Community-based Management of Psychotic Clients: the Contributions of D. W. and Clare Winnicott

While the term "management" connotes images of impersona ! care, D. W. Winnicott repeatedly used this term to describe the responsive envi' ronmental holding that is central to all human development. Influenced by observations of how normal mothers and families address the physical and psychic needs of children, he and his wife, Clare, a distinguished British social worker, operationalized this concept in finding and supporting "facilitating environments" with a wide range of disturbed children and adults. Using case material from a contemporary community program for the mentally ill, this paper will review the Winnicotts' important, but often neglected , perspectives on the environmental management of psychotic adults. As the burgeon ing field of "case m a n a g e m e n t " has focused a t t en t ion on the e n v i r o n m e n t a l needs of psychotic clients, the lack of direct practice models has c rea ted a d i s turb ing conceptual vacuum which has been filled by bureauc ra t i c a t t empt s to define this work. Reflect ing an all-toocommon perspect ive, one au tho r defined case m a n a g e m e n t as: the process of planning for individuals or families who require the organization of services to effect desired outcomes by assuring that all aspects of that outcome are controlled by reducing harmful effects . . . . case management is carried out by case managers, who in turn maintain a complete record of interactions by timely notations in the case record" (Sullivan, 1981, p. 120). Reac t ing to such perspect ives, m a n y concerned clinicians have come to view case m a n a g e m e n t as an impersonal service more concerned wi th Presented at the Washington School ef Psychiatry, J a n u a r y 14, 1989. I would like to t hank Janice Quinter and the Archives of Psychiatry ef The New York Hospital icornel l Medical Center for thei r assistance i n researching the D. W. Winnicott collection. 23 9 1990 Human Sciences Press