By Joel Kanter

Date Posted: December 18 2013

Joel Kanter is a social worker in independent practice near Washington, DC. He is a Consulting Editor of the Clinical Social Work Journal and is the editor of “Face to Face with Children: The Life and Work of Clare Winnicott” (Karnac 2004) at www.clarewinnicott.net

 

Joel has written extensively about community care of persons with severe mental illness and about the influence of Clare Winnicott on therapeutic work and social care. Email Joel at joel.kanter@gmail.com

 

 The Trauma of Dislocation and the Transitional Participant

Joel Kanter, MSW, LCSW-C

 

While the psychoanalytic literature has frequently addressed issues involving separation, loss and attachment, the experience of “dislocation” encompasses much more than these commonplace phenomena. The experience of dislocation is vividly illustrated in the lives of immigrants. Some have migrated without any special duress; others have escaped war, persecution or desperate poverty. Some leave with family, or meet family and friends in a new land; others leave with minimal social support. Inevitably, Yet, all enter a new world that is disorienting in any number of respects. As Bonovitz (2004) has noted,

the holding functions provided by familiar faces, voices, routines, customs, language, food, sights, smells, and sounds are abruptly lost, creating an internal sense of confusion, uncertainty, and unaccustomed disorganization. The sustaining, reassuring presence of the “things” of everyday life, hitherto taken for granted, is lost, creating an unexpected void in the internal landscape (p. 130).

While the trauma of dislocation is impossible to overlook in the context of immigration, there are many commonplace experiences that have similar, though perhaps less dramatic, psychic effects:

• children in divorcing families; often this involves repeated dislocations as parents move, custody arrangements change, remarriages occur and so on.
• divorcing adults; homes are sold, social networks are severed, family life is dramatically altered.
• “intranational” migration; rural to urban or vice versa, economically-driven relocation .
• military personnel and families; notably deployment overseas and to war zones.
• children in the child welfare system; foster care, changing familial arrangements.
• adopted children; international and domestic.
• college students living away for home for the first time.
• graduating college students; living in a new locale with a new career.
• elderly persons; moving from a comfortable home to retirement communities, assisted living or nursing homes.
• persons with severe psychiatric conditions; multiple transitions between family, hospitals, homeless shelters, residential programs and even jail (Sheehan, 1982).

 

All of these dislocation experiences are traumatic in their own way. While the impact of separation and loss from significant relationships are self-evident, Ahktar (2011) has described the importance of the changes in the “non-human environment”. Sights, smells and sounds are all relevant here, but there is also the alterations of the cultural milieu; how people talk and interact in everyday life apart from the intimacy of family and friendships.

Such issues surface constantly in contemporary psychotherapy practice. Some examples from my current caseload include:

• a high functioning 60 year old man whose alcoholic father from an upper class background died suddenly when he was 14. Subsequently, his newly impoverished mother moved from a large home in a desert city to a small town on the Pacific Ocean and remarried.
• a 21 year old African immigrant whose family found asylum in the United States when he was 18. After a year in this country, he enrolled in a small Midwestern college with perhaps 4 students from his nation. He became depressed and withdrew after six months.
• a 45 year old woman with schizophrenia who has been hospitalized at least 15 times, homeless for months at a time, jailed four times, and evicted from two apartments.
• a 50 year old professional man facing six months imprisonment for a “white collar” crime.

 

Akhtar (2011) suggests that dislocated persons resort to a number of measures “in an attempt to diminish… anxiety, pain and perceptual instability… These involve operations in the inner world, interpersonal realm, and external reality. An admixture of regressive and progressive trends is evident in all such mechanisms. … they are stop-gap transitional phenomena (D. Winnicott 1953) that facilitate self-holding in perceptually uncertain and affectively turbulent times” (p. 12).

 

The Role of the “Transitional Participant”

Akhtar (1999) also refers to Winnicott’s (1953) concept of the “transitional object” as a coping strategy commonly employed by immigrants and other dislocated persons. As a small child develops a deep attachment to a special blanket, doll or toy, inanimate, treasured objects are taken from the homeland and are carried or displayed in a new land, helping to maintain a connection between the past and the present.

Yet, Donald and his second wife, Clare, described a quite human “transitional” participation in the lives of children dislocated during Britain’s massive wartime evacuation in their 1944 paper “The Problem of Homeless Children”. This paper emerged from their collaboration in Oxfordshire supporting five residences that served evacuated children with special needs; Clare was the full-time social worker on this project and Donald was the psychiatric consultant. They wrote that:

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. (Kanter, 2004, 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.” (Kanter, 2004, p. 130).

After the war, Clare (Britton) Winnicott became a leader in British child welfare and pursued psychoanalytic training which included a personal analysis with Melanie Klein. Familiar with both psychoanalytic therapy and social work practice, Clare distinguished between these practice modalities:

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….” (Kanter, 2004, pp. 171–172).

Besides focusing on how the social worker can be used by children to keep alive positive internal representations of significant others, Clare also described how the worker’s ongoing presence in the child’s life helps 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. (Kanter, 2004, p. 171)

Any parent will immediately recall the “remember when” game that is such a significant component of parent-child interactions. Beyond our universal fascination with photo albums or home videos—especially when shared by significant others—we all 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 inanimate transitional object, Clare Winnicott’s “transitional participant” is not a passive recipient of the child’s projections; the social worker actively positions himself 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.

In my professional social work practice, I practice both as a conventional psychotherapist and as a “clinical case manager” (Kanter, 1989, 2010). In the former role, I mostly function in a world apart from the lives of my clients. I listen to their life narratives, both past and present, and co-create a narrative in our therapeutic relationship.

But when I practice in some situations as a clinical case manager—usually with severe disturbed persons—I am very personally involved in the lives of these individuals. I find myself in a complex interpersonal field involving a network of caregivers and concerned parties that may involve dozens of individuals over the years: doctors, nurses, attorneys, home care aides, relatives, acquaintances, pharmacists, social workers, probation officers, rehabilitation workers, and so on.

In more ordinary work with children, there is also an element of this role as a “transitional participant”. With a child of divorce, I may be the only person the child knows who communicates directly with both parents and, in some instances, I may visit the school and the child may witness me communicating with his or her teacher.

Our professional function as a transitional participant is highlighted when there is a psychic deficit, which Werner Mendel (1976) identified as a “failure of historicity,” a characteristic that is common to many clients unable to construct coherent personal narratives. Mendel wrote as follows:

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 . . . 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. (pp. 43–44)

To address this deficit, Mendel recommended:

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).

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” (professional or otherwise), whose capacity for historicity is unimpaired; certainly, a process of internalization plays a major role in this process.

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.

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, extended family members, childhood friends or neighbors. The maintenance of these relationships throughout the lifecycle is one of the cornerstones of mental health.

Considering these issues of continuous involvement, psychotherapists may wonder how—for better or worse–actual participation in the patient’s life impacts the therapeutic process. As Clare Winnicott reported earlier about Brian’s mother, her capacity to help the mother feel an evocative connection to Brian “could not have happened if I had not really known her child….”.

Ahktar (1999) refers to the concept of “emotional refueling” when describing the importance of an immigrant’s connection to others from his homeland, whether family, friends or casual acquaintances. He relates this experience to the rapprochement subphase in a toddler’s separation and individuation experience; when the separating child returns briefly to the mother for “refueling” before venturing off again. Certainly, this occurs with the transitional participant, but there is far more to this experience. The cognitive dimension in the interaction with the transitional participant is critical here; the comparing of “notes”. “Remember Mrs. Jones in second grade.” “Remember Dr. Smith at St. Patrick’s Hospital.” “Remember when you visited me in jail.”

Or consider what happens to the transference when, after several years of listening to a patient discuss a parent or other relative, the relative appears one day in the waiting room, is involved as a collateral in a family session, or is encountered when a therapist attends a funeral or wake. In the next session, the patient tells the therapist “Now you can see what my mother is like” —and the therapist has joined a special club—a club entitled “Persons Who Know My Mother”.

Similarly, consider the psychic processes that transpire both before and after a person has some sort of “reunion” experience, perhaps a family wedding or a class reunion and meets various individuals from years long past. Often there are lively dreams, fantasies and ruminations about the event and the persons one encounters. A therapist may listen to the reports of these encounters with various “transitional participants” in their patient’s life, but still stands outside the “life” itself.

 

Implications for Treatment

How can our understanding of the “transitional participant” enhance our therapeutic engagement with clients who have experienced traumatic dislocation? First, the therapist might consider the value of occasionally including family members in the therapeutic process. This is certainly helpful with children of divorce. If possible, I like to have some sessions with the child and each parent so the child can observe me interacting with “Mom” and with “Dad”. Occasionally, it may be useful to also include a sibling in a session. In doing so, one becomes a “transitional participant” in small part who the child experiences as travelling with them as they venture between “Mom-world” and “Dad-world” .

A similar process occurred when a young unmarried Asian professional who lives at home and has a central role—for better or worse—in a successful family business brought his father (and “boss”) to one of our sessions. When family tensions were subsequently discussed, I would hear “you know what my Dad is like….”

In a different vein, when a patient in outpatient therapy requires psychiatric hospitalization, I usually try to visit the patient in the hospital at least once. As such, I witness the inanimate aspects of the ward milieu and observe the staff and other patients, some of whom may be introduced to me. At such times of psychic “breakdown”, I am in a better position to assist the patient retroactively in creating a workable narrative about the stressors, the “breakdown” and the recovery.

When such involvements ensue, as Clare Winnicott points out, it is difficult to continue as a purely “subjective object” in the transferential field. For better or worse, the intersubjective field has changed and there are new issues to explore.

Alternatively, when the conventional psychotherapeutic paradigm is sustained—and the therapist maintains a separate position apart from the rest of the patient’s interpersonal field—he or she can remain attentive to the role of “transitional participants” in the lives of clients who have experienced traumatic dislocations. When encounters with such persons are described in session, the therapist may listen closely to the description of such encounters, understanding that such encounters may involve much more than “refueling”; they may facilitate the repair of a “dislocated” self.

Occasionally, patients may express deep ambivalence about attending some sort of “reunion experience”, anticipating an upsurge in painful affects. These opportunities are often rare—and offer unique opportunities to reconnect with “transitional participants”. Exploring and “holding” the anticipated affects often helps patients overcome their ambivalence and enables them to attend an event which can have both immediate and longterm reparative significance.

Also, therapists should attend to the loss of significant “transitional participants” in their patients’ lives. For example, the death of a sibling or close friend to an elderly patient may have a greater impact than the loss of a parent. When there is no one alive who can “remember when” with an older person, there is a deep sense of loneliness and isolation.

Ahktar (2011) suggests that the trauma of dislocation continues through the lifecycle and is never fully healed. That said, certainly many persons with such backgrounds learn and grow from these experiences. There are many therapeutic approaches to address the feelings of loss and disorientation that ensue from such dislocations. But involvement with a “transitional participant”—either inside or outside of a professional relationship—can enable individuals to ameliorate the painful and disorienting impact of dislocation and assist in integrating the fragmented sense of self that ensues from such experiences.

References:

Akhtar, S. (1999). Immigration and identity: turmoil, treatment, and transformation. New York: Aronson.

Akhtar, S. (2011). Immigration and Acculturation: Mourning, Adaptation, and the Next Generation. Lanham (Md), Aronson.

Bonovitz, J (2004). The Child Immigrant. American J. of Psychoanalysis, 64 (2), 129-142.

Kanter, J. (1989). Clinical Case Management: Definition, Principles, Components. Hospital and Community Psychiatry, 40(4):361-368, April 1989.

Kanter, J. (2004). Face to Face with Children: The Life and Work of Clare Winnicott. London, Karnac.

Kanter, J. (2010). Clinical Case Management. In “Theory and Practice of Clinical Social Work (2nd Edition), J. Brandell (Ed.), Thousand Oaks (CA), Sage.

Mendel, W. (1976). Schizophrenia: The Experience and Its Treatment. San Francisco: Jossey-Bass.

Sheehan, S. (1982). Is There No Place on Earth for Me? New York: Houghton Mifflin.

Winnicott, D. (1953). Transitional Objects and Transitional Phenomena. International Journal of Psychoanalysis. (34), 89-97

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