The Facilitating Partnership: A Winnicottian Approach for Social Workers and Other Helping Professionals • Fostering Healing and Growth: A Psychoanalytic Social Work Approach

Developmentally informed, psychodynamic psychotherapy is dead. Or is it? According to the official story, dynamic psychotherapy is time consuming, costly, unsuitable for patients with serious and chronic emotional disorders, insufficiently concerned with symptom alleviation, and insensitive to issues of race, class, and culture. With the widespread implementation of managed care, psychodynamic treatment has been replaced by medication supplemented by cognitive-behavioral psychotherapy.

The two volumes reviewed here challenge the official story by creatively adapting contemporary analytic theory for use with a wide range of patients and by illustrating the theory's applicability through a rich array of creative and thought-provoking case presentations. Essentially, both books advocate for therapeutic relationships that help patients knit past and present together in a growth-promoting, mutually constructed narrative.

In The Facilitating Partnership, Applegate and Bonovitz review D. W. Winnicott's developmental insights, applying them systematically to therapeutic practice in mental health settings and in private practice. The authors particularly value Winnicott's ideas about the interaction between individuals and their social (caregiving) environments, the "holding" function of the therapeutic relationship, transitional phenomena, and the "true" and "false" selves. Special attention is paid to patients whose early development has been significantly compromised, who carry a diagnosis of borderline or narcissistic personality disorder, and who experience significant levels of environmental stress.

Reflecting current social norms, most contemporary psychotherapists view regression and dependency as antitherapeutic because they impair functional adequacy, undermine self-sufficiency, and thereby loot the public purse. Ubiquitous though these views are, they ignore what child development researchers and therapists know about the ways early emotional development influences adult functioning.

Applegate and Bonovitz follow Winnicott in arguing that regression to dependence reflects "an unconscious effort to return to the true self, to repair gaps in ego development, and, thus, to remobilize psychosocial growth. By welcoming and accepting the client's dependency, he [Winnicott] offered himself as a new object—someone who was reliable, consistent, and able to withstand and survive the intensity of the client's frightening impulses and feelings."

The authors are also guided by Winnicott's view that antisocial behavior both in children and in adults is a signal of distress reflecting care that was not adequately provided during childhood. Accordingly, antisocial acts represent "an urge toward cure," a hope that caregivers will repair childhood deprivations through meaningful, need-gratifying relationships and firm, nonpunitive limits. Case reports document that such patients modify antisocial behavior after projecting their destructive feelings onto a symbolic caregiver, the therapist, without destroying the therapist or being destroyed by retaliatory aggression.

Fostering Healing and Growth approaches psychotherapy from a related but somewhat broader psychodynamic perspective. Expertly edited by Joyce Edward and Jean Sanville, this book features case reports by distinguished, analytically trained social workers. The case reports are framed by five chapters that provide an overarching theoretical framework and by a concluding "postlude" that summarizes the book's major themes.

Books that feature psychotherapeutic case reports are rare, even though such reports offer exceptional opportunities to study the relationship between theory, practice technique, process, and outcome. In this volume each contributor presents a significant segment of therapeutic interaction or dream work in the context of a particular theoretical framework. Most patients have experienced significant trauma and demonstrate serious difficulties in ego integration and self-organization. In the past most would have been "deemed unreachable by a psychoanalytically informed perspective." For this reason the contributors focus on promoting progressive emotional development—that is, "growth" rather than insight. Interpretations are mutually arrived at rather than presented authoritatively by the therapist.

In comparing this approach with practice approaches that emphasize premature cognitive understanding and behavioral change, it is instructive to listen to patients freely describe their life experiences. Among others, we hear a paranoid schizophrenic man describe his father's threat to kill him, and a woman who is terrified because she dreams of cutting off the top of her baby's head. The therapists represented here do not interrupt these narratives, or discourage patients from becoming dependent, or insist on discussing functional impairments. They struggle to understand what patients communicate when they evoke frightening, painful, angry, and hopeless feelings, and they work toward metabolizing such feelings to promote healing.

Most remarkable, perhaps, is the creativity contributors exercise in treating clients whose life experiences make it difficult for them to consider or "use" a human relationship. For six years Aronson used telephone interviews to maintain therapeutic contact with a repeatedly hospitalized, severely anorexic, often autistic young woman until the woman could tolerate a face-to-face relationship and begin addressing overwhelming feelings of hopelessness and despair. Another contributor, Graziano, approached the "trust-fragmentation-mistrust cycle" that characterizes "catastrophically traumatized" sexual abuse survivors by modifying the frame of treatment. She extended therapeutic sessions to two hours, read the patient's writings aloud during sessions, sat next to the patient at moments of terror, and, when asked, held the patient's hand. She "linked affects with words," bore witness to the reality of unspeakable events, and helped the client "move from isolation inside the events toward a fuller life in the external world." In the finest tradition of clinical social work practice, Aronson, Graziano, and others "started where their patients were" and creatively modified accepted treatment procedures to address the most pressing developmental needs.

If we now reconsider the litany of criticism that introduced this review, it is fair to acknowledge that analytically informed psychotherapy is long, and sometimes expensive. It does not yet effectively address the complexities of interracial treatment, and it is often slow in alleviating symptoms. However, the analytic practitioners represented here do thoughtfully consider issues related to social class, culture, and gender. Moreover, they treat patients who have serious and persistent emotional disorders with impressive efficacy. If we then consider the bottom line, we are justified in emphasizing how many health care dollars are saved by, for example, reducing or eliminating rehospitalization for Aronson's anorexic patient, or by eliminating the need for protective services on behalf of a patient's infant daughter.

As social workers provide well over half the psychotherapy offered in this country, it is fitting that these books are written by social workers for a social work audience. Nonetheless, they have much wider value. Because they thoughtfully consider how psychological growth takes place within the context of a developmentally attuned relationship, as well as the effect environmental impingement has on individual functioning, they make a vital contribution to psychotherapy theory and practice. They should be required reading in every graduate program for mental health practitioners, and they will be of compelling interest to experienced therapists who study therapeutic process.

Mr. Schamess is professor at Smith College School for Social Work in Northampton, Massachusetts.