Winnicott and the therapeutic community

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Setting Factors

In his 1954 paper on regression, Winnicott makes the startling statement that “Freud takes for granted the early mothering situation and…it turned up in his provision of a setting for his work” (1954a, p.284). For Winnicott, it could not have been otherwise; Freud could not have provided, nor could his patients have used, such a deeply holding setting unless early mother-child experiences had been “good enough” and therefore able to be taken for granted. But with more severely disturbed patients, patients for whom regression to dependence is essential to the therapeutic action because the early environment has failed in some way, the treatment setting materializes as a crucial feature.

Winnicott’s advice to analysts who might want to treat such patients is to “watch the operation of setting factors; watch the minor examples of regression with natural termination that appear in the course of analytic sessions, and watch and use the regressive episodes that occur in the patient’s life outside of analysis” (p.293). In this chapter, I shall examine a therapeutic community program as a holding environment, attempt to illustrate the value of some of Winnicott’s concepts in understanding unfolding clinical events, and consider the role of the setting as a system, the dynamics of which may lead to “failures” of holding and consequent problematic regression in patients.
The particular therapeutic community program to be discussed takes place in a completely open and voluntary treatment setting, in which intensive psychoanalytic psychotherapy is supported by a range of clinical services. Patients agree upon admission, in the context of professional assessment of their difficulties, to be responsible for themselves with staff help. They enter a setting with no locks, restraints or privileging system, and they come and go as they wish. Nor are they required to attend psychotherapy sessions, group meetings or any other part of the program. The issue is always their alliance with the treatment, rather than their compliance. The hospital assists patients with their self-management by offering them a sensitive, well-trained staff and by building with them a therapeutic community program in which they can collectively organize themselves, join the staff in management tasks and reflect as a group on the community’s process.

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