Winnicott and the therapeutic community

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Tall, strong, competent and aggressive, this patient’s longstanding instability in her work and relational life had long since led to the diagnosis of borderline personality disorder. After some time in the community program, she was elected to the position of treasurer in the committee that coordinates and funds patient recreation projects. Another part of the treasurer’s role, for reasons lost in the program’s history, was membership on the patient-staff group that tries to deal with social problems in the patient community. Soon after being elected, this patient aggressively protested aspects of her job, especially participating in the social problems group. After discussion, the relevant patient chairpersons agreed to review job descriptions, but this was not enough for her. She refused to come to any meetings and to provide funds for ongoing projects until her demands were met, thus bringing a portion of the community’s recreation to a temporary standstill.

After a number of efforts to engage her individually and in the appropriate meetings had failed, this was brought to the Community Meeting for resolution. When full discussion and efforts at honest reflection with all relevant parties made no headway, the community, in the face of an escalating threat from this patient, voted to replace her in her role. A new Treasurer was elected and the patient was required to turn over the relevant funding materials. She had been amazingly blind to the impact of her rages and her denigration, then horrified and humiliated that the community had, in essence, voted to go on without her.
At that climactic Community Meeting, patients spoke to her about how bullying and intimidating she had been. Her first response was that they were lying, that no one was truly afraid of her and that the nursing staff did not see her as intimidating. One nurse then spoke caringly but honestly: “I agree with these patients. You have been angry and threatening lately. Last night, when you told me that if I left your side, you couldn’t be responsible for yourself, I felt like I was being held hostage. I’m surprised you don’t see yourself as threatening. I guess you need to know that sometimes you do come across that way.” Other patients and staff added their own recent perceptions, reminding the patient of other aspects of herself they had come to know besides her anger. The meeting then shifted abruptly from a tense, confrontational tone to a more conciliatory one, in which the patient began to talk about her loneliness and how friendless she had become. Later, at the evening coffee hour, patients made informal overtures to her. She joined them and soon thereafter began to help with the technical aspects of a play the community was producing.

During her subsequent treatment in and out of the treatment setting, this patient did not again enact her difficulties in this extreme way. Instead, this experience in the therapeutic community assumed the status of a symbolic event for her, to which she referred frequently in her psychotherapy whenever she found herself wanting to impose her psychological needs on external reality. Her immediate reaction, which sustained itself over time, was enormous relief that she was not necessarily the overwhelmingly powerful and destructive person she feared herself to be, and she came to understand this sense of herself as evolving from a control-or-be-controlled dynamic originating in her early life.

Getting to this level of understanding and acceptance required that the patient’s therapist remain firmly situated in empathic connection with her while also in symbolic connection with the community. The patient’s defensive tendency was toward splitting the therapist from the community and re-creating a dyadic relationship more sympathetic and yielding than her relationship with the intransigent community. These two relationships came to be seen by the patient as representing aspects of her early life experience, including sharply split experiences of her mother and later of the parental couple. The therapist’s interpretation of this triangular dynamic, including the pressure to choose sides rather than choose understanding, eventually helped the patient see the family basis for her intense feelings, but only after the concrete community situation had been held and lived through empathically.
Disturbed patients regularly threaten destructive acting out, but they are also quite sensitive to the limits of those around them. Though they recurrently flirt with those limits in order to discharge affective tension and to substantiate a sense of self, they also find ways, as this patient did, to modulate their feelings in order to preserve their relationships and their membership in the community. In the interplay between patient and community, defensively disintegrated elements of the patient’s personality are held by the process in sharp relief and made more consciously available for potential re-integration. This patient’s roles on the recreation committee and the social problems committee involved giving (money and attention respectively) to others. Not only could this large woman not stand to fit in with already established procedures, she apparently could not bear the envy that the giving aspect of her job stimulated in her.

The fallout from these difficulties had real effects on others, putting into the group the conflict the patient was experiencing. Would they be able to hold the tension, to consider her issues, to imagine granting her special request, to reflect upon what all of this might mean for them, and to face aggression without dissociation? These questions highlight the link between holding and containment (Ogden, 2005d). A primary role for community program staff is to help the total community hold this difficult situation and to facilitate the containment process: that is, to help the group direct its attention to unfinished business, to assist in the articulation of both resistance and task, to make sense of one’s own feelings, to counter pressures toward group fragmentation and to establish a “continuity of situation” through to whatever resolution the group might make (Stern et al, 1986, p.30).

The working through of this kind of episode in the community program pre-supposes the total community’s capacity to absorb aggression and yet maintain differentiated relationships (informal alliances, a range of perspectives) with the disturbing patient. Sometimes, as this one did, it ends with a reparative gesture of the patient and a deeper confidence in all concerned that the community can handle the problems that may arise. As Winnicott (1969) understood, it is no small accomplishment for the community and no small joy for the patient to find that the object of the patient’s destructive assault has survived, has held all concerned through an emotional storm, and is genuinely available to be re-joined. The psychic outcome for the patient may well be a variation of that decisive experience Winnicott refers to in the context of the object’s survival, namely, that the omnipotently destructive self, alone in a world of projections, evolves toward a potently reparative self in a world of others.
There is, however, another set of questions to be asked about this episode. Why a crisis in the community’s “chief financial officer” at that time? Why did the community elect a person so determined to say “No” in roles that also required saying “Yes”? Why was there tension at the link between social problems and recreational projects? Did this patient represent something beyond her own personal difficulties in the current community or organizational dynamic?

On this level of examination, the patient’s situation might not have come to so dramatic and risky a climax had we been able to find ourselves in her. By this I mean that it may have been no accident that issues of money and envy came to the fore in the person of this patient. Managed care in America was making its first serious inroads into psychiatric treatment. A number of patients had suffered abrupt terminations of their funding. Marked differences had erupted into the community’s consciousness between those patients whose funding was private and relatively secure and those patients whose funding was through insurance and suddenly quite insecure. Envy was inevitable around these issues of money, and recreation seemed a luxury.

All of this led not only to anxiety in the patients, but also to strong differences within the staff about how to respond to the gathering crisis. This patient’s declarations within her treasurer role that “I’ve got the power because I’ve got the money,” and “If you let me go, I’ll do something destructive” captured the enormous strains, fantasies and clinical dilemmas the staff was struggling with during this time. This broadens the issue of survival to the level of the treatment frame and the mission itself. From a psychoanalytically informed, organizational perspective, we could perhaps have seen this patient’s disturbance as both a symptom of, and a consultation to, the survival processes of the institution itself.

  1. Democracy

In his paper on democracy, Winnicott (1965b) makes the point that “a democracy is an achievement at a point of time of a society that has some natural boundary. Of a true democracy…one can say: In this society at this time there is sufficient maturity in the emotional development of a sufficient proportion of the individuals that comprise it for there to exist an innate tendency towards the creation and re-creation and maintenance of the democratic machinery” (p.157-158). Winnicott adds: “The essence of democratic machinery is the free vote…The point of this is that it ensures the freedom of the people to express deep feelings, apart from conscious thoughts. In the exercise of the secret vote, the whole responsibility for action is taken by the individual, if he is healthy enough to take it. The vote expresses the outcome of the struggle within himself” (p.157). The issues of the external world are “made personal” (p.157) through gradually identifying oneself with all parties to the struggle, thus making it a true internal struggle, and resolving the struggle, for better but quite possibly for worse, in a decisive and necessarily depressive moment.

In contrast to the “mature” individual who is able to “find the whole conflict within the self” and is therefore “capable of becoming depressed about it” (p.158), Winnicott describes first those individuals with an antisocial tendency, born of deprivation and eventuating in a ruthless and aggressive claim against authority and second, the “hidden antisocial” (p.158), insecure in his personal identity and borrowing on the authoritarianism around him to keep an internal peace. For Winnicott, the “whole democratic burden” (p. 159) falls on that crucial critical mass of relatively mature individuals. He finds an anti-democratic tendency in many of society’s institutions, cautioning “the doctors of criminals and of the insane…to be constantly on guard lest they find themselves being used, without at first knowing it, as agents of the anti-democratic tendency”(p.160). What nurtures the democratic tendency? Winnicott simply refers to “ordinary good homes” (p.160), focusing only on the possible interferences of society with the good sense and natural authority of parents.

How does this apply to a therapeutic community? To the degree that the therapeutic community is built upon democratic principles - principles such as the belief that each person’s voice matters, the conviction that finding one’s authentic voice is therapeutic, and the recognition that participation in decisions by which one is affected is both just and healthy - it relies upon the collective maturity of embattled, deprived and insecure people. To the degree that the therapeutic community exists within a medical model, it is vulnerable to the hidden antisocial or authoritarian tendencies involved in the localization and control of illness. And yet, one could also make the case that a therapeutic community program that facilitates the living out of democratic principles is inheritantly therapeutic and its successes increase the collective maturity of the whole.

Winnicott once quipped that an adult is a person with a point of view. A democratic frame of reference invites a person toward discovering his or her point of view, toward declaring it publicly, toward listening to the points of views of others and, in doing so, toward learning more, surrendering or standing one’s ground. It faces its members with problems of difference, conflict and compromise, with moments of decision that both join and separate one from others, and with the requirement to re-join, after the battle so to speak, in order to carry on something larger than the self, namely, the total community’s life. This terrain - between one-ness and two-ness (on the way to third-ness) - is the political equivalent of that developmental territory leading up to the depressive position, which Winnicott linked with severe personality disorders.
Patients in this kind of therapeutic community program are challenged in the place they most need to develop, that is, toward taking authority in a world of others rather than simply being subject to the authority of others or attempting to dominate them. The open setting for a therapeutic community structurally recognizes the separate authority of the patient group, the authority of a citizen-consumer rather than a quasi-employee and rather than a patient role in which authority is simply surrendered to the staff. It requires a partnership between an authorized patient group and a receptive staff group in order to maintain its functioning and maximize the treatment benefit. It also requires staff leadership to hold this authority differentiation, to work with it and to lead reflection about democracy-eroding inter-group dynamics.

  1. Cultural Crisis

At a Community Meeting, a young, first generation, Korean American woman challenged the candidacy of an older man who was running for an eight-week term as Community Chairperson, a position of considerable authority in the community program. She confronted him with his overtures toward a new female patient and the dangers of romantic entanglement while in treatment. She justified her insistent questioning by saying: “It’s not that I don’t want you to become chairperson. It’s that I want you to really want it, to love it, to not be put off by anything that I or anybody else could say to you.”

The consultant to this large meeting found himself commenting on a theme in the discussion that linked to cultural differences. The candidate was arguing what could be heard as an American position. There was the community’s need for leadership, but there was also this man’s own “pursuit of happiness” with this new female patient; he emphasized the good job he could do for the community, but also how this job would be “good for (his) therapy.” His challenger was speaking with passion against this divided self, from a place where role and person could be imagined to be one, where giving oneself over to the role might occur so completely that it would be distracting, trivializing and irrelevant to wonder about one’s own therapy as in any way separate from this commitment to community. From this perhaps more Eastern place, “loving it” meant not concerning oneself at all with any notion of personal desire as separate from the community’s.

This issue resonated deeply in the patient’s life history. Her life had been shaped by events before she was born. Her father had sent his first child back to his home village because he and his wife could not care for an infant while they were completing their law degrees in the city. Later, during the patient’s early childhood, her mother’s rage and guilt at having acquiesced to this separation led the father to forfeit his place with his second child and to give her over to a now fiercely possessive mother. The patient’s adolescent struggle to separate could only be seen by her mother as an evil betrayal by her daughter or as an evil infiltration by American culture bent on taking away her second child. Thus, along with her ferocious but deeply guilt-inducing autonomy struggle, the patient also felt an enormous wish and fear about surrender.

The Community Chairperson position eventually served an important compromise function for her. During the next term, to everyone’s surprise, this quite young woman firmly declared her candidacy and took up the position with more natural authority than anyone in recent memory. She unambivalently surrendered herself, not to another person, but to what is best in the American system, and she found in her learning about authority a way of becoming clearer about her life in her family.

As though a microcosmic study in Erikson’s Life History and the Historical Moment (1975), she led the entire community through a fascinating period. Because of the discharge of a number of more experienced patients, newer patient leadership was struggling to develop, some patient offices were not filled, and some functions, which patients had performed ably, were left undone. Staff became anxious, unconsciously longed for their older culture of long-term treatment with less frequent patient turnover and began, again unconsciously, to direct patients as though they were employees. This patient as Community Chairperson felt this possessiveness based on a potentially lost culture keenly, and she stopped it through an amazing clarity about the distinction between patient and staff authority. In Bion’s (1961) terms, she brought a powerful unconscious “valency” (p.116) from her family dynamic to the community, which became available as a resource in the face of an unconscious democracy-eroding staff-patient process. Perhaps representing the Third (Muller, 1996), which derives from a paternal function, the staff consultant firmly supported the effort to hold the distinction between staff and patient authority.

Instead of complying with staff need and losing the patients’ authority in the process, the Chairperson addressed her constituency. She realized that they had lost touch with whether or not they wanted these endangered community functions, and she had the strength to let them go, rather than to cajole or coerce people toward keeping them going for the sake of tradition. She led the community in risking that many age-old community practices would not survive, in order to find what the community might actually want to survive from within itself. In a sense, she led a process that Winnicott (1945) once called “realization”, that is, the developmental process through which necessary illusions - in this case, the patients’ illusion that the community is only a play-space and the staff’s illusion that the community carries out their dreams - admit an appreciation of external reality.

Soon the patient community felt the value of these community functions and took them up again in a more vital way. And the staff too, with considerable gratitude, rediscovered their appropriate roles as partners to the patient enterprise. This was true cultural renewal. In leading it, this patient seemed to have reworked important family issues for herself, as she was also helping the community. For example, one meaning of suicide in this patient’s life, as she came to realize in her psychotherapy, related to an extreme claim to her own personal authority, an effort to kill a false-self adaptation (Winnicott, 1960) and to discover what might survive as her true desire. She insisted, almost at the cost of her life, on truly being let go of by her mother (and on her own letting go of her mother) so that a felt and chosen connection to her culture and to her mother might have a chance to develop from within. We see here personal crisis meeting community crisis in which a particular person seems to have been called unconsciously to a role and a crucial task: namely, redressing the total community’s shift toward false-self adaptation by rediscovering what, if anything, within the prevailing tradition might be actively joined as true.

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