Winnicott and the therapeutic community

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The Open Setting

In the regression paper, Winnicott “glance(s)” at Freud’s clinical setting and lists what, for him, are some of its obvious features (1954b, p.285). Winnicott was a theorist of the unnoticed obvious, nowhere more so than in his twelve observations of Freud’s clinical setting. His description captures the essential qualities of presence, boundary and space. For example, the room: “a room, not a passage”, “quiet…yet not dead quiet”, “not liable to sudden unpredictable sounds, yet…not free from ordinary house noises”, “lit properly, but not by a light staring in the face”, “comfortably warm” (p.285). Winnicott’s setting is not too much this or too little that; rather, it is nicely in-between, both special and ordinary. It offers the reliable solidness and the spaciousness in which movement, play, spontaneous gesture might arise.

A chronically disturbed patient, when asked, in the middle of a very difficult phase, what it was that made her want to continue treatment in this particular therapeutic community, answered without hesitation: “Because it’s on Main Street!” This spontaneous statement startled the staff. It spoke to the way in which the openness of this treatment setting is not simply a physical description. It is also a deep and paradoxical structural intervention for both patients and staff. In a sense, it is a loving refusal on the part of the staff to take care of patients in the traditional way, at least insofar as that tradition includes the exchanging of the patient’s resources for the expert’s care. In the same way that there is no such thing as a baby (1957, p. 137), says Winnicott, there is no such thing as a patient without a clinician, and no such thing as a chronic patient without a collusive institution.
As a refusing intervention, the open setting can be frustrating, and destructiveness is brought to bear upon it in order to test its survival capacities. But its advantages are many. It provides the space for the patient to find his or her own optimal distance and pace. It also sets up a system of values - for example, values of freedom, responsibility and negotiation - that can play a powerful part in ameliorating narcissistic pathology. Finally, even though coming to such a setting implies some breakdown in the early caretaking phases of development, it presents even the very disturbed patient with a sharply experienced choice about joining. The holding environment cannot be taken for granted as a one-directional provision of care; rather, it invites patients to join in building that which might take care of everyone and the treatment task itself. This requirement to join - to join an always uncertain enterprise involving self-declaration and the negotiation of differences - is not easy, even though it is therapeutic. It is particularly difficult for people damaged or conflicted in their relationships with others. Hence, the importance of the therapeutic community program.

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