before she could
enroll in a college course, she obtained an entry level technical position with
the help of the state employment commission. Laid off two months later, I was
uncertain whether she had been able to handle this cognitively demanding work.
However, within two weeks she secured a higher paying position in her field
through a private employment agency, evidencing her developing social skills.
Nearly a year after her hospital discharge,
Sharon continues to build a life for herself in the community. She receives
Prolixin injections (1 cc.) on a monthly basis, participates in a weekly
apartment meeting and a weekly individual session. In our individual meetings,
we discuss recent events in her work and social life, her ambivalence about her
medication, and future plans for housing after she leaves the residential
program. Gradually, she has begun to talk about events from her past, a process
I foster by bringing her clippings about news from her native land.
Besides her external accomplishments of stable
housing and employment, she now interacts with a gleam in her eye and sense of
humor, both missing during her earlier period of stabilization. Although
initially schizoid and isolated, she now enjoys the companionship of others,
especially the aforementioned volunteer, a 22-year-old roommate and an older
gentleman she has recently begun dating.
Discussion
Although many of my interactions with Sharon
involved psychotherapeutic techniques, the core of my work was management of her
needs for environmental support in the areas of housing, work and her social
network. Although I had some intermittent contact with her for a year before her
hospitalization, I was not able to establish a psychotherapeutic or managerial
relationship during her residence in three different settings, which offered
inadequate support: the motel shelter program, her rooming house, and the first
large shelter. I did learn, however, that she responded poorly to both isolation
and over stimulating chaos.
When I visited her
in the hospital, I observed that Sharon was able to benefit from the combination
of medication and a non-intrusive inpatient setting. During this
hospitalization, observing that I continued to demonstrate interest while
experiencing repeated rebuffs, she began to allow me to attend to her needs for
support. Unfortunately, the forensic nature of her hospitalization made smooth
discharge planning difficult and my attempts to securely house her after her
release from jail were temporarily unsuccessful.
Like a parent of a lost child, I had to charge
around the network of services for the homeless trying to find her. When I did,
she allowed me to try again, moving her to a smaller, more familial shelter and
then again to our clinic's supervised apartment program, settings that
facilitated "regression to dependence”. At each placement, I spent much
time consulting with the residential staff to help them respond appropriately
to Susan's needs.
Vocationally, in spite of the
severity of Sharon's illness, I supported her interest in working, resisting
the advice of other caregivers to help her apply for Social Security. Knowing
she could work successfully while quite disturbed, I also knew that her schizoid
and paranoid characteristics would make it difficult for her to find work on
her own. Fortunately, a job counselor was able to quickly place her in a job
with a minimum of red tape. I also used a volunteer to help her negotiate the
immigration bureaucracy to replace her lost "green card." Later, as Sharon's
paranoia diminished and her interpersonal skills improved, she began to manage
most of her vocational concerns.
Finally, in
the social sphere, my recruitment of the volunteer who spoke her native language
seemed to facilitate a rapid relaxation of her paranoid and schizoid defenses.
This volunteer, a reserved older professional woman, offered Sharon an
opportunity for a maternal interaction that was rewarding without activating her
paranoid defenses.
Overall, I can count
contacts over the past two and a half years with more than twenty caregivers
involved with Sharon's case, including our clinic's psychiatrists and nurses,
outreach workers, residential staff, volunteers and social workers. As almost
all responded supportively, I experience a sense of gratitude for their
assistance analogous to a parent's gratitude to his or her child's teachers,
babysitters and activity leaders. Somehow, Sharon's sense of my reliable holding
is inextricably interwoven with the quality of these other caregivers. The
developing trust from our direct interactions would have easily eroded if I had
failed her in these managerial interventions.
Practice Considerations in Management
Reviewing this case, Winnicott's concept of the
ego-supportive mother helps us understand a process of personality growth
involving neither interpretation, unmanageable regression, catharsis, or
exploration of the patient's childhood. In this approach to management,
clinicians, families and other caregivers provide specialized environments where
the "highly complex internal factors" in troubled individuals and their social
milieu could "rearrange themselves... over a period of time" (Rodman, 1987,
p.141). He primarily saw this work as the function of social workers, noting
that "psychiatrists and psychoanalysts constantly hand over (psychotic patients)
to the care of the psychiatric social worker (because) they can do nothing
themselves" (1963b, p.227). In such cases, he viewed the psychoanalyst as
relatively impotent "unless... he steps outside his role at appropriate moments
and himself becomes a social worker" (p. 219). He suggested that analysts might
learn from social work that "interpretation is not the most important part of
the work" with these difficult patients (Rodman, 1987, p.
142).
Winnicott (1961) viewed this work as the
"professionalized aspect of the normal (holding) function of parents and
(communities), a 'holding' of persons and situations, while growth tendencies
are given a chance" (p. 237). He viewed "each social worker as a therapist, but
not as the kind of therapist who makes... well-timed (transference)
interpretations" (1963b, p. 227). He argued that they could do this if they
liked, but argued that their more important function is therapy of the kind that
is always being carried on by parents in correction of relative failures in
environmental provision. Winnicott asked:
What do such parents do? They
exaggerate some parental function and keep it up for a length of time, in fact
until the child has used it up and is ready to be released from special care
(1963b, p. 227).
Winnicott then offered a
listing of the essential tasks for caregivers involved in the management of
psychotic clients:
You apply yourself
to the case.
You get to know what it
feels like to be your client.
You become
reliable for the limited field of your professional
responsibility.
You behave yourself
professionally.
You concern yourself
with your client's problems.
You accept
being in the position of a subjective object in the client's life, while at the
same time you keep both feet on the
ground.
You accept love, and even the
in-love state, without flinching and
without
acting-out your
response.
You accept hate and meet it
with strength rather than with
revenge.
You tolerate your client's
illogicality, unreliability, suspicion, muddle, fecklessness, meanness, etc.
etc., and recognize all these unpleasantness as symptoms of
distress.
(In private life these same
things would make you keep at a
distance.)
You are not frightened, nor
do you become overcome with guilt-feelings when your client goes mad,
disintegrates, runs out in the street in a nightdress, attempts suicide and
perhaps succeeds. If murder threatens you call in the police to help not only
yourself but also your client.
In all
these emergencies you recognize the client's call for help, or a cry of despair
because of loss of hope of help. In all these respects you are, in your...
professional area, a person deeply involved in feeling, yet at the same time
detached in that you know that you have no responsibility for the fact of you
client's illness, and you know the limits of your powers to alter a crisis
situation. If you can hold the situation together the possibility is that the
crisis will resolve itself, and then it will be because of you that a result is
achieved (p. 229).
While these
comments eloquently outlined the personal dimension of management, Winnicott
frequently referred his readers to his wife Clare's writings for further
elaboration. Although her papers address management problems in social casework
with children, it can adapted to the difficulties of adult psychotic clients. To
elaborate D. W. Winnicott's perspective on management, I will briefly summarize
Clare Winnicott's discussion of three topics: 1) the integrative function of the
managerial relationship; 2) authority issues in the managerial relationship; and
3) the relationship between the case manager and residential caregivers.
Integrative Functions
of the Managerial Relationship
Although Clare Winnicott (1954) saw the social
worker's "first responsibility" as determining where the client will "sleep
tonight," she viewed the his or her ongoing participation in the reality of the
client's life as having profound intrapsychic significance. While the
psychotherapist is largely a subjective figure, the social worker "starts off as
a real person concerned with external events and people in the (client's) life"
who "attempts to bridge the gap between the external world and his feelings
about it" (C. Winnicott, 1963, p. 45). Bound to external reality by his or her
actual involvement in the client's world, the social worker cannot serve as a
relatively opaque receptor of transference fantasies.
However, this unique relationship offers
alternative therapeutic possibilities. As the social worker may be the only
person familiar with the family and other caregivers, he or she can "make links
between places and events and bridge gaps between people which they are unable
to bridge for themselves" (p.45). Having lived through significant life events
with the client, including transitions between family and residential programs,
he or she can explore the feelings about these events at an appropriate
moment.
Clare Winnicott (1961b) described how
children in her care would:
go over
the same ground again and again. It might begin with: 'Do you remember the day
you brought me here in your car?' And we would retrace our steps, going over the
events and the explanations once more. This was no mere reminiscing, but a
desperate effort to add life up, to overcome fears and anxieties, and to achieve
a personal integration. In my experience, feelings about home and other
important places cluster round the caseworker, so that when the children see her
they are not only reminded of home but can be in touch with that part of
themselves which has roots in the past and the (outside) world... (p.
34).
Case managers have similar
experiences with mentally ill adult clients, helping them connect their internal
experiences with such significant events as a family dispute, a psychiatric
hospitalization or a period of homelessness (Harris and Bergman,
1987).
Clare Winnicott (1954) viewed the
casework relationship as a reliable environment "within which people can find
themselves or that bit of themselves which they are uncertain about" (p. 13).
Foreshadowing Ogden's (1982) discussion of projective identification and
Searles' (1986) recent work on borderlines, she described how social workers
"can 'hold' the idea of (the client) in our relationship so that when he sees us
he can find that bit of himself which he has given us" (p. 13). She goes on to
describe how social workers also:
hold
the difficult situation... by tolerating it until (the client) either finds
a way through it or tolerates it himself. If we can hold the painful experience,
recognizing its importance and not turning aside from it as the client re-lives
it with us in talking about it, we help him to have the courage to feel its
full impact; only as he can do that will his own natural healing processes
be liberated (p. 13).
Authority Issues in the Managerial Relationship
Clare Winnicott (1961a) forthrightly addressed
the tension between the therapeutic and social functions of the managerial
relationship. Recognizing that child welfare agencies assume parental
responsibility for their clients, she viewed the social worker as "the overall
caring parent behind the parents and (other caregivers), supporting their
relationship and preserving continuity and reliability" (p. 66). Acknowledging
that "it is difficult... to know when the rights of the (client) to exercise
self-determination must be overridden," she observed that such actions can often
make the relationship more real and lead to "more productive work" (p. 67).
While she was referring to decisions concerning parental custody and placement,
similar decisions are made by case managers in initiating commitment petitions
or referrals to community residential
programs.
These authoritative actions are not
without transference implications. Clare Winnicott (1954) noted that the social
worker is:
not just the accepting
understanding person... which she wants to be... she is also a powerful person
who can be a threat or a saviour... Unless (the social worker) fully recognizes
the implications of this fact... (and) brings into the open the possibility that
she may be felt as a threat or a saviour, she will find her relationship
confused and will find her relationship difficult to handle (p.
10).
Given the tendency of psychotic
patients to create grotesque transference fantasies from kernels of reality
(Searles, 1979; Kanter, 1988), social workers have to be constantly attentive to
such phenomena.
Collaborating with Other Caregivers
Whenever disturbed persons require residential
care, be it in a hospital, halfway house, supervised apartment or foster home,
caregivers will disagree in their appraisal of the client's needs or behavior.
Often these differences crystallize around the intensity of contact. For
example, staff nurses in hospitals frequently disagree with attending
psychiatrists while halfway house counselors often disagree with case managers
and therapists.
While there is a common belief
that these differences can be resolved with adequate discussion, Clare Winnicott
(1961b) argued that these tensions are inherent in the work of management and
should be "understood and recognized and experienced" (p. 37). Besides the usual
jealousies and rivalries, she attributed these tensions to the inherent
difference between residential staff and case managers in the nature of their
involvement and identification with their clients. In comparison with caregivers
who have only intermittent contact, residential staff develop a more subjective
identification with their clients.
Both make
themselves available to clients for identification who internalizes them in
different ways. The client thus "represents... something of themselves to each
worker and each feels possessive about him." Clare Winnicott argued that these
competing identifications are:
the
fundamental source of tension, although it may be disguised in discussion
about... hours of work, pay or status or demands of the job. But contained in
the tension and possessiveness is the most valuable bit of each worker, the bit
that enables each to do his or her job well. If there is no tension there has
been no real identification, no real giving, and (the client) will remain
fundamentally unhelped although he may have been adequately housed and fed (p.
38).
The Therapeutic Action of Management
Keeping these ideas in mind, I would like to
return again to the case of Sharon presented earlier. Although I view empathy as
an important element of our relationship, a transcript of our interactions would
contain little evidence of any concerted attempt to understand her. For the most
part, we chat about her current activities without any psychic exploration.
Sharon's experience of my empathic appreciation comes more from my management
activities than from my verbal statements. This empathic appreciation extends
far beyond my respect for her defences; it also encompasses an appreciation of
her changing needs and capacities as she interacts with a complex environment.
If I had offered too much (applying for disability benefits or referring her to
a halfway house with 24 hour supervision) or too little (expecting her to
negotiate the immigration bureaucracy by herself), the empathic failure would
have been at least as damaging as any comment. Of course, my managerial
interventions have decreased as Sharon's capacities have developed, perhaps
partially through identification with the managerial functions I have performed
(Harris and Bergman, 1987).
The importance of
the child's internalization of such management functions has been largely
neglected in developmental theory. How parents assess a two year old's readiness
to give up the bottle, a five year old's readiness for kindergarten, a six year
old's readiness for piano lessons, or a twelve year old's readiness to ride the
subway conveys as much or more to the child than empathic comments or
expressions of affection.
As Sharon's
management needs diminish, the importance of the integrative function of the
managerial relationship that Clare Winnicott (1961b) described becomes
increasingly apparent. Sharon's isolation led to an almost total fragmentation
of her life experience prior to our initial contact. She had no one who knew
her in her country of origin, in her initially successful years in this country,
and in her years of psychosis and homelessness. Having lived with her through
periods of schizoid rigidity, psychotic disintegration, and recovery, I can
refer back to these periods and facilitate the ongoing process of psychic
integration. The volunteer from her country also helped Sharon rediscover
disassociated "good" self-object representations, which greatly enliven her
current interactions.
Although the extent of
Sharon's recovery is striking, this vignette vividly illustrates the therapeutic
impact of the approach to management that Winnicott advocated, an approach,
which integrates clinical sensitivity with environmental intervention. Like
several other case reports (Sheppard, 1963; Khan, 1982; Kanter, 1984), it
suggests that substantial personality growth is possible for severely disturbed
persons outside of psychoanalysis or intensive
psychotherapy.
Although Sharon's progress in
the past eighteen months overshadows the earlier period, the despair and
helplessness she evoked in our first year cannot be overlooked. Repeatedly,
Sharon refused to acknowledge my existence as a professional or as a human
being: a condition I was willing to endure but not accept. Reflecting on those
trying months, Winnicott's (1970) comments from a lecture to social workers
given just three months before his death seem most
apt:
Your job is to survive. In this
setting the word survive means not only that you live through it and that you
manage not to get damaged, but also that you are not provoked into
vindictiveness. If you survive, then and then only you may find yourself used in
a quite natural way by the (client) who is becoming a person and who is
newly able to make a gesture of a rather simplified loving
nature...(Management) can be a very deliberate act of therapy done by
professionals in a professional setting. It may be a kind of loving but often it
has to be a kind of hating, and the key word is not treatment or cure but rather
it is survival (p. 227-228).
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