Winnicott and the therapeutic community



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The Therapeutic Community as a Holding Environment

M. Gerard Fromm, Ph.D.



  1. Preliminary Comments on the Issue of Authority



Freud famously outlined the clinical trajectory of psychoanalysis in his comment “Where Id was, there Ego shall be” (1923, p.80). This description of psychoanalysis launched the field of ego psychology, leading to a rich set of theoretical concepts and a point of view about clinical technique. The conceptual contributions included the potential neutralization of the drives, and the technical approach emphasized supporting the ego in its all-important efforts at synthesis and mastery, both of which are relevant to the therapeutic community task.

As part of his radical “return to Freud,” Jacques Lacan drew on Freud’s original German and re-translated the above foundational quote as “Where It was, there I must come to be” (1977, p.129). He thereby shifted the field of discourse from one of forces and their control - Freud’s proverbial horse and rider - to the dimensions of subjectivity and authority. He recognized that it had been Freud’s genius to discover a model of psychological treatment that reversed the ordinary positions of doctor and patient. Within a traditional medical model, the patient was to make himself the object of the doctor’s knowledge and ministrations. But Freud - though he sometimes struggled with his startlingly new paradigm - set up a clinical situation in which he was to become the object of the patient’s unconscious strivings. As this transference from the past was gradually interpreted, Freud would return to the patient his or her own, formerly inchoate, knowledge about the sources of the illness.


Lacan drew attention to a different task for clinical psychoanalysis: pathology reflected a position of objectification, and treatment facilitated a subject’s coming into being. For Lacan, the essence of being human is our immersion in meanings - first of all what we mean to the all-important other person - and the essence of human activity is our effort to grasp meaning for ourselves. The psychoanalytic situation was set up for exactly this purpose: to discover, within a therapeutic relationship, the unconscious meanings the patient is carrying, much to their psychic discomfort. The technique of clinical psychoanalysis was organized around this profoundly different understanding of the locus of authority within the treatment. In an earlier paper (Fromm, 1989), I outlined the analyst’s role in setting the frame for the treatment, which reflects his authority, and the patient’s role in using the analyst as a medium for emotional communication, which reflects the patient’s authority.
This bears directly on the problem of “treatment resistance.” By the latter term, I am not referring to resistance in the usual psychoanalytic sense, i.e., resistance to experiencing anxiety or to unacceptable thoughts or feelings, or resistance as a specific transference to the analyst. Rather, at an empirical level, treatment resistance simply refers to negative treatment results over time, and at a clinical level, it refers to the patient’s difficulties in truly joining a treatment alliance. I would argue that treatment resistance can be considered the response of some patients to treatments that do not take into account the critical issues of subjectivity - i.e., of the core meaning-making dimension of human experience – and of authority.
Of course, many treatments do not do so, for reasons that make sense within their frames of reference. Psychopharmacology operates within a traditional medical model and aims toward an objective assessment of symptoms, to be followed by a therapeutic action upon them. Cognitive-behavioral treatment invites the patient to isolate self-defeating thoughts and apply a more constructive way of thinking in those situations of anxiety where habitual, maladaptive thoughts arise. These ordinary, non-psychoanalytic approaches rely on patients’ lending themselves as both partners and “objects” to the treatment process, and may work well for those who can take themselves for granted as subjects and take the good intentions of the doctor for granted as well. But it may be that many patients who eventually come to be regarded as treatment resistant can do neither. They cannot fully use treatments that do not address the role of meaning in their symptoms and of relationships in the origin of their disturbances, and they cannot surrender to the authority of the doctor if their own confused or disabled sense of authority is not recognized.
Freud’s ideal clinical course, as re-framed by Lacan, is about the patient’s authority - the “I” that must become able to stand in the place where “It” was: the “It” referring to unintegratable affective experience, regardless of its source in impulse life or external impingement. To the degree that such affective experience overwhelms the ego’s capacities, we enter the realm of trauma. For the purpose of this discussion, suffice it to say that experience that may not be traumatic for a person who has developed a cohesive sense of self may be quite traumatic for a person who has not. For the latter patient, fantasies related to the trauma are concretized and lived out in and as reality. Their ability to use words to symbolize experience is compromised, and they need an interpersonal space to play out and thereby learn about their internal experience through the responses of others and the interpretive work of their therapy. This is the kind of space a psychodynamic therapeutic community can provide and one purpose for its work.
It was indeed the issue of trauma that led Freud to a re-consideration of the ego and its operations “beyond the pleasure principle,” this reconsideration resulting from his encounter with the psychological casualties of World War I. Trauma studies have burgeoned in the last several years, and one issue currently receiving considerable attention (Coates, 2003; Davoine and Gaudilliere, 2004; Faimberg, 2005; Fonagy, 2003; Fromm, 2012; Volkan, 2002, 2004) is the transmission of trauma from one generation to the next. Susan Coates and her colleagues (2003), studying the impact of the 9/11 attacks, argue persuasively that trauma and human bonds are inversely related, i.e., trauma is often a phenomenon of aloneness and, on the other hand, going through a terrible situation with other people tends to mitigate its traumatic effects. She and her colleagues also illustrate powerfully the unconscious attunement between children and parents, especially in situations of trauma, and the ways in which child and parent can be both in unconscious resonance with, but also dangerous isolation from, each other.
In another recent study, Davoine and Gaudilliere (2004) present findings from their psychotherapeutic work over many years with traumatized and psychotic patients. They are convinced that the psychotic patient is madly conducting a research into the rupture between his family and the social fabric, a rupture brought about through trauma and betrayal. They suggest that the unthinkable traumatic experience of the preceding generation lodges itself in highly charged but chaotic fragments in the troubled mind of the patient, who, in a sense, are attempting to give a mind to that which has been cut out of the social discourse surrounding them. Their work powerfully links the clinical arena with the historical and the political, and they illustrate persuasively that the experience of trauma must be communicated, or at least communicable, if the traumatized person is to carry on as a whole person. When it cannot be communicated in words that carry genuine emotion, it is transmitted through action - a kind of unspoken, unspeakable speech - and inevitably someone is listening: our children or, in the clinical situation, our patients.
All of this, to my mind, relates powerfully to another quote from Freud: his remarkable, mysterious and completely unelaborated declaration that "Everyone possesses in his own unconscious an instrument with which he can interpret the utterances of the unconscious in other people" (1913, p. 320). Erikson noticed similar phenomena: “the subtler methods by which children are induced to accept…prototypes of good and evil” and the way that “minute displays of emotion…transmit to the human child the outlines of what really counts” (1959, p.27-28). It seems to me that treatment resistance for some patients reflects a complex authority issue. The experience of some children has been “authored” by the unspeakable traumas of their parents. Some have been especially, if unconsciously, “authorized” to carry their parent’s trauma into the future – what I have referred to elsewhere as “unconscious citizenship” (Fromm, 2000). This “unthought known,” in Christopher Bollas’ apt phrase (1987), must come into being as emotional understanding if the patient is ultimately to take authority for his or her own life as distinct from that of the traumatized parent. Treatments that threaten to further dissociate this experience or threaten the unconscious mission to which the patient may be deeply loyal will be resisted to the death, no matter how valuable they have objectively been for other patients.
There are, of course, implications of this way of thinking for therapeutic communities as well as for individual psychoanalysis, some of which I hope will become clear in the main body of this paper, to which I now turn.





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