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Beyond Psychotherapy: Therapeutic Relationships in Community Care

Joel Kanter
joel.kanter@gmail.com


(Originally published in: Smith College Studies in Social Work. 70(3), 397-426, June 2000.

In an old house there is always listening, and more is
    heard than is spoken.
And what is spoken remains in the room, waiting for
    the future to hear it.
And whatever happens began in the past, and presses
    hard on the future.
The agony in the curtained bedroom, whether of birth
   or of dying,
Gathers in to itself all the voices of the past, and
    projects them into the future.
 The treble voices on the lawn
The mowing of hay in summer
The dogs and the old pony
The stumble and the wail of little pain
The chopping of wood in autumn
And the singing in the kitchen
And the steps at night in the corridor
The moment of sudden loathing
And the season of stifled sorrow
The whisper, the transparent deception
The keeping up of appearances
The making the best of a bad job
All twined and tangled together, all are
    recorded.

(From: The Family Reunion  by T.S. Eliot)


INTRODUCTION

The community care of the mentally ill extends far beyond the consulting room, beyond the psychotherapeutic alliance. We often have to enter into our clients' lives, their homes, their families, their communities, even their deaths. The detachment, the neutrality of the psychoanalyst is a distant ideal. The comforting rules of psychotherapy training and practice--the 50 minute hour, the well-furnished office, the regular intervals of contact, the verbal interchange, the questions, the interpretive comments--all diminish as the imperatives of daily life intrude. Instead we find ourselves acting as both a therapeutic agent and a participant in their daily lives, becoming involved in a communal relationship that may involve profound interpretations on one day and the most mundane tasks on another.

Because the nature of this work cannot be assumed, I am going to begin this paper with an extensive case study that spans an eight year period. First, I will share this story as it unfolds over time; then I will describe my work in detail in a recent week. While many aspects of this case are unique, it contains all 13 elements of case management that I have outlined elsewhere (Kanter 1989, 1996a). Using this case study as background, I will then discuss several clinical and theoretical issues that emerge in this ongoing work.

CASE PRESENTATION

I read the poem by T.S. Eliot that began this paper during a memorial service last December for two long-term clients. Their story began in 1991 when I received a call from Ms. Greene,* an attorney representing a Mrs. Stevens. Our local Department of Social Services was pursuing legal action to declare Mrs. Stevens and her husband incompetent and to place them under legal guardianship. Ms. Greene sought to engage my active assistance for the Stevens' survival in their home as an alternative to the guardianship--a legal process which would likely result in a speedy transfer for both to nursing homes.

Mrs. Stevens' husband had been a successful orthopedist who had suffered a severe stroke five years earlier which left him brain damaged and largely bedridden. Mrs. Stevens had a progressive alcohol-related dementia which involved significant short-term memory loss. Their home was a chaotic mess. Home care aides came daily to bathe and feed Dr. Stevens. Although physically able, Mrs. Stevens could or would not assume any consistent responsibility for her husband's well-being.

Several agencies that work with the elderly had been approached about working with this family. They declined however because they were afraid of Kevin, the son who lived in the basement room. A disheveled man in his mid-thirties who walked around with a menacing stare, Kevin suffered from paranoid schizophrenia and drug and alcohol abuse which had been untreated for years. With a history of several hospitalizations and imprisonments, Kevin was facing legal charges for threatening the assistant manager of a local grocery store with a knife. Social workers also suspected he had abused his mother, causing bruises and a broken arm.

Another worry was Buddy, the large black family dog. An undisciplined mixed-breed, Buddy had bitten several persons, including a visiting aide. While not vicious, he would jump on visitors and viewed gnawing on an arm or leg as a form of play. Although there are strict rules governing dogs who repeatedly bite, the family had somehow evaded having the dog put down.

At the time I was first contacted about this situation, Mrs. Stevens was in the hospital after a serious medical crisis involving a bleeding ulcer and other difficulties. I recommended that the recovering Mrs. Stevens be discharged to a convalescent nursing home for several weeks while I familiarized myself with the situation.

Unfortunately, this cautious plan immediately went awry one afternoon when I received four messages in one hour (from the attorney and social workers at the hospital, nursing home and social services) reporting that Mrs. Stevens (whom I soon called by her first name, Kate) had taken a taxicab home from the nursing home within two hours after transfer from the hospital. Suddenly, I found myself waist deep in the morass of this chaotic family, responsible for a fragile woman who had just lost several pints of blood during a recent medical crisis. Working with her physician, I visited daily for 10 days, bringing daily doses of critical medications as well as groceries and other supplies.

Eventually, with the help of the social services department, I worked out arrangements for home care aides to assist in the care of both Dr. and Mrs. Stevens on a daily basis. There was no informal network to assist us. Their other son was in the military overseas and there was no extended family in the area. Some old patients of Dr. Stevens dropped by intermittently. They would bring vodka in exchange for Dr. Stevens' signing prescriptions for benzodiazipines. He had lost his medical license years earlier, but was oblivious to the illegality of his behavior. Meanwhile, Kate, a 65 year old former fashion model, would have sex downstairs with her sons' acquaintances. And, for the first several years I was involved, she frequently propositioned me, sometimes trying to hug or kiss me.

In the midst of this chaos, the home care aides deserved special attention. Accused by Kevin and Kate of stealing valuables, they would appear each day, ignore Kevin's paranoid muttering, the dog's unruly behavior and Kate's racist remarks, and devote themselves to caring for and bathing Dr. Stevens, a large man with limited mobility.

Over time, a degree of order was restored to this home. After several months, Kevin allowed me to arrange for psychiatric consultation and began taking antipsychotic and antidepressant medications. I brought food and medications twice weekly. To help Kevin and Kate remember to take their medicines appropriately, the pills were packaged in envelopes for twice daily administration. A new attorney assumed responsibility for the family's limited resources; together we worked out a plan which assured their basic needs were met while minimizing the availability of funds which could be used to purchase drugs and alcohol.

The family maintained a strange equilibrium. Although they spent little time together, Dr. Stevens' presence offered some comfort to Kate. And Kevin would look after his mother in minimal, yet important, ways when she was weak or ill. He also walked the dog--and Buddy was essential to Kate' well-being. Meanwhile, Kate provided companionship for Kevin. Kevin had only one long-term friend, although other companions would intermittently come into his life. Several years after my initial involvement, the Stevens' other child, a man several years older than Kevin, returned from overseas military duty. He occasionally stayed overnight in the family home; then he purchased an apartment nearby and visited erratically.

Every 12 to 18 months, Kate would become ill and require hospitalization. She would become extremely weak, unable to walk and sometimes unable to speak. She would be admitted and evaluated. After several days of evaluation, no underlying cause would be found, but her low body weight seemed related to her overall fragility. Once she required special care and went to a group home for the elderly for a month after a hospital stay.

My goals for this family were rather simple:

1. Promote each member's health and survival. This involved providing adequate nutrition, assisting with medications, and coordinating medical consultations. I regularly brought Kate to her internist, consulting with him after he completed his examinations. When Kate' weight was low, I would attempt to supply her with appealing high-calorie foods: milk shakes, ice cream and cheeseburgers.

2. Minimize alcohol consumption by family members. Although I could not prevent the Stevens' family from consuming alcohol, I worked with the guardian to minimize the amount of cash available to family members. Instead, I would check with the family before each of my visits regarding their needs and, if possible, I would buy various items directly rather than give them funds to do this. When I departed from this policy, the funds rarely were used for their intended purpose.

3. Coordinate activities by a network of caregivers. Although this report focuses on my activities, I provided less than 10% of the services delivered by a loose network of caregivers: social workers, attorneys, home care aides, physicians and rehabilitation staff. My unique function involved my continuity in the lives of a family where each member suffered from major cognitive impairments: a stroke, dementia and schizophrenia. I was in direct contact with almost all members of this network and often consulted about various problems that arose.

4. Promote Kevin's recovery and rehabilitation from mental illness. Dr. and Mrs. Stevens suffered from irreversible brain damage; in their situations, I could only hope to slow their functional decline. However, in Kevin's situation, there was reason for long-term optimism. He responded to medications and worked intermittently. However, his loyalty to his parents--concealed under a gruff veneer--made it difficult for him to sustain his progress. Yet, I was constantly aware that his parents' health or functioning would eventually decline and require movement to a new residential setting. At some point, Kevin would have to live apart from them.

Several years after beginning medications, Kevin allowed me to refer him to psychosocial rehabilitation program in his community. For a time, he attended social activities through that program. Their vocational unit helped him obtain a 12-hour per week position cleaning the agency's building in the evening. With minimal supervision, Kevin performed well in this position. As he did few chores in his chaotic home, I was surprised at the quality of his work. However, because they used these positions to evaluate vocational readiness, he was only allowed to work for six months on this job.

Five years after I began my twice weekly visits, Dr. Stevens suffered a heart attack. Although not severe, his doctors believed that the home situation did not offer enough support and he was discharged from the hospital to a nursing home. Kate was strongly opposed to this, as was I, but we were overruled by a consensus of doctors, nurses and social workers who were involved in his care. Occasionally, I would drive Kate and Kevin to the nursing home to visit him. We would bring him food from McDonalds. Kate and Kevin were generally eager to leave after 15 minutes.

Subsequently, Kate's health appeared to decline gradually. She was weaker, took less initiative around the house, and bounced back more slowly from her mysterious ailments. Finally, in December 1999, she was hospitalized again: very weak, thin and nearly mute. The doctors ran many tests, but found no medical illness to account for her decline. In the hospital, instead of recovering substantially after three to four days, she continued to decline. She ate reluctantly and was very lethargic. Both the doctor and nurse expressed their fears she might not survive. But then her condition improved; she seemed alert, even conversational.

Visiting the hospital during this period, I asked Kate if I might call her sister from her room and put her on the phone. She was delighted with this suggestion and we reached her sister at home. They spoke briefly and Kate seemed to be on the road to recovery. In previous illnesses, she often regained her functioning within two days once her condition had stabilized. Two days later, the hospital transferred her to a convalescent unit of a nursing home for several weeks of rehabilitation. I visited her a couple days later in the nursing home. She sat alone at a table in the day room, staring into space, speaking in monosyllables. Her condition seemed even weaker and disorganized. When I asked if she was depressed, she nodded affirmatively. Within 3 days, Kate suffered a massive heart attack and died before arriving at the hospital.

I was contacted with this news by Kate's attorney on a Saturday afternoon. To her knowledge, Kevin had not been informed about his mother's death. I called his brother and asked him to meet me at the house. As I rarely visited the home on the weekend, both knew that something had occurred, but Kevin was visibly shaken when I told them what had happened. His brother seemed unfazed, wondering if the house would have to be sold. I asked him to stay with Kevin as I was not able to stay long. I told them I would return in a few hours to discuss their loss further.

When I returned at the prearranged time, Kevin was missing. I became somewhat panicked, fearing he had done something impulsive. His brother and I drove around the neighborhood. We found Kevin 10 minutes later, walking home from the store with a six-pack of beer. We drove him home. He opened a beer and we talked at more length. His response was appropriate: How did his mother die? Could she have been saved? What would happen to him now? What sort of funeral options did they have? Who did they need to contact? After listening, I told him explicitly about the grieving process and what he might expect. The essence of my message was that grief is painful, but survivable.

We also discussed their father's condition which had become quite grave. The nursing home had called recently and told me that his condition had worsened. They only expected him to survive a number of weeks. When I called the facility to talk to his nurse, I learned that he was heavily sedated and not able to communicate. We decided not to tell him--even if he could understand--about his wife's death.

Over the next few days, I coordinated funeral arrangements, working with Kevin and his brother, the lawyer and her assistant, the sister that Kate spoke to days before her death, and several other parties. My work involved calling various cemeteries and funeral homes, learning about options and prices, and arranging for a memorial service at a church adjacent to Kevin's rehabilitation program. Kevin and his brother had no idea how to go about this and were most grateful for my help.

Several days later, their aunt came to assist with funeral arrangements and the memorial service. She was a capable woman, sensitive to the family problems. I was saddened, though, that she had never been directly involved with the family during the many years I had worked with them. She joined Kevin and his brother when we met with the minister to plan the memorial service.

And we soon learned that an aunt and uncle on their father's side were traveling to attend the memorial service. They had made their travel plans before learning of Kate's death, when they learned that Dr. Stevens' death was imminent. They, too, had not visited in a decade. But as Kevin's network was so minimal, I appreciated the presence of any interested relative.

Arriving the day before the memorial service, these relatives went directly to the nursing home to visit Dr. Stevens. He was comatose and breathing heavily. His siblings left to check in to their hotel. Returning two hours later, they found their brother had died in the interim. Hearing the news, I again went to visit Kevin, but discovered he had learned about this from others. As Kevin had been closer to his mother, his father's death had less impact on him and I felt comfortable leaving him with his brother and aunt. I then called the minister to expand the scope of the memorial service.

The memorial service was attended by about 15 people: Kevin, his brother and 4 other relatives, the attorney's assistant, another social worker, a home care aide, one neighbor, and a handful of staff from the rehabilitation program. Not a single friend of Kevin, his brother or his parents attended the funeral. The formality of the Episcopal service and the organ was comforting. There is little one can say about the deaths of two people in a family that has been ravaged by mental illness, alcoholism, drugs, abuse and brain damage. The deceased were limited, if not destructive, in their parenting and their sons barely grasp the extent of the damage. Both sons were handicapped in their capacity even to grieve these losses. The only speaker, I read from T.S. Eliot, Kahil Gibran and Tagore, concluding with last line of the Jewish prayer of mourning: "May You who establish peace in the heavens, grant peace to us, to Israel, and to all the earth, and let us say, Amen."  I spoke directly to Kevin. I hoped he would grieve productively, without becoming psychotic or inebriated. He appeared to listen carefully and thanked me for my comments after the service.

As we left the sanctuary, we gathered in the church social hall to share a tray of food that I had purchased with funds from the attorney. Kevin conversed "normally" with his handful of relatives. I watched and hoped that at least one or two of these relationships would continue in the future. Before we dispersed, I talk individually with each of the visiting relatives; all expressed concern about Kevin but indicated that they are pleased with his present functioning. At that moment, he exhibited no signs of mental illness.

About 2 weeks after the service, I drove Kevin and his brother to a nearby military cemetery where the cremated remains of both parents are interred with full military honors. This involved a horse-drawn carriage for the remains, soldiers in full dress, and a rifle salute. It was a cold sunny day and Kevin shivered as he walked with his brother behind the carriage. This time, only two staff from the rehabilitation program and I were present. Not a single friend or relative attended.

Although Kevin's brother is stayed at the house, I was disheartened by Kevin's isolation. He had had one good friend, but something had happened to the friendship several months earlier. When I suggested that Kevin invite this friend to the memorial service, he expressed no interest. Finally, I located the friend's phone number and, without Kevin's knowledge, informed him of Kevin's losses. Upset, he drove to Kevin's home within the hour and met me there. Both were obviously glad to resume their friendship.

After the service, I increased my contact with Kevin to three visits weekly for a month or so, then reduced contact to two visits weekly. I brought medications, money and groceries. We continued our discussions about his future. He preferred to stay in the family home with his dog, but recognized that the house must be sold in order to pay off debts. When these debts are paid, Kevin and his brother will have a modest inheritance. With a special legal trust, he would be able to use these resources and still keep his government disability pension and medical benefits.

For the next several months, I continued my usual twice weekly visits, intermittently addressing the need to find a new residence. Kevin initially refused to consider a residence with other people with mental illnesses. He also wanted to be able to keep Buddy, their dog. I suggested this would not be possible as few rentals will accept a large pet. I promised that we would find a temporary home for Buddy. After the house was sold and some funds were available, we could try to find residence for Kevin that would allow the dog.

We made several attempts to search the classifieds of the local newspaper for a room or apartment to share. I rehearsed with Kevin how to leave a voicemail message in response to one of these advertisements, but this was very difficult for him. I suspected it was unlikely that anyone will respond to his awkward inquiries and, indeed, he received no replies. And I knew that almost no one would rent to him if I made the initial contact; if his history of mental illness and drug abuse was known, this search would be more difficult.

Finally, a foreclosure letter arrived from the mortgage company. Kevin was faced with clear evidence that the house would be sold whether or not he cooperated. He then agreed to visit a supervised apartment program for the mentally ill. This program involved a cluster of four large apartments in one group of buildings. Three residents lived in each apartments and a counselor was present during each day to provide support and prepare lunch and dinner. He was not enthusiastic about this program, but the visit provided evidence of pleasant companionship and decent housing.

In subsequent weeks, he made several attempts on his own to rent a room, but none were successful. Meanwhile, his brother continued to suggest that he could locate an investor who could give them a new loan. He then would sell his apartment and move in with his brother. Both Kevin and his brother suggested that they were only interested in this idea to please the other, but it was clear that both were reluctant to allow the sale of the family home. On one day, the attorney's assistant joined Kevin and me during a regular visit. Together, we reviewed the financial advantages of moving out promptly and selling the house before foreclosure. Kevin finally accepted this and reluctantly agreed to move into the apartment program.

Meanwhile, I made a number of calls to find a home for his dog. None were successful and I placed an ad for a dog foster home. I was delighted to receive five responses. I invited one woman, Serena, to visit Kevin and the dog. All parties seemed pleased with each other and the final steps toward Kevin's move proceeded.

Now I will present a week in my work with Kevin in greater detail:

Monday: Early in morning, I called Serena to confirm the plan to bring Kevin and his dog, Buddy, over to visit her home. She would be expecting us around noon. I drove to Kevin's home around 11:30 AM and dropped off some medications and groceries. Kevin was showered and groomed neatly; I suspect he found Serena, with her slim figure and long blonde hair, attractive and wanted to make a good impression. Buddy climbed into my car; he seemed cooperative, but started to whimper during the 20-minute drive to Serena's home. Kevin was quiet and pensive. The impending move was clearly becoming real.

We arrived at Serena's several minutes late, but she was waiting for us with her adorable three-year-old daughter. The daughter was clearly excited about the dog's visit. We briefly visited their flat, but spent most of the time outside in the yard on a glorious day. Serena and Kevin talked for 20 minutes about the dog. She was concerned about a tremor in his leg and wanted us to have it examined by a veterinarian before Buddy moved in with her. She handled the dog and seemed to feel comfortable with him. Kevin communicated comfortably about the dog's history and seemed comfortable with Serena. Before leaving, we reviewed when Serena could have the dog move in. She was having a friend visit and was starting a new job the following Monday; however, she would be off work on Wednesdays. We agreed to bring Buddy to live with her next Tuesday night; she would have the following day to care for him before returning to work.

On the way home, I stopped at McDonald's and picked up a fast food lunch to eat on the way home. I deliberately drove back to Kevin's home via a different route which took us by the apartment he planned to move to. I showed him where a bus travels directly between the apartment and Serena's home. I also pointed out nearby stores that we had not seen on a prior visit.

For much of the ride, Kevin was quiet, neither chattering in his 1960's adolescent tone nor ranting in one of his paranoid monologues. Kevin indicated that he was comfortable with allowing Serena to care for his dog. He again questioned whether he should move into this supported housing program with counselors on duty eight hours daily. He suggested he would rather live in a less expensive rented room. I reminded him that he would have several months to find such a room--that with foreclosure looming, he needed to move on quickly. Again, I mentioned that I believed that the support available in this program will help him in the long run when we looked for a permanent housing situation. Running late, I dropped Kevin and Buddy near his home and drove on.

Later that afternoon, I made several follow-up calls. In one, I informed the assistant for the attorney (Ms. Lucci) managing the estate of Kevin's parents that the visit to Serena's had gone well and that we planned to move Buddy in eight days. If things go well, Kevin would move to a supported apartment on the following day. Ms. Lucci had been eager for Kevin to move so she could fix up the home and sell it. (One third of the sales price would pay off debts and the remainder would be shared by Kevin and his brother.) I also called Mr. Hatfield, the attorney who would become the trustee of Kevin's funds and checked to see if Kevin's brother had signed certain papers needed to implement the trust. As this brother can be erratic, I am relieved to learn this has been completed.

Tuesday: Ms. Lucci's assistant called me to report that she received a document that finalized the establishment of Kevin's trust from Mr. Hatfield. Having previously agreed that it would be best to have Kevin sign this in Ms. Lucci's office instead of at Mr. Hatfield's, we set up a time on Friday to meet with Kevin to review this. Because signing this document involved a voluntary surrender of Kevin's direct access to his modest inheritance, we understood that this might be a very delicate meeting. Afterwards, I called the director of the supported housing program to make final arrangements; he was not available and I left a message.

Wednesday: A beautiful Spring day!

Thursday: I again called the director of the housing program. He was available and we made plans for Kevin to move next Wednesday. He e-mailed me a list of items that Kevin wiould need in their program.

Friday: Before going to Kevin's home and on to the attorney, I stopped at the pharmacy to pick up a bottle of antidepressant medications. Kevin's psychiatrist had changed this medication last month and recently had increased the dosage. I called Kevin to remind of him of the meeting with Ms. Lucci and to tell him I would be at his home in 45 minutes. He was clearly unenthusiastic about this meeting and asked if it could be later in the day. I responded that a delay was not possible and that he needed to get ready. I felt somewhat guilty that I have not disclosed the precise reason for this meeting, but had talked in general terms about the need to sign some legal papers in relation to the estate. Kevin had previously expressed ambivalence about allowing his funds to be managed by a trustee, so I was worried he would not agree to this. If he would not agree, we could not assure funding for his housing and the whole plan would collapse.

On the way to the meeting, I explicitly informed Kevin about the purpose of our meeting with Ms. Lucci. He accepted this information without comment. Kevin again expressed his concerns about the supported apartment. I reminded him that many young adults live in transitional settings (such as colleges and the military) before moving from their family to complete independence. Although he is older, he could benefit from a similar transition. He mentioned his brief stays in jail as an exposure to independent living. Arriving at the attorney's building, he was impressed by its opulence. (Although Ms. Lucci's law office had managed Kevin's parents' funds for some years in a pro bono program, Kevin had never visited the office or met Ms. Lucci.)

After a ten-minute wait, we were escorted to a conference room by Ms. Lucci's assistant and were soon joined by Ms. Lucci. Although Kevin had heard this before from Mr. Hatfield and myself, Ms. Lucci. again outlined the legal rationale for establishing the trust. Without such a legal process, Kevin would lose his disability pension and medical benefits until his inheritance was nearly exhausted. As these benefits, including 100% of the cost of expensive medications, probably totalig close to $15,000 annually, the failure to establish a trust could be very costly. Ms. Lucci calmly explained this and answered Kevin's questions. I occasionally participated, inviting, for example, Ms. Lucci to explain how the trustee is legally bound to manage Kevin's funds wisely. After about 20 minutes of discussion, Kevin agreed to sign the document without any hesitation.

The conversation then shifted to a discussion on the disposal of the possessions and furniture in Kevin's parents' home. An acquaintance of Kevin's brother had offered $600 for the furniture. Allegedly, some are antiques, but we know that most were in fair to poor condition. Kevin expressed that he was overwhelmed by the challenge of moving and we discussed how we could help him. On the way out, I discussed the timing and details of Kevin's planned move next Wednesday. Kevin showed no evident anxiety about this. On the way home, however, Kevin refuses my offer of lunch.

Saturday: Kevin's brother left a message on my voicemail in the morning asking my opinion on the furniture sale. I replied on his voicemail that I wa not able to appraise the value of the furniture. Later, I called Kevin's aunt who lived 1800 km away. She was the only relative on Kevin's mother's side to attend the funeral and was helpful to Kevin and his brother. I informed her about the status of the estate, the establishment of the trust, and Kevin's plan to move. She agreed to call Kevin more often to lend support. Late in the day, Kevin's brother again called me to discuss the furniture sale. Again, I informed him that I cannot appraise property and have no objective method for determining whether or not the offer they received was fair. Although he didn't live at home, Kevin's brother was also overwhelmed by the task of removing the possessions of his parents' home. He also asked if it would be acceptable if he kept the full $600 to pay bills until the home sold. Aware that he would likely fail to repay this sum, I discouraged him from doing this.

CASE DISCUSSION

To focus our attention on the process of this work rather than the outcome, I will abruptly interrupt this presentation to address several theoretical and clinical issues, but will return to the case material at the conclusion of this paper. This presentation outlines a lengthy, complex situation involving relationships with Kevin and his mother, several other relatives and a plethora of caregivers. These relationships have multiple functions and dimensions, but are not easily characterized as either psychotherapeutic or environmental. This discussion will focus on two important concepts,--that of "management" and that of the "transitional participant"--before returning to the case presentation.

Invariably, my involvement with Kevin and his family required attention to both subjective experience and objective reality. Relational models of psychotherapy-- including interpersonal, object relations and constructivist approaches--have moved beyond a classical framework that conceptualizes the therapist as a neutral, detached observer of the patient's intrapsychic processes. In these models, the objective reality of the therapeutic relationship is assumed and the subjective impact of this relationship on both parties, in the transference and countertransference, is continuously examined. Sullivan's interpersonal model goes even further, acknowledging the impact of the "real world" outside the consulting room. The therapist is a participant in the interpersonal field of the therapeutic relationship, but also a keen observer of life outside (Levinson, 1985).

However, in the intervention model outlined in the aforementioned case, which I have identified elsewhere as "clinical case management" (Kanter 1989, 1995, 1996a), the therapist (or social worker or case manager) becomes part of the interpersonal field outside of the consulting room. In doing so, the therapist enters a new realm of experience which requires different theoretical frameworks. Unfortunately, our capacity to understand care-giving relationships has been impaired by a psychoanalytic metapsychology that conceptualized the parent-child relationship in terms of the instinctual responses to classical psychosexual stages. The mother is a "breast"--a nursemaid--for the infant: later, a central figure in an oedipal drama.

MANAGEMENT

While these experiences play an important role in development, Winnicott's concept of "management" has been largely ignored by psychoanalytic theorists (Kanter, 1990). By management, Winnicott, an experienced pediatrician and psychoanalyst, focused on the parental provision of ego support in everyday life:

A source of misunderstanding here is the idea that the term "adaptation to need" in treatment of schizoid patients and in infant care means meeting (or frustrating) id-drives. There are more important things going on, and these are of the nature of giving ego support to ego processes. (1963a, p. 241)

Winnicott (1963b) postulated,

The existence for the immature child of two mothers... (an) "object-mother" and (an) "environment-mother." (These terms) describe the vast difference... for the infant between the two aspects of infant-care, the mother as object... that may satisfy the infant's urgent needs, and the mother as the person who wards off the unpredictable and who actively provides care in handling and in general management. (p. 75).

Winnicott's writings are very explicit that the "ego support" implicit in his concept of management is much more than a form of verbal support. For the infant, this can involve provision of food, regulation of temperature and stimulation, and regulation of frustration. For an older child, this could involve helping select an appropriate school or engaging the child in stimulating activities.

Winnicott goes on to link issues of management in the care of children with issues in the treatment of psychotic patients. Responding to a case presentation of the analytic treatment of a schizophrenic man, he remarked that the presenter, Herbert Rosenfeld, a leading Kleinian:

mentioned the fact that no one would analyze somebody who had not had food for five days. Presumably they would give food. You went on to imply that there is no essential difference between the management needs of a psychotic and a neurotic patient. If you really mean this, heaven help your psychotic patients, and until you recover from this point of view I am afraid you will not make a very interesting contribution to the theory of psychosis...If you really believe... that the psychotic patient is in an infantile state... then what you are really saying is that there is no essential difference between the management needs of an infant and those of a grownup. Yet... I am sure that you would admit that whereas a mature person can take part in his own management, a child can only take part to some extent and an infant... is absolutely dependent on an environment which can either chose to adapt (or fail to adapt) to the infant's needs... As management problems are essentially different according to the level of development... then (they) must be different in the analysis of psychotics and neurotics. As you know, I am one of those... who say that in the analysis of psychotics we must actually study what we do when we take part, as we always must do, in management. (Rodman, 1987, p. 47)

Discussing the role that management plays in development, Winnicott suggested that the "individual introjects the ego-supportive mother" (1958) as "de-adaptation" occurs in "graduated doses" as "part of the gradual change toward independence" (1963a). Later, the family unit as a whole continues this process, providing a "graduated failure of adaptation that is an essential part of the healthy environment" (1965). This titration of environmental support in response to the child's changing needs is one of the core elements in successful development.

The importance of the child's internalization of such management functions has been largely neglected in developmental theory. How parents assess a two year old's readiness to give up the bottle, a five year old's readiness for kindergarten, a six year old's readiness for piano lessons, or a twelve year old's readiness to ride the subway conveys as much or more to the child than empathic comments or expressions of affection.

Harris and Bergman (1987) outline a similar process in the case management of the mentally ill. They suggest that case managers help their mentally ill clients integrate the disparate elements of their social environment, develop a rational approach to life planning and activities, and proactively anticipate life events and crises. By observing and experiencing the case manager's problem-solving approach to the challenges of daily life, a process of internalization occurs which enables many clients to use these same ego capacities. As clients develop these capacities to manage their own lives, the need for professional intervention diminishes.

With the Stevens family, my managerial interventions addressed a disparate array of clinical and developmental needs. On one level, this care was addressing the most basic needs for survival. I helped supply food and medicine, helped Kate seek medical treatment, and supported the home care services that were vital to their survival. On another level, by working with the attorney on limiting their direct access to funds, I had to acknowledge and directly address Dr. Stevens' and Kate's irreversible cognitive deficits.

For example, when I became involved with this family, expensive monthly supplies of medication would vanish within two or three days. No one seemed to know where they had gone. Had Kevin, for instance, taken his mother's medication? Had Kate, forgetting when she last took a dose, taken excessive amounts of medication? Had she hidden the medication (to keep Kevin from getting it) and forgotten where she had placed it? Or had Buddy the dog eaten it? No one seemed to know. And more of their limited finances would be spent to replace the missing medications. As having nursing assistance twice a day was impracticable, I worked out an approach, with medical consultation, that allowed no more than a four-day supply of medications in the home at any one time. Although not optimal, this minimized the intentional or unintentional misuse of this medication.

Once--on a rare home visit by the attorney--the phone rang at Dr. Stevens' bedside. He showed no concern that we were listening to him authorize a refill for benzodiazepines at a nearby pharmacy. When the attorney informed him that this practice was illegal because Dr. Stevens no longer had a medical license, Dr. Stevens seemed genuinely surprised at this news. To protect him and others, I contacted the government agency that regulates pharmacies and asked them to send an alert on Dr. Stevens to local drugstores.

Such attempts to reduce real financial and legal threats are analogous to the way in which a parent prevents young children from endangering themselves: putting knives away, supervising the child's fascination with electrical appliances and outlets, and holding the child's funds. Mediating the child's desires in relation to the family's wealth is also essential to the child's survival. Unless family resources are appropriately conserved, the child's welfare will obviously be endangered.

Even the provision of food required managerial decisions. I had to continually assess the clinical status of Kevin and his mother and consider their current cognitive readiness to prepare foods from raw ingredients. When functioning on a higher level, Kate could cook from fresh meats and vegetables; but on other days, she could barely put a frozen dinner in a microwave oven.

Throughout my involvement, these managerial activities had to be implemented while maintaining an awareness of the family's narcissistic sensitivities. As with many elderly persons, assistance has to be offered in a way that did not injure their pride. In this regard, I recall how my father would hire a companion for my elderly grandmother--who had previously cared for "old people" until she was 85 years old--but tell her that the companion was hired through a government program.

Meanwhile, Kevin required a somewhat different approach to management that respected his latent capacities. For example, when Kevin required medical attention, I would only transport him to the first appointment with a new physician; then I would only remind him of subsequent appointments when bus transportation was available. Or, more recently, I prevented the attorney from pressuring Kevin to move precipitously, allowing him time to grieve and explore various residential options. When he was unable to find any housing through his own efforts, I located a facility that I believed would fulfill Kevin's needs and openly influenced him to consider the suitability of this residence.

THE "TRANSITIONAL PARTICIPANT"

While the work of management is the rational mind, the ego, of community care, the role of the "transitional participant" is the heart and soul of this work. While Winnicott's (1953) concept of the "transitional object" addresses the use of inanimate objects--such as the child's stuffed animal or blanket--to maintain ties between past and present, between fantasy and reality, his wife, Clare, explored how social workers and other caregivers play a similar role. In a jointly authored paper, the Winnicotts described Clare's role as the social worker in a program for evacuated children with special separate threads of the child's life and to give him the opportunity of preserving something important to him from each stage of his experience (Winnicott and Britton, 1944).

The function of the psychiatric social worker as far as the children are concerned is to give them a sense of continuity throughout the changes to which they are subjected. She is the only person who knows each child at every stage. It is she who first comes to his rescue in the billet in which he is causing a disturbance. She sees him in his school and billet, and then in the hostel, and possibly in more than one hostel. If there is a change in hostel wardens, it is the psychiatric social worker who gives some feeling of stability during the period of change. It is the psychiatric social worker who re-billets the child if and when the time comes. She is also in contact with the child's home, visiting the parents whenever possible. She is thus able in some degree to gather together the separate threads of the child's life and to give him the opportunity of preserving something important to him from each stage of his experience. (p. 157).

Years later, Clare Winnicott recalled the impact of her trips to besieged London to seek out the parents of her charges:

So what I did there was try and make a link between the parents and actually I got such a name for it that every time I appeared into a hostel they would rush up and say, "Miss, have you seen my mum? When did you see my mum last?" And it was quite hard for them when I had to say, "I can't see your mum every week"... But it did awaken some parents to their own responsibilities... Because I could say, "Look he's missing you terribly. What about a note? Give me something to take to him." (Interview with Alan Cohen, June 27, 1980)

In her later writings, Clare Winnicott (1964), having completed her analytic training and a personal analysis with Melanie Klein, elaborated on the difference between psychotherapy and social work This is a lengthy passage, but the implications for the community care of the mentally ill should be apparent:

The social worker.... starts off as a real person concerned with the external events and people in the child's life. In the course of her work with him, she will attempt to bridge the gap between the external world and his feelings about it and in doing so will enter his inner world too.

As a person who can move from one world to another, the social worker can have a special value all her own for the child, and a special kind of relationship to him which is quite different in kind from the value and relationship that a psychotherapist has. (The social worker) can never become entirely the subjective object which the psychotherapist becomes; she is bound to external reality because she is part and parcel of the child's real world, and often is responsible for maintaining that world. The social worker...is therefore in a strategic position in their lives because she is in touch with a total situation representing a totality of experience.

Undoubtedly, a very valuable part of our relationship with children lies in their knowledge that we are also in direct touch with their parents and others who are important to them. Of a time, perhaps, our relationship is the only integrating factor in their world, and we take on a significance which is beyond what we do or say. We make links between places and events and bridge gaps between people which they are unable to bridge for themselves. As we talk about real people and real happenings, feelings about them soon become evident and before we know where we are we have entered the inner world of the individual, and so we bridge another gap, that between fact and fantasy.

I remember very clearly in my own experience as a social worker this awareness I so often had that I was bridging gaps between people. It struck me first one day when a mother said to me with incredulity on her face: "You saw Brian yesterday--it doesn't seem possible." To her, Brian was more than a matter of miles away--he almost didn't exist anymore. But as I told her about him, ordinary things, that he was learning to swim, and had lost some more teeth since she'd seen him, gradually her feelings came to life and he existed once more in her inner world. But this could not have happened if I had not really known her child. (p. 45-46).

Besides focusing on how the social worker can be used by children (and parents) to keep alive positive internal representations of significant others, Clare also described how the worker's ongoing presence in the child's life can help to facilitate psychic integration across time and space:

[We would] go over the same ground again and again. It might begin with 'Do you remember the day you brought me here in your car?' And we would retrace our steps, going over the events and explanations once more. This was no mere reminiscing, but a desperate effort to add life up, to overcome fears and anxieties, and to achieve a personal integration. In my experience, feelings about home and other important places cluster round the caseworker, so that when the children see her they are not only reminded of home but can be in touch with that part of themselves which has roots in the past and the [outside] world. (p. 34)

Any parent will immediately recall the "remember when" game that is such a significant component in parent-child interactions. Beyond their fascination with photo albums or home videos--especially when shared by significant others--children (and adults) take great satisfaction in the mutual recollection of memorable shared experiences; these might include vacations, the death of a first pet, birthday parties or even a burnt dinner.

Unlike her husband's concept of the transitional object, Clare Winnicott's transitional participant is not a passive recipient of the child's projections; the social worker actively positions him or herself in the child's life, making direct contact with an array of significant others and informing all parties of this array of contacts. With the knowledge of this participation, the child is then able to internalize the social worker as an embodiment of this life experience.

This phenomenon of the transitional participant has implications for understanding a wide array of human experience beyond social work with children. Consider, for example, the profound psychic impact of a visit after many years from a long-lost relative or an evening at a school reunion or family gathering. The actual presence of such "participants" in one's life has an emotional resonance that hundreds of hours in psychotherapy can never replicate.

My role as a transitional participant with the Stevens family should be readily apparent. I positioned myself in the middle of a network of caregivers and concerned parties that involved dozens of individuals over the years: doctors, nurses, attorneys, home care aides, relatives, acquaintances, veterinarians, pharmacists, social workers, probation officers, rehabilitation workers and so on. While our professional literature addresses building therapeutic relationships with our patients, it has largely neglected the professional skills involved in engaging these significant others (Kanter, 1996b). These involve a knowledge of the relevant medical, psychiatric, legal and social welfare systems as well as some facility with the unique language employed in each. As our community has become increasingly internationalized, skills in collaborating with caregivers from other cultures are also important.

Besides a familiarity with generic negotiation skills (Ury and Fisher, 1981), successful engagement with caregiving networks requires considerable clinical skill and understanding. Consulting with caregivers involves a multifaceted understanding of the client's situation. With the Stevens family, this involved understanding medical, psychiatric and legal issues and being able to communicate this knowledge to a wide range of concerned parties without resorting to diagnostic and technical jargon.

For example, on several occasions, I had to consult with the rehabilitation agency that assigned a series of young, attractive, female rehabilitation aides to meet with Kevin at his home. These idealistic young women met with him behind closed doors in a tiny cramped bedroom, unaware of Kevin's active sexual fantasy life. Although I had little concern about sexual assault, Kevin's comments to me suggested that these workers' attractiveness was their main appeal. Contacting a supervisor, I suggested that their contacts might be more useful if they went on walks or outings.

My active participation in the daily life of the Stevens family also helped me maintain a leadership role in their care and treatment. Unlike the classical hierarchical model of hospital medicine where the role of the physician is analogous to an officer of a military unit, the community care of the mentally ill has no explicit organization of caregivers. Physicians have the most status, but are often least involved. And the array of caregivers is often not under their authority.

The case manager (which can be a social worker, a nurse or even a relative) must organize the energies of these caregivers toward common goals in each situation. This leadership role is often a subtle one--perhaps analogous to the leadership of a soccer player on a field of continual motion--but nonetheless it is essential.

My awareness of this role affected my long-term strategy. Given the health problems of Dr. and Mrs. Stevens, it was not hard to imagine that Kevin would eventually be on his own, perhaps sooner rather than later. While his quality of life was perhaps diminished while they were alive, I could foresee that their deaths would be an important crisis in Kevin's life. On the one hand, his parent's deaths could possibly lead Kevin to homelessness, psychosis and alcoholism, and, on the other, to recovery, stability and fulfillment.

Influenced in an ephemeral way by Klein's (1975) concept of the "depressive position," I have observed that successful mourning experiences by persons with schizophrenia often triggered major improvements while unresolved grief often further exacerbated psychotic symptoms.

These clinical concerns are complicated by a core deficit in persons with schizophrenia which Werner Mendel (1976) has called a failure of historicity. Mendel writes:

Historicity is that quality in human existence that makes our lived personal history available to us to draw on for the conduct of our lives.... This lived, available history makes it possible for each of us to risk new situations, new relationships and new experiences. (p. 43)

Mendel goes on to note that:

In the schizophrenic existence, this lived history seems not to be available.... It is as though prior relationships and experiences have gone right through the person. They have not stuck to his ribs. Each new relationship has to be entered into anew. Each new activity is taking place for the first time. Thus the day becomes long and strenuous. The schizophrenic human being enters into situations and relationships like a new-born infant, having no experience, no way of predicting, no way of using shared assumptions with others in the transaction. (p. 43-44)

To address this deficit, Mendel recommends:

Arranging concrete experiences with the patient in the therapeutic transaction that allow him to establish the flow of time from past through present to future. ...the ongoingness of the relationship, not as an abstraction, but as a concrete series of events, helps to counteract the failure of historicity. The patient comes for his therapy appointment. If he does not appear, the therapist goes out and gets him... During the therapy appointment, the patient is concretely reminded of the prior appointment and he is told some of the things that were discussed and planned at that time. He is asked to tell what has happened since his last appointment and how the plans that were formulated have worked out. Then he is told of the next appointment. (p. 46)

For many patients who are terribly uncomfortable in the interpersonal transaction and who find it difficult to sit and talk in an office, activity is a more concrete vehicle for a relationship. With many such patients we found it useful to take walks, eat lunch, engage in physical activity (playing ping-pong, going for a ride, doing errands, helping him to enroll in a class and going to his first class with him, going to his wedding, and so on. (p. 101-102)

Clearly, Mendel is addressing the same issues as Clare Winnicott; whether a child in need or an adult with schizophrenia, a sense of personal integration--of people, places and events--develops as the flow of time is experienced through the actual involvement of a transitional participant in the flow of life. This integration occurs first in the mind of the transitional participant whose capacity for historicity is unimpaired; undoubtedly, a process of internalization plays a major role in this process.

While this can be accomplished to some extent, as Mendel suggests, through an office-based psychotherapy, profoundly impaired children and adults require a more concrete presence in their daily lives. Perhaps this should not be surprising; such processes are likely an essential part of normal development. Fortunate children have such experiences with sensitive and involved parents. However, many others develop this personal integration through ongoing relationships with siblings, childhood friends or neighbors. The maintenance of these relationships throughout the lifecycle is one of the cornerstones of mental health. One of the tragic aspects of the Stevens family was that both Dr. and Mrs. Stevens lost such relationships in their later years; both essentially died alone.

Unfortunately, community programs for the mentally ill too often neglect the need for this interpersonal continuity in their participants' lives. It is enough to focus on symptoms, problems and goals. Treatment is evaluated every 90 days; administrative requirements rarely consider any long-term strategy for long-term illnesses. Low salaries and corporatization in the human services leads to continuing staff turnover; in many programs, staff tenure averages one year. This staff instability has profound implications for clinical care and residential stability. Successful interventions are disrupted; failed interventions are repeated. Without the long-term involvement of a transitional participant, the treatment process is too often in disarray (Sheehan, 1981). The frequency of disrupted or damaged family networks in our country exacerbates this problem; too often, there is no relative to assume this role.

In our community, the rehabilitation agency that has worked with Kevin is an impressive program. They have a wonderful new building, enthusiastic staff, creative programming and stimulating activities. Yet, Kevin's rehabilitation workers were almost always left the agency or transferred positions in 6 to 12 months. Although the agency assigns pairs of workers to each client, Kevin had had three pairs of workers in the year before the deaths of his parents. It was literally difficult to keep up with their names. By the time the third pair was assigned last year, Kevin was avoiding contact with them, rarely picking up the phone or keeping appointments.

Notified of the deaths, the agency had little idea how to respond. Death was not on the treatment plan. Although the church where the memorial service was held was adjacent to the agency, I had to repeatedly call the agency to emphasize the importance of having as many people as possible attend the memorial service. Yet they failed to organize the attendance of even a single client from Kevin's network of acquaintances at the service. (In contrast, another rehabilitation agency in our community brings a van full of clients to the funeral of each member's close relative.) When the interment of ashes was held at the military cemetery, a supervisor and a vocational counselor attended, but neither of the rehabilitation workers found time to attend. As a result, their role in the grieving process and Kevin's life transition was minimal.

THE COMMUNAL RELATIONSHIP IN COMMUNITY CARE

While this case report and discussion has outlined a troubled family experiencing major losses and transitions, everyday life over the years has more often been placid than tumultuous and dramatic. Bringing in food, money and medications, riding in the car with Kevin listening to the Rolling Stones, doing my parody of Kevin's "psycho-hippie" persona; Kevin and his mother had a directness, perhaps a crudeness, that was often enjoyable to banter with.

I also learned they were often untrustworthy. However, it was difficult to discern in any given situation whether their actions stemmed from dementia, illness, or just ordinary dishonesty. They were good liars, especially around alcohol consumption. I knew I could not stop them from drinking. Because Kate' medical presentation sometimes involved symptoms (such as tremors) or injuries that could be related to alcohol usage or its cessation, I preferred to have some idea about whether and when she had been drinking.

About once a year something would happen that would cause me to lose my temper and I would rant on for a minute or two, cognizant while doing this that I was--on some level--imitating Kevin's occasional tirades. Kevin would stand by telling me to "Calm down, Kanter. Chill..." He seemed more bemused my rage than upset. In these moments, I often reflected on one of my favorite quotes from Winnicott (1971):

Your job is to survive. In this setting the word survive means not only that you live through it and that you manage not to get damaged, but also that you are not provoked into vindictiveness. If you survive, then and then only you may find yourself used in a quite natural way by the (client) who is becoming a person and who is newly able to make a gesture of a rather simplified loving nature... [Management] can be a very deliberate act of therapy done by professionals in a professional setting. It may be a kind of loving but often it has to be a kind of hating, and the key word is not treatment or cure but rather it is survival. (p. 227-228)

Loving without hating in this context seemed somehow beyond my capacities. Transference and countertransference were irrelevant. These phenomena were like oxygen; omnipresent, yet somehow invisible--hardly worthy of analysis. In the early years, Kevin was paranoid when not suspicious. But some trust developed and he often shared his vulnerability with me, especially when his mother became ill.

As mentioned earlier, Kate was very flirtatious with me in the first years. Her overtures could be very direct--putting her hand on my thigh while I was driving or trying to embrace me. I think it was quite clear that she was prepared to act on her invitations. When I rebuffed these overtures, she wondered if I was homosexual. I worked at responding to these incidents with a playful quality. Understanding that the fading beauty of this former fashion model was perhaps one of her few narcissistic gratifications, I wanted to avoid shaming Kate for her flirtatiousness.

Kate also became furious at me at times, calling her attorney to fire me on several occasions. Perhaps because her dementia made it hard for her to recall the reason for her grievance, this rage rarely lasted more than a day. Clearly, Kate chafed for the first year at the financial regimen I imposed on the family. But transference interpretations would have had no positive effect.

PLAY

With the Stevens family, humor was critical to my "survival". Well before meeting this family I came to understand the importance of play in the therapeutic process (Kanter, 1984). As Lewis Hill remarked several years ago, "Schizophrenic patients as a group give the impression of being less interested, or successful, in pursuing pleasure than any other group of patients" (p. 60).  Winnicott (1971) extended this formulation into the therapeutic process by suggesting that the work of psychotherapy cannot begin until the patient has developed a capacity to play. He also suggests that the psychotic delusion is a failed attempt at play. Obviously, when a person is struggling with schizophrenia, it is difficult to enjoy the boundary between fantasy and reality that is such an important part of playful activity. Nor does the person with schizophrenia have the empathy and capacity to control aggression that differentiates mischieviousness from cruelty.

The capacity to play cannot be learned through pedantic efforts. It is learned by playing. Winnicott, a talented artist, enjoyed playing with his child patients through artistic games. Others, like Frederickson (1992), encourage a verbal interchange where the therapist gingerly plays with the patient's symptoms. A capacity to laugh--with the patient--at one's own foibles is critical. Another approach is to pay close attention to the patient's reports of his or her recreational activities. This may merely involve watching a television show or going out for ice cream.

Being with Kevin, I came to understand that his two main pleasures, rock music and alcohol, were more often a form of anesthesia than a form of pleasure. For a time, he attended a Friday night dinner at the rehabilitation agency. He seemed to have some friends there, but withdrew about a year before his parents died when he started working part time as a custodian. When that job ended six months later, his withdrawal continued, but he seemed more depressed than psychotic. I wondered if his awareness of his mother's increasingly fragile health was affecting him.

But when we were together, especially in the car with the radio on playing music from the 1960's and 1970's, we could recall an earlier, more innocent time--an era of nostalgia for me, an era that Kevin had never emerged from: a 44-year-old adolescent. I sometimes felt guilty indulging in this nostalgia; should I be telling Kevin to grow up and leave that era? Instead, I sometimes joked with him that he should have pursued sex instead of drugs. Although attractive and charming when not psychotic, he had not had a real girlfriend in over twenty years, only several unrequited flirtations.

BOUNDARIES OF THE COMMUNAL RELATIONSHIP

In a wonderful 1964 case report titled "Casework as Friendship," Marjorie Sheppard (1995), a British social worker, explored the boundaries between friendship and professional activity in a 10-year relationship with an older paranoid woman. She stated that:

There is too much involvement with the mechanics of the mind in treating the mental patient, when we are too busy thinking and asking questions (both of ourselves and patient) while we are with him, the person--the human being--tends to be forgotten. This attitude communicates itself to the patient and something in the relationship is lost. (p. 16)

Sheppard went on to decry the tendency among highly trained workers "to consider the 'friendly relationship' way of working with the client [as] an inferior way" (to analytic psychotherapy). She notes that an acknowledged difference between social work and friendship is that "in friendship two people each expect to receive from and give to the other, whereas in the professional relationship the first consideration is to the client.' Yet, she continues:

Most of us probably have amongst our personal friends one who gives more to us than we to him and one to whom we give more. But we still consider this person our friend. I think we can extend this sort of friendship to certain clients. The difference is perhaps that, while we permit ourselves a similar involvement in the sense of allowing ourselves to feel liking or love for the client and are able to receive from him as well as to give to him, we do retain a certain professional distance: but only in the sense that we do not "demand" anything of the client or feel we have the 'right' to return of affection or reciprocal behavior which we might still expect from our other friends. (p. 16)

Suggesting that the worker listen and empathize, Sheppard then suggests that "You are not worried about your position vis-à-vis the client in the sense that you a 'worker,' and you are not worried about 'what things mean' any more than you are likely to be in your relationship with a personal friend"(p. 17). She argues that such a stance is perhaps most valuable with older clients who are unlikely to "alter" , where therapeutic change is unlikely.

Clearly, Sheppard is courageously addressing the implications of the approach to community care discussed in this paper. Once we become part of our client's actual lives, we cannot assume at will a stance of therapeutic neutrality and detachment. Yet our professional identity--and its accompanying sense of professional responsibility--are just as authentic components of our personal identity as our capacity for friendship.

In this work, we cannot forget, while we partake of the satisfactions of the "communal relationship"--of the transitional participant--that we are also responsible, to a greater or lesser extent, for the management of the client's situation. This is often a thankless task and we are paid to carry this work out; gratitude and fulfillment are insufficient rewards. A recollection: Mrs. Stevens gets drunk. She falls down the stairs and is in pain. The home care aide calls me and asks what should be done. I am busy with other work and family obligations. I am not scheduled to visit for 2 days. Should she call the ambulance? Should I visit later that day? Should she visit her doctor? Kate has no painkiller in the house---but now I need the aspirin.

In order to maintain my involvement as a transitional participant over the years, I need to survive the demands of this work. Unlike a friend in the sort of unbalanced relationship that Sheppard described, I cannot withdraw for several months when the burdens of this relationship feel excessive. Like a parent with a headache, I cannot just climb into bed and ignore my responsibilities; if I don't attend to my clients, I need to find someone who will. Life is more than birthday parties and sunny Saturday afternoons. Maintaining this profound awareness of professional responsibility, I can maintain the boundaries needed to continue my professional mission in a chaotic social field. I understand that boundaries are a means to the end of this professional mission, not an end in themselves.

CONCLUSION

Although our work in community care has been inadequately conceptualized in the professional literature, our involvement in the day-to-day lives of our clients poses both clinical and theoretical challenges. The work of management--of establishing "facilitating environments" for our mentally ill clients--becomes combined with other dimensions of our relationship, most notably that of transitional participant, and a communal relationship develops which is significantly different from traditional psychotherapy. We no longer only just hear about the people and places in our clients' lives, we begin, at least in small ways, to participate in their lives. Such participation, while not psychotherapy proper, can facilitate therapeutic change as management interventions and transitional participants are internalized, enhancing the client's capacities for self-care and psychic integration.

MOVING DAY

Before picking up the rental truck, I stopped by the pharmacy to pick up a medication refill. Arriving in the truck to take Kevin and several furniture pieces to his new residence, I find his brother and a yard full of furniture. While Kevin only wanted to bring 2 pieces from his parents home, his brother wanted me to load half the furniture in the truck. I had no idea how he would use all this furniture in a small apartment. Worried about my schedule, I agreed to help load and unload this furniture at the brother's building, but he would have to get it up to his apartment by himself.

Kevin was quiet as we went through the house deciding what to take along. They would have access to the house for several days so they could return to seek any forgotten items. But the truck would not be available. Kevin decided to take a reclining chair, a large dresser and a lamp from his bedroom. He was not interested in taking any of the pieces for sentimental value. We took half an hour to load the truck and drove several miles to his brother's apartment.

After unloading most of our load, we drove off to Kevin's new residence. Almost immediately, Kevin said he was sick and rolled down the window. He vomited three times, wiped his mouth with his hand and refused my offer to stop for something to drink. We were quiet for a time. I commented that this has to be one of the most painful days of Kevin's life. I recall a day 13 years earlier when my brother and I drove a rental truck to remove furniture from a summer home that had been in our family for nearly 60 years. I told him that I had dreams now and then about that home; sometimes I woke up feeling very sad that the home had been sold. Kevin shared that he often sees his parents in his dreams and wakes up near tears.

We drove into his new neighborhood. We were both silent as I parked the truck in front of the townhouse he would share with two others recovering from mental illness. As I got out of the truck, I saw his new roommate coming out to greet us. He was casually dressed, wearing a baseball cap, a t-shirt, and sporting a goatee beard. He looked over at Kevin, noted the package of cigarettes in his shirt pocket, and extended his hand. "Hi, I'm Tom. What's your name? I see you smoke too."

REFERENCES

Fisher, R and Ury, W. (1981). Getting to yes: Negotiating agreement without giving in. New York: Houghton Mifflin.

Frederickson, J. (1992). From delusion to play. Clinical Social Work Journal, 19(4), 349-362.

Harris, M and Bergman, H. (1987). Case management with the chronically mentally ill. American Journal of Orthopsychiatry, 57(2), 296-302.

Hill, L. (1955). Psychotherapeutic intervention in schizophrenia. Chicago: University of Chicago Press.

Kanter J. (1984) Resocialization in schizophrenia: Renegotiating the latency era. International Review of Psychoanalysis, 11, 43-59.

Kanter J. (1988). Clinical issues in the case management relationship. In M. Harris  and L. Bachrach, eds., Clinical Case Management:(New Directions in Mental Health Services, Vol. 40. San Francisco: Jossey-Bass.

Kanter J. (1989). Clinical case management: definition, principles, components. Hospital and Community Psychiatry, 40(4), 361-368.

Kanter, J. (1990). Community-based management of psychotic clients: the contributions of D.W. and Clare Winnicott. Clinical Social Work Journal, 18(1), 23-41.

Kanter J. ed. (1995). Clinical studies in case management: New Directions in Mental Health Services, Vol. 65. San Francisco: Jossey-Bass.

Kanter J. (1996a). Case management with long term patients: a comprehensive approach. In S. Soreff, ed., Handbook for the treatment of the seriously mentally ill. Bern: Hogrefe and Huber.

Kanter J. (1996b). Engaging significant others: the Tom Sawyer approach to case management. Psychiatric Services, 97(8), 799-801.

Kanter J. (1999) Clinical issues in delivering home-based psychiatric services. In A. Menikoff, ed., Psychiatric Home Care. New York: Academic Press.

Klein, M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis. 21.

Levinson, E. (1985). The interpersonal (Sullivanian) model. In A. Rothstein, ed., Modes of the mind: Their relation to clinical work. New York: International Universities Press.

Mendel, W. (1976). Schizophrenia: Its experience and treatment. San Francisco: Jossey-Bass, 1976.

Sheppard, M.L. (1995). Casework as friendship: A long-term contact with a paranoid lady. In J. Kanter, ed., Clinical Studies in Case Management: New Directions in Mental Health Services, Vol. 65, San Francisco: Jossey-Bass.

Sheehan, S. (1982). Is there no place on earth for me? New York: Houghton Mifflin.

Winnicott, C. (1964). Child care and social work. Hertfordshire (UK): Codicote Press.

Winnicott, D.W. (1965a). Psychiatric disorder in terms of infantile maturational processes. Maturational processes and the facilitating environment. New York: International Universities Press, 1965.

Winnicott, D.W. (1965b). The development of a capacity for concern. Maturational processes and the facilitating environment. New York: International Universities Press, 1965.

Winnicott, D.W. (1975). Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34.

Winnicott, D.W (1989). Letter to Herbert Rosenfeld, in F.R. Rodman, ed.,. The spontaneous gesture: Selected letters of D.W. Winnicott. Cambridge: Harvard University Press.

Winnicott, D.W. (1970a). Playing and Reality. London: Penguin.

Winnicott, D.W. (1970b). Residential care and therapy. Deprivation and Delinquency. London: Tavistock.

Winnicott, D.W. and Britton C. (1944). The problem of homeless children. The New Era in Home and School, 25, 155-161.

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Joel Kanter is a Senior Therapist at Fairfax County (Virginia) Mental Health Services and is in clinical social work practice in Silver Spring, Maryland. He is currently editing the collected writings of Clare Winnicott.

Mailing Address:
8811 Colesville Road, #104
Silver Spring, Maryland 20910

Email: joelssmd@juno.com

(Posted to Psyche Matters November 19, 2001)

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