Clinical I DB. Week 5

Child and Adolescent Social Work Journal Volume 10, Number 1, February 1993

Winnicott and Clinical Social Work: A Facilitating Partnership

Jeffrey S. Applegate, DSW

ABSTRACT: This article examines the applicability of D. W. Winnicott's theoretical concepts to clinical social work practice with clients whose psycho- social well-being has been compromised by environmental deprivation and related developmental vulnerabilities. This examination is organized around three questions: (1) Why is Winnicott relevant for social work? (2) Which of his concepts are most useful for social workers? (3) How can these concepts be put into practice with social work problems and populations? The translation of theory to practice is illustrated with case material.

Recently, in tandem with the widening scope and broader application of psychoanalysis, there has been renewed recognition of and enthusi- asm for Donald Woods Winnicott's unique contributions to clinical theory and practice. Since the mid-1980s, several collections of Win- nicott's previously unpublished papers have appeared (see Winnicott, 1984, 1986, 1988a, 1988b, 1989); and there is a growing body of schol- arship about his ideas and their application to clinical practice (see Clancier & Kalmanovitch, 1987; Davis & Wallbridge, 1981; Fromm & Smith, 1989; Giovacchini, 1990; Grolnick, 1990; Grolnick & Barkin, 1978; Phillips, 1988). Scholars of psychoanalytic metapsychology have identified Winnicott as a pivotal figure in the paradigm shift in psychoanalysis from a drive-based to a relational psychology (Green- berg & Mitchell, 1983; Hughes, 1989; Rudnytsky, 1991). And several social work authors have written about the applicability of Win- nicott's concepts to their work in a variety of settings (Applegate, 1984, 1989, 1990; Applegate & Barol, 1989; Chescheir, 1985; Ches- cheir & Shulz, 1989; Kanter, 1990; Sanville, 1991; Zerbe, 1990).

The author wishes to acknowledge and thank Jennifer Bonovitz, Ph.D., for her con- tribution of the case material for this article.

Dr. Applegate is on the faculty of the Graduate School of Social Work and Social Research, Bryn Mawr College. Address correspondence to the author at the School, 300 Airdale Road, Bryn Mawr, PA 19010.

3 © 1993 Human Sciences Press, Inc.

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A British pediatrician and psychoanalyst who died in 1971, Win- nicott devoted much of his distinguished career to work with deprived children and their families. He theorized, practiced, and taught from a hmnanistic value base that is strikingly congruent with social work's values, principles, and mission. He was sensitively attuned to the impact of separation, loss, and environmental trauma on human development and well-being. He consistently paid attention to issues of context and culture in his work and, among psychoanaljrtic theo- rists, he was the first to articulate a rigorous conceptual framework for understanding people's interactions with the inanimate environ- ment. Many of Winnicott's key formulations lend depth and precision to social work's person-in-situation perspective—a perspective that, despite a century of development, remains conceptually elusive.

The purpose of this paper is to explicate the compatibility between several of Winnicott's key concepts and clinical social work practice. The paper will address three questions: (1) Why is Winnicott relevant for social work? (2) Which of his concepts are most useful for social workers? (3) How can these concepts be put into practice with social work problems and populations? The translation of theory to practice is illustrated with case material.

Why is Winnicott Relevant for Social Work?

Since its inception, the profession of social work has viewed the help- ing relationship as the bedrock of practice. Through decades of accu- mulating practice wisdom in a wide vEU-iety of settings with clients and social systems presenting the most challenging of human diffi- culties, we have learned to take the centrality of the relationship for granted. But, nearing the end of the 20th century, the profession finds itself in an age of efficiency and accountabihty that asks us to make assessments and treatment plans quickly, often after one session; to demonstrate the efiFectiveness of our interventions through a focus on outcome rather than on therapeutic process; and to do all this in a con- text of restricted funding and diminishing resources. In this climate it is easy to overlook the value of the relationship in our work—to lose sight of process as we get caught up in content and outcome.

Winnicott's concepts offer clinicians a frame of reference and an accessible language for keeping the relationship in the spotlight, re- gardless of the nature of the intervention. His ideas speak to the cru- cial importance of the details of relationship building. These ideas

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derive from his (literally) thousands of consultations with infants and their caregivers. From attending carefully to infant-caregiver interac- tions and theorizing about the meaning of these interactions, Win- nicott developed concepts that highlight the importance of the early facilitating environment in enabling infants to begin to put the bits and pieces of their inner and outer worlds together. He then trans- posed elements of his evolving theory to clinical work with children and adults, recognizing that through supporting and sustaining adap- tive person-environment transactions, clinicians help clients put the bits and pieces of their worlds together.

Much of Winnicott's work was, in fact, social work. Through his activities in the World War II Evacuation Project and his practice in a pediatric clinic in London's poverty stricken East End, he became aware of issues of family fragmentation, homelessness, neglect, depri- vation, and other aspects of environmental failure (Phillips, 1988). His exposure to these issues roused him to social action; he was an advocate, public spokesman and activist for the mentally ill, depen- dent children, delinquents, and other vulnerable popidations. He was a vocal opponent of psychosurgery, ECT, aversive behaviorism and other procedures which he believed to be dehumanizing (Rodman, 1987; Winnicott, 1989). Winnicott's extensive work with people suf- fering from major mental illness involved him with psychiatric social workers, one of whom, Clare Britton, became his second wife. To- gether they practiced and wrote about what today is called mental health "case management"—finding and sustaining facilitating envi- ronments for troubled people in the community (Kanter, 1990). He also taught social workers at the London School of Economics.

Winnicott was committed to the principle of client self-determina- tion. He believed the aim of clinical services to be "not a directing of the individual's life or development, but an enabling of the tenden- cies that are at work within the individual, leading to a natural evo- lution based on growth" (Winnicott, 1963, p. 228). In addition, he was throughly grounded in a person-in-environment conception of human functioning and helping efforts, rejecting dualistic conceptions and in- sisting that individual development and the environment are in con- tinuous transaction. As he put it, "the unit [of clinical attention] is not the individual, the unit is an environment-individual set-up" (Winnicott, 1952, p. 99). In summary, much of Winnicott's approach to understanding and aiding others is epistemologically congruent with social work's commitment to combining "people-helping" and "society-changing." His developmental and clinical concepts help us

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re-value and re-emphasize an understanding of the dynamics of the helping relationship as central to all social services.

Which of Winnicott's Concepts Are Useful for Social Work?

Five of Winnicott's concepts have particular relevance for social work: the holding environment; ego relatedness; the transitional object; ob- ject relating and object use; and the true and false self These con- cepts can be used to conceptualize the range of social work activities, from providing concrete services to conducting psychotherapy and psychoanalysis.

The Holding Environment

Chescheir (1985) notes that "Creating holding environments is the essence of social work and the beginning link between Winnicott's concepts and good clinical practice" (p. 220). Winnicott (1960b) first spoke of the holding environment in relation to caregivers' ministra- tions to infants in the earliest weeks arid months of life. But, beyond the physical act of cradling the infant, Winnicott believed that hold- ing describes the entire environmental provision, including inani- mate surroundings. As he saw it, this provision should be charac- terized by consistency, reliability, and protection from impingement or trauma from within (internally generated anxiety) and from with- out.

Winnicott applied the holding environment concept directly to so- cial work in a number of instances. He asserted that "the term 'case- work' c£in be looked at as a highly complex extension of the use of the word 'holding' and as a practical application of care-cure" (Winnicott, 1970a, p. 120). In another instance, he noted that "Casework might be described as the professionalized aspect of this normal function of parents and local units, a 'holding' of persons and of situations, while growth tendencies are given a chance" (Winnicott, 1961, p. 107). Fur- ther, he articulated a systems view of the holding function: "One can discern a series—the mother's body, the mother's arms, the parental relationship, the home, the family including cousins and near rela- tions, the school, the locality with its police stations, the county with its laws" (Wiiuiicott, 1956b, p. 310). As he saw it, sustaining inter- ventions can occur at any of a variety of these systems levels.

Attention to the holding concept is crucial in initial engagement with clients. From his observations of infants and their mothers. Win-

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nicott (1956a) noted the importance of the mother's turning inward toward the end of pregnancy to "attend" to the fetus growing inside her. He termed this indwelling state "primary maternal preoccupa- tion" (p. 300), an altered state of consciousness that lingers for sev- eral weeks after birth until mother and infant are seciirely bonded. The mother's preoccupied state fosters her empathy for the infant as she draws from her own experience of being mothered to tune into what the infant must feel like and need. Similarly, initial engage- ment with, clients requires a "primary therapeutic preoccupation" with what they feel and need. Providing this kind of interpersonal "holding" for clients requires that social workers are adequately "held" and attended to by their practice environments.

In social work we encounter many clients whose earlier holding environments have let them down or "dropped" them, jeopardizing their capacity for basic trust and leading to what Winnicott (1988a) called "unbearable agonies"—feelings of falling forever, of bodily dis- integration, of depersonalization and disorientation. To defend against the rearousal of these anxieties, clients may fear and avoid interpersonal situations—including the clinical relationship with its inherent dependency—which might make them feel vulnerable to be- ing "dropped" again. Working with clients whose earlier holding en- vironments have let them down calls for acute sensitivity to their tolerance for closeness and their need for an optimal distance that helps them feel safe. With clients for whom sitting in an office may feel too close, for example, clinicians may make home visits, take a walk, talk on the phone, or chat at a bus stop, "starting where the client is" in building a trusting relationship. Sometimes vulnerable clients can tell us how they feel only through projective identification, i.e., by setting up interpersonal conditions that compel us to feel what they are feeling but can't contain or articulate. Judging the parame- ters of optimal closeness and distance, therefore, requires that clini- cians turn inward to attend to their countertransference and related affective states.

Ego Relatedness Once at a meeting of the British Psycho-Anal5i;ic Society, Winnicott (1960b) declared, "There is no such thing as a baby!" Elaborating on this provocative assertion, he said that "whenever one finds an infant one finds maternal care, and without maternal care there would be no infant" (p. 39). Presaging recent findings from research on infants, Winnicott (1988b) was quite aware that even very young infants have

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experiences of themselves as distinct individuals. He noted, for exam- ple, that "By the end of two weeks any baby has had plenty of things happen that are entirely personal" (p. 29). His focus was not on the baby and caregiver as individuals, however, but on the deeply at- tirned "nursing couple" created by their interactions. He recognized the importance of the baby's earliest spontaneous gestures in shaping infant-caregiver mutuality (Winnicott, 1970b). For example, he noted that, at a certain point in development, the nursing infant will reach up to put a finger in the mother's mouth, symbolically "feeding" her as she or he is being fed.

As applied to clinical work, ego relatedness suggests that "there is no such thing as a client"—only the relationship between collabora- tive partners in the helping relationship. This concept does not ne- gate the existence of two individuals in different roles; rather it em- phasizes the necessity of a profound sense of mutuality between client and clinician. Such mutuality has the paradoxical effect of helping the client discover her or his sense of self as separate and self-regulat- ing. In a paper entitled "The Capacity to Be Alone," Winnicott (1958) suggested that only when alone in the intimate presence of another can the infant discover a personal life. Similarly, only when they learn to tolerate the experience of feeling separate in the presence of a concerned other do clients claim their true selves. Many clients seen by social workers have not yet developed the capacity for this ego relatedness; the therapeutic relationship may provide one of their first opportunities to do so. This concern underscores the crucial im- portance of attending to the relationship as the primary context for everything else we may do with the client.

Transitional Objects and Phenomena The concept of the transitional object constitutes Winnicott's most well-known contribution to psychoanalytic development psychology. In the paper in which he coined this term, Winnicott (1953) observed that, as the baby becomes aware that the caregiver is a self-regulat- ing entity who may not always respond in perfect synchrony with her or his needs, the baby may reach into the inanimate environment for an ohject—a hlanket, piece of blanket, stuffed toy—that smells, tastes, and/or feels like the caregiver aitid which becomes a symbolic substitute for maternal care in the caregiver's absence. Sometimes a lullaby or other bedtime ritual can become a less concrete transi- tional phenomenon. Whatever its form, such behavior signals the de- velopment of a transitional process which enables the child creatively

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to find her or his own means of self soothing while dealing with the ambivalence associated with self-object differentiation and giving up the illusion of omnipotence. Winnicott (1953) believed that, while at- tachments to early transitional objects and phenomena may fade, the transitional process continues throughout life and becomes trans- posed to a capacity for imaginative engagement with such cultural expressions as art, music, and religious feeling. The transitional pro- cess gives rise to an awareness of an intermediate area or "potential space" between self and other that is the realm of imagination, play, culture, and psychotherapy (Winnicott, 1971a).

Social work clinicians see many people whose capacity for transi- tional relatedness has been compromised by various forms of environ- mental deprivation. We must be alert, therefore, to the junctures in our work when clients begin to develop this capacity. Sometimes it becomes clear that we as clinicians become transitional "objects" for clients; they may need to phone us between appointments in order to activate a self-soothing capacity, for example. Sometimes a toy in the playroom can serve a transitional function. Providing an appointment card at the end of a session can be transitional, symbolizing some sense of ongoing connection between appointments along with a con- crete promise of reliability and constancy.

Object Relating and Object Use

Winnicott (1971c) believed that the transitional process facilitates the journey from object relating to object usage. Demonstrating his ten- dency to use language in elliptical, idiosyncratic ways, he employed the term "object relating" to describe the subjective, projective mode of experiencing in which the other seems to be under the infant's om- nipotent control. "Object usage," in contrast, is related to the infant's growing perception of the other as self-regulating and separate, and, thus, outside omnipotent control. "Use" in this context does not con- note exploitation, but rather suggests the capacity for relating to others as external, objectively perceived persons who can serve as re- sources for growth rather than as projective entities.

To understand how the transition from object relating to object use occurs, we must consider Winnicott's (1971c) unorthodox views of ag- gression and destructiveness. He viewed aggression, not as an innate antisocial drive, but as synonymous with motility, activity, and vital- ity—part of the life force that seeks differentiation. To render the object usable requires "that the subject destroys the object" (1971c, p. 89). By this Winnicott meant that the infant, in fantasy, must "de-

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stroy" the old version of the subjectively perceived, projective object as she or he moves from feelings of merger and omnipotence toward the acceptance of separateness. The trick is for the caregiving object to "survive" these destructive fantasies and associated behaviors. If the caregiver can survive and not retaliate, the infant is able to say to herself or himself, "You have value for me because of your survival of my destruction of you" (p. 90). From experiencing the resiliance and indestructability of the other, the developing child is reassured of the durability of the self.

As clinicians we must recognize and be accepting of our clients' aggression and their periodic need to "destroy" us as they learn to use the helping relationship to gain a solid sense of self. Many of our clients have had early experiences wherein environmental depriva- tion made it difficult for their caregivers to respond adaptively to their normal aggression. Rather than applaud their children's ag- gressive thrusts toward differentiation, some caregivers have retali- ated. With such clients, we may need to he ready for repeated tests of our ability to "survive" without retaliating. Out of the mutuality and feeling of safety that develops from this capacity suises the capacity for concern—the striving to make reparation to, care about, and con- tribute to others. Here is bom the sense of interpersonal connected- ness, intersubjectivity, empathy, and social responsibility.

The True and False Self

The capacity to integrate a sense of normal aggression and sensuality into one's self-image is part of what comprises the "true self—a sense of feeling real and alive in the world (Winnicott, 1960a). This sense of self includes a capacity for spontaneity and a tolerance for being in touch with one's bodily (instinctual) feelings and impulses without having to discharge them immediately. The development of a true self in infancy depends in turn upon the caregiver's capacity to receive the infant's spontaneous gestures, hoth loving and hating, without retaliation or putting one's own needs before the infant's.

Either hecause of lack of support or because of their own develop- mental vulnerabilities, some caregivers substitute their own "ges- tures" for the infant's and demand the infant's compliance. In re- sponse, the infant, rather than feeling free to assert a hody-connected "true" self, constructs a compliant "false" self that lacks spontaneity and may be overlain with an obsequious, subtly distancing veneer. Such children learn to take care of their caregivers—to tune into others but cut themselves off from their needs and impulses. As

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adults, they may appear outwardly successful and socially facile but report a feeling that life has no meaning or substance. Instead of a psychological organization that remains grounded in the aliveness of the body, the mind takes over, blunting emotional experience. With such clients, it is paramount to make sure they do not need to take care of us or put our needs first. Responsive clinical work with these clients includes attending to countertransference and remaining open to and accepting of their spontaneous gestures (both loving and hat- ing) as signals of a beginning experimentation with the "true" self in a safe relationship.

How Can Winnicott's Concepts Be Put Into Practice?

Winnicott did not systematically articulate his principles and tech- niques of practice. Rather, his views on practice are woven through- out his theoretical papers and exemplified in accounts of his work. In addition to a collection of brief consultations with children (Win- nicott, 197Id), there are two extensive narrative accounts of his ana- lytic work: one with a child (Winnicott, 1977) and the other with an adult (Winnicott, 1972/1986). And two of his patients have written about the experience of being in treatment with him (Guntrip, 1975; Little, 1990). These accoiints reveal a clinician well grounded in clas- sical psychoanalytic theory who was also free to experiment and "play" creatively with new ideas and intuitively derived interven- tions.

In a paper addressed specifically to social workers, Winnicott (1963) offered a set of practice guidelines that, while intended for work with the mentally ill, are applicable to a wide range of people and situa- tions and clearly evolve from the concepts described above. They are quoted here as Winnicott wrote them:

"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 respon- sibility. You behave yourself professionally. You concern yourself with your client's problem. You accept being in the position of a subjective object in the client's life, while at the same time you keep both your feet on your ground. You accept love, and even the in-love state, without flinching and with- out acting-out your response. You accept hate and meet it with strength rather than with revenge.

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You tolerate your client's illogicality, unreliability, suspicion, muddle, fecklessness, meanness, etc., etc., and recognize all these unpleas- antnesses as symptoms of distress. (In private life these same things would make you keep at a disteince.) 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 the client. In all these emergencies you recognize the client's call for help, or cry of de- spair because of loss of hope of help" (p. 229).'

These guidelines, simply put but deceptively complex, can serve as a conceptual holding environment for clinicians confronting the range of perplexing human difficulties. They touch on the basic attitudes and inner psychological state of the clinician. They imply that, if we are to contain and integrate the powerfully ambivalent feelings pro- jected onto us by our clients, we need to have faced and reached some level of comfort with these feelings in ourselves. The foUoAving case vignette demonstrates the application of several of these guidelines.

The Case

A hospital social worker sat in her office preparing to meet Ms. C, a 29 year- old woman referred by the emergency room pediatrician who had treated her two year-old son. Tommy, for a severe burn on his arm. Though Ms. C. re- ported that Tommy had "messed around", with a pan of boiling water on the stove, a glove-like pattern to the bum led the pediatrician to suggest that Ms. C. had inflicted it.

In telephone conversations, the pediatrician and the emergency room nurse both portrayed Ms. C. as sullen, uncooperative, and openly hostile. She en- raged the staff by her apparent nonchalance about Tommy's injury. This in- formation evoked in the social worker image^ of an angry, punitive, unfeeling person. She became aware of feelings of trepidation and vincertainty, along with an expectation that her overtures would be met with hostility. Pausing for a moment to tune in to her own feelings gave the worker a chance to identify with feelings that Ms. C. might be e^eriencing as she sat waiting to meet the worker. Perhaps, she, too, was uncertain and fearful of the worker's hostility. With this awareness the worker recognized that demonstrating a capacity to stay with Ms; C. emotionally, even when confronted by hostility and in spite of her own reactions toward Ms. C.'s possible abuse of her son, would represent a successful beginning.

The worker's first glimpse of Ms. C. and Tommy in the emergency room

'From T h e mentally ill in your caseload" by D. W. Wimiicott, 1963, The matura- tional processes and the facilitating environment, ^. 229. Copyright 1965 by Interna- tional Universities Press, Inc. Reprinted by permission.

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cuhicle revealed a prohahle disturhance in their relationship. Tommy lay list- lessly on the hed, his head turned toward his mother who sat in the comer furthest from him, filing her fingernails. This scenario evoked strong mater- nal feelings in the worker, who fought impulses to comfort the hoy or to en- courage his mother to do so. Instead, she noted the detachment as a signed that forming an attachment to Ms. C. might he a formidahle challenge.

Taking a chair at as much distance from Ms. C. as the small cuhicle would allow, the worker hegan hy commenting, "I'm so glad you brought Tommy in so quickly. You were right in realizing that the hum on his arm is severe and that it needs medical attention." Ms. C. put her nail file away and a fiicker of surprised irritation crossed her face: "All I want is to get out of here—Fm tired of waiting around for all these people to poke their noses in my husi- ness. I hrought my kid here to have his arm fixed and now that that's done I w£int to go home and get some rest." She then stood up and picked up her coat. The social worker felt challenged and had a sense of the importance of standing her ground.

Ms. C.'s allusion to people asking too many questions suggested that she was feeling attacked and needed to strike hack and flee in an attempt to protect herself against overwhelming anxiety. It was as though she dared not risk trusting the worker. To help Ms. C. contain this anxiety, the worker focused on providing a firm, calm presence. Remaining seated, she said that Ms. C. did look tired and that she'd heen through a lot. She added firmly, however: "We do need to talk further ahout Tommy, and then you will he ahle to go home." At this point she noticed heavy nicotine stains on Ms. C.'s fin- gers and surmised that smoking might he one way she soothed her anxiety. Since smoking was not permitted in the emergency room, she invited Ms. C. to her office where she could smoke and have more privacy. With a cigarette and a snack, Ms. C. appeared to calm down.

Over several contacts, it hecame clear that Ms. C. had in fact inflicted Tommy's hum and that she was hecoming increasingly depressed. A psychi- atric consultation was arranged and she was given a prescription for anti- depressant medication. Tommy's father, Mr. S., hrought Ms. C. to the consul- tation and they hoth met hriefiy afterward with the social worker. When the worker explained to them that the child protective services worker was ar- ranging a temporary foster care home for Tommy until Ms. C. could get hack on her feet, Mr. S. stood up and swore, declaring that "There's going to he no foster home for my son." The worker was aware that, though he wanted to control this situation, Mr. S. had refused to support Ms. C. and Tommy finan- cially hecause he did not yet want to make a commitment to them. The worker hecame a conscious of struggling to hold hack a surge of anger; she felt on the verge of losing control £ind saying something hurtful to Mr. S. She sensed herself withdrawing from him, and, perhaps sensing this, he hegan to pace and threatened to call a lawyer.

Struggling to keep control, the worker remained silent a few moments as she tried to find some meaning in her feelings of anger and helplessness. Realizing the strength of her impulse to strike hack at Mr. S., she hegan to sense whiat his internal struggle might he. Perhaps he, too, was harely man- aging an impulse to strike at her in anger, perceiving her as not truly com- mitted to helping him keep his family together. She realized that he may

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have felt trapped and helpless, fearing that if he alienated her she would retaliate hy presenting him unfavorahly when the case went to court. Finedly, armed with this awareness, the worker looked Mr. S. in the eye and said, "Tommy means a lot to you. I understand that. Being out of control of what happens to him must feel terrihle." This intervention seemed to calm Mr. S.'s anger and preserve the relationship.

Later, on a home visit, the elevators in the project where Ms. C. lived were hroken and the worker had to climh 12 flights of stairs on a steamy summer day. By the time she arrived at Ms. C.'s door, she was hreathless and trem- hling, not only from the unaccustomed exertion hut also from fears generated hy newspaper stories of muggings and stahhings in the housing project. Ms. C. greeted the worker, and, after looking her over for a moment, said, "You'd hetter sit down and have a cool drink." Here Ms. C. had an opportunity to "feed" the worker, who was touched hy Ms. C-'s capacity for concern for her— a strength she helieved could he mohilized to help Ms. C. in her mothering of Tommy.

During this visit, Ms. C. recalled growing up in a high-rise huilding with no elevators. Because her parents fought a lot, she spent a good part of her early years with her grandmother.

Ms. C : "She was strict hut you always knew where you stood with her. Worker: "It sounds like you could count oh her." Ms. C : Yes, not like my dad. We never even knew if he was coming home at night or if he would just start whipping us hecause he felt like it. Mom used to leave sometimes just so he woiildn't start heating up on her, too." Worker: "So there was nohody there to protect you?" Ms. C : "Not unless I could run to my grandmother's."

With the worker's encouragement, Ms. C. went on to descrihe several mem- ories of her grandmother. One recollection that she recounted in detail and with great affection was that of getting dressed up every Sunday to go to church. The grandmother loved to sing hymns in a very loud voice, and Ms. C. would stand hy her side, swaying hack arid forth as she sang, too.

Worker: "When you were with your grandmother you could feel good ahout yourself. You knew she really cared."

. Ms. C : "I often used to think ahout her when things got had after she passed. I'd think ahout her up in heaven singing with the angels and looking down on me."

When the worker called the follovdng week to confirm the time of her next home visit, Ms. C. responded in a fiat tone and said she was too tired to straighten up the apartment and would rather cancel the appointment. The worker speculated that the sad feelings Ms. C. had experienced during the previous session might have precipitated soine depression. The worker asked, "Do you think your not wanting me to come today could also have to do with all the painful things we talked ahout last time?" Ms. C. said that she had spent a good part of the day after the last interview in hed and she didn't

JEFFREY S. APPLEGATE 15

want to go through that again this week. The worker responded, "I think that you are so used to dealing with all your sad, angry feelings hy yourself that you are afraid to try it any other way. I would like to come today even though you don't want to see me. If you still feel the same way after we have talked a little, you can tell me and I will leave."

By the time the worker arrived, Ms. C. had straightened the apartment. She sat at one end of the couch and the worker sat at the other. There was an awkward silence dviring which the worker pondered ahout how to reconnect with Ms. C. Then, almost imperceptihly, Ms. C. hegan to rock hack and forth, singing softly to herself. At first the worker was unsure of the meaning of this hehavior, wondering if Ms. C. were hallucinating. But as Ms. C.'s voice grew stronger, the worker recognized a hymn from her own childhood. Trust- ing her intuition that Ms. C. was trying to recapture the image of the good grandmother who had loved and protected her, the worker responded hy singing softly. Ms. C.'s face lit up, and at the end of the next chorus of this impromptu vocal duet, she stopped and said that she had found some photo- graphs of her grandmother that morning and wanted to show them to the worker. She recalled happy memories ahout the things they had done to- gether.

The visit ended with Ms. C. informing the worker that she had made a medication follow-up appointment with the psychiatrist. She asked if she could come to see the worker on the same day. As the worker confirmed the appointment time, she realized that Ms. C. was sitting next to her on the couch. She had moved closer in order to he ahle to share with the worker the photographs of her grandmother.

Discussion

As the social worker prepared to meet Ms. C. for the first time, she achieved an empathic identification -with her hy tuning into her own mixed feelings generated by the information received from collat- erals. Her capacity to reflect quietly on the range and meaning of her feelings fostered a primary therapeutic preoccupation that prepared her to offer Ms. C. a facilitating environment for their first meeting. Her keen observations of Ms. C. and Tommy helped the worker find the parameters of optimal closeness and distance and, then, to ar- range the interview in ways that would not threaten her. For Ms. C, the holding environment needed to he supportive hut not too confin- ing.

Early in their work, Ms. C. used anger and avoidance to test the worker's capacity to "survive" without retaliating. During this phase, the worker remained calmly consistent and empathic while setting firm limits that helped keep the clinical holding environment intact. Throughout, the worker made supportive and interpretive comments

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that demonstrated an understanding that Ms. C.'s hehavior had meaning and adaptive value. By responding in ways that were at odds with Ms. C.'s expectations, the worker surprised her hy surviv- ing the anger, offering her a glimpse of a separate, self-regulating person who differed from her peist objects and could possibly oflfer a different kind of relationship.

Permitting Ms. C. to "feed" her during the initial home visit gave the worker an opportunity to further solidify the ego relatedness that was taking shape between them. Suhsequently, painful feelings asso- ciated with emerging memories of the lost grandmother threatened to overwhelm Ms. C.'s fragile ego and to disrupt the therapeutic rela- tionship. By gently urging Ms. C. to let her make the home visit in spite of Ms. C.'s wishes to cancel it, the worker demonstrated that she could care about her even when she felt depressed and fhat she could help Ms. C- hear the sadness associated with her feelings of loss. Based on these sustaining techniques, Ms. C. and th? worker were able to connect further through the transitional process: the worker was ahle to recognize and respond to the spontaneous gesture of Ms. C.'s singing. With music, they discovered a shared intermediate area, or potential space, within which their engagement could be solidified and affirmed. Pictures of the grandmother—treasured transitional objects—helped bring the pair closer still. With the relationship more firmly grounded, the sense was that Ms. C. could begin to give up her hostile, defensive "false self posture to reveal her "true self to the worker. In turn, the holding environment provided for Ms. C. enabled her to "hold" rather them abuse her youing son.

Conclusion

A review of several key concepts and a case vignette suggest that D.W. Winnicott's theoretical contributions can inform and enrich clinical social work practice. For clinicians committed to a psycho- dynamic approach, these creative contributions have particular rele- vsmce to practice with clients whose well-being has been compromised by environmental deprivation and related developmental vul- nerabilities. Winnicott's ideas help us respect the centrality and com- plexity of the therapeutic relationship, regardless of the urgency and seeming concreteness of the presenting problem. Moreover, they pro- vide a useful map for navigating the intermediate terrain that lies between clients' inner worlds and their challenging external realities.

JEFFREY S. APPLEGATE 17

In closing, two caveats related to the application of Winnicott's ideas should be noted. First, the seeming simplicity with which he expressed his concepts may lead some clinicians to adopt them in a literal manner. Such reification can promote an infantilizing re- parenting posture that barely masks potentially dangerous assump- tions. One assumption is that, sometime early in the client's life, caregivers did a poor job. Lurking just beneath this assumption is another that can be even more insidious: that the clinician can do a better job, thus rescuing the client. Combined, these assumptions can promote fantasies of omnipotence that may culminate in the misuse of clinical authority and other expressions of countertransference act- ing-out.

Second, some feminist scholars have suggested that the emphasis on the centrality of the mother in Winnicott's and other object rela- tions theorists' concepts contributes to gender-unequal childcare, mother-blaming, the cultural devaluation of women, and the perpetu- ation of the patriarchy (see Okun, 1992). These critics also point out that object relations theory ignores the social, political, historical, and economic factors that influence people's internal lives. Perhaps more than others, Winnicott did address issues of culture and context (see 1971b); and his frequent suggestion that mothers need be only "good-enough" would seem to support rather than blame them for im- perfection. Nevertheless, as social workers we do need to pay special attention to the sociopolitical messages embedded in theory and to consider the range of situational factors that influence practice. Such concerns offer opportunities for clinical social workers to build cre- atively on Winnicott's idesis. I believe he would be delighted hy this prospect.

Acknowledgement

A version of the article was presented at the Fourth National Confer- ence of the Committee on Psychoanalysis, National Federation of So- cieties for Clinical Social Work, Los Angeles, California, October 16, 1992.

References

Applegate, J. S. (1984). Transitional phenomena in adolescence: Tools for negotiating the second individuation. Clinical Social Work Journal, 12, pp. 233-243.

18 CHILD AND ADOLESCENT SOCIAL WORK JOURNAL

Applegate, J. S. (1989). The transitional object reconsidered: Some sociocultiural varia- tions and their implications. Child and Adolescent Social Work Journal, 6, 38-51.

Applegate, J. S. (1990). Theory, culture, and behavior: Object relations in context. Child and Adolescent Socidl Work Journal, 7, 85-100.

Applegate, J. S., & Barol, B. I. (1989). Repairing the nest: A psychodynamic develop- mental approach to clients with severe behavior disorders. Clinical Social Work Journal, 17, 197-207.

Chescheir, M. W. (1985). Some implications of Winnicott's concepts for clinical practice. Clinical Social Work Journal, 13, 218-233.

Chescheir, M. W., & Schulz, K. M. (1989). The development of a capacity for concern in antisocial children: Winnicott's concept of hur^an relatedness. Clinical Social Work Journal, 17, 24-39.

Clancier, A., & Kalmanovitch, J. (1987). Winnicott and paradox: From birth to creaiion. New York: Tavistock.

Davia, M., & Wallhridge, D. (1981). Boundary and space: An introduction to the work of D. W. Winnicott. New York: Bninner/Mazel.

Fromm, M. G., & Smith, B. L. (1989). The facilitating environment: Clinical applica- tions of Winnicott's theory. Madison, CT: International Universities Press.

Giovacchini, P. L. (Ed.) (1990). Tactics and techniques in psychoanalytic therapy: The implications of Winnicott's contributions. Northvale, NJ: Jason Aronson.

Greenberg, J . R., & Mitchell, S. A. (1983). Object relations in psycho-analytic theory. Cambridge, MA: Harvard University Press.

Grolnick, S. A. (1990). The work and play of Winnicott. Northvale, NJ: Jason Aronson. Grolnick, S. A., & Barkin, L. (Eds.) (1978). Between reality and fantasy: Transitional

objects and phenomena. New York: Jason Aronson. Guntrip, H. (1975). My experience of analysis with Fairbaim and Winnicott (How com-

plete a result does psycho-analjrtic therapy acihieve?). The International Review of Psycho-Analysis, 2, 145-156. ]

Hughes, J. M. (1989). Reshaping the psychoanalytic domain: The work of Melanie Klein, W. R. D. Fairbaim, & D. W. WinnicoU. Berkeley, CA: University of Califor- nia Press.

Kanter, J. (1990). Community-based management of psychotic clients: The contribu- tions of D. W. and Clare Winnicott. Clinical Social Work Journal, 18, 23-41.

Little, M. I. (1990). Psychotic anxieties and containrnent: A personal record of an anal- ysis with Winnicott. Northvale, NJ: Jason Aronson.

Okun, B. F. (1992). Object relations and self psychology: Overview and feminist per- spective. In L. S. Brown & Mary Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 20-45). New York: Guilford.

Phillips, A. (1988). Winnicott Cambridge, MA: Harvard University Press. Rodman, F. R. (1987). The spontaneous gesture: Selected letters of D. W. Winnicott.

Cambridge, MA: Harvard University I*ress. Sanville, J. (1991). T?ie playground of psychoanalytic therapy. Hillsdale, NJ: The Ana-

lytic Press. Rudnytsky, P. L. (1991). The psychoanalytic vocation: Rank, Winnicott and the legacy of

Freud. New Haven, CT: Yale University Press. Winnicott, D. W. (1952). Anxiety associated with insecurity. In Through paediatricB to

psychoanalysis (pp. 97-100). New York: Basic Books, 1975. Winnicott, D. W. (1953). Transitional objects and transitional phenomena: A study of

the first not-me possession. The International Journal of Psycho-Analysis, 34, 39-97.

Winnicott, D. W. (1956a). Primary maternal preoccupation. In Through paediatrics to psychoanalysis (pp. 300-305). New York: Basic Books, 1975.

Winnicott, D. W. (1956b). The antisocial tendency. In Through paediatrics to psycho- analysis (pp. 306-315). New York: Basic Books, 1975.

JEFFREY S. APPLEGATE 19

Winnicott, D. W. (1958). The capacity to be alone. In The maturational processes and the facilitating environment (pp. 29-36). Madison, CT: International Universities Press, 1965.

Winnicott, D. W. (1960a). Ego distortion in terms of true and false self. In The matura- tional processes and the facilitating environment (pp. 140-152). Madison, CT: Inter- national Universities Press, 1965.

Winnicott, D. W. (1960b). The theory of the parent-infant relationship. In The matura- tional processes and the facilitating environment (pp. 37-55). Madison, CT: Interna- tional Universities Press, 1965.

Winnicott, D. W. (1961). Varieties of psychotherapy. In Home is where we start from (pp. 101-111). New York: W. W. Norton, 1986.

Winnicott, D. W. (1963). The mentally ill in your caseload. In The maturational pro- cesses and the facilitating environment (pp. 217-229). Madison, CT: International Universities Press, 1965.

Winnicott, D. W. (1970a). Cure. In Home is where we start from (pp. 112-120) New York, W. W. Norton, 1986.

Winnicott, (1970b). The mother-infant experience of mutuality. In E. J. Anthony & T. Benedek (Eds.), Parenthood: Its psychology and psychopathology (pp. 245-256). Bos- ton: Little Brown.

Winnicott, D. W. (1971a). Playing: A theoretical statement. In Playing and reality (pp 38-52). London: Tavistock^

Winnicott, D. W. (1971b). The location of cultural experience. In Playing and reality (pp. 95-103). London: Tavistock.

Winnicott, D. W. (1971c). The use of an object and relating through identifications. In Playing and reality (pp. 86-94). London: Tavistock.

Winnicott, D. W. (1971d). Therapeutic consultations in child psychiatry. London: Hogarth Press.

Winnicott, D. W. (1972/1986). Holding and interpretation: Fragment of an analysis. New York: Grove Press.

Winnicott, D. W. (1977). The piggle: An account of the psychoanalytic treatment of a little girl. New York: International Universities Press.

Winnicott, D. W. (1984). Deprivation and delinquency. London: Tavistock. Winnicott, D. W. (1986). Home is where we staH from. New York: W. W. Norton. Winnicott, D. W. (1988a). Babies and their mothers. Reading, MA: Addison-Wesley Winnicott, D. W. (1988b). Human nature. New York: Schocken Books. Winnicott, D. W. (1989). Psycho-analytic explorations. Cambridge, MA: Harvard Uni-

versity J'ress. Zerbe, D. H. (1990). The therapist at play and the patient who begins to play. Clinical

Social Work Journal, 18, 9-22.