The Holding Environment

The frame that supports the analytic relationship is also referred to as the holding environment, an expression that highlights its containing function.

Bion (1967) drew a parallel between the mother's capacity to receive the raw intensity of her baby's projections, to empathise and to bear them, thereby rendering them eventually manageable for the baby, and the therapist's function of receiving, containing and transforming the patient's communications. This helps the patient eventually to internalise the capacity to manage feelings in himself and to think about them.

Just as mothers provide the baby with a dependable, secure environment that maximises the opportunities of physical and psychic growth, the therapist's function to an extent mirrors the early parental function with its emphasis on responding to the patient's needs without impinging on them. Winnicott, who suggested that the function of the analytic frame was to provide the necessary conditions for the development of ego strength so that the therapy could proceed, also proposed this view. The frame was, according to Winnicott, a potent symbol of the maternal holding that he so emphasised in his writings; he believed that it was this holding function that allowed the baby to manage difficulties in early life. When we transpose these ideas to the therapeutic setting, it becomes clear that the holding function of the frame depends primarily on the therapist's mental holding that is supported and protected by the pragmatic aspects of the frame.

The frame thus acts as a container. It allows for the unfolding of the patient's story and an understanding of his internal world within safe confines. The safety or otherwise of the so-called container is communicated in practical terms through the respect of the boundaries of the analytic relationship. The safeguarding of a secure frame is a core part of analytic technique. It involves managing the physical boundaries of the relationship, namely, the provision of a space where therapist and patient can meet without interruptions, where confidentiality can be assured, where the therapist can be relied upon to turn up on time, at the same time, week after week, as well as to finish the sessions on time. The thoughtful administration of these boundaries conveys a great deal of information to the patient about what kind of person he is entrusting his pain with.

A therapist who starts her sessions late or cancels sessions repeatedly is conveying a very different message to the one who strives to adhere to the agreed boundaries. We are human and fallible, however, whatever projections the patients may make on us. This means that the ideal frame we try to provide is just that: an ideal. In reality there will come a time when we will be late for our patient or we may overrun the session, or someone will walk into our room whilst in a session. This may well encourage self-recriminations (e.g. ''I am not a good therapist'') or anger at the colleague who interrupts the session. There will always be a reason for every deviation from the frame, but whatever feelings we might have about it, what matters in the therapeutic work is the meaning the deviation acquires for the patient.

Tony was a forty-year-old man who had been orphaned at age three after both his parents were killed in a car accident. He had been brought up at first by his maternal grandmother, but after her death, when he was aged ten, he was placed in the care of various relatives and eventually spent one year in residential care. On our first meeting, he described how, after his grandmother's death, he had never lived anywhere for longer than two years.

As an adult Tony was very precise and a stickler for routines - a propensity that verged on the obsessional. He arrived to his sessions punctually and would monitor the time often announcing, before I could, that the session had come to an end. I felt that this was one of his many ways of retaining control in our relationship.

On one occasion, I am delayed on a train and arrive five minutes late for the session. As I collect Tony from the waiting area I sense his tension: he does not establish eye contact with me and utters a barely audible ''Hello''. When he sits down, he starts by saying there is not much to say today. He adds that he had not wanted to come because he was busy at work and it bothers him when he cannot finish a task he has started. He speaks a bit about pressures of work and deadlines not being met by colleagues, which he finds ''infuriating''. He barely looks at me as he speaks. As I listen, I feel that he is very angry with me but I also know it is one of Tony's characteristic patterns never to express directly what he feels.

Approaching my intervention, I take into consideration that Tony began the session non-verbally displaying signs of anger (e.g. he did not look at me) and verbally telling me that he did not have much to say and that he had not wanted to come to the session. This kind of start to a session invites me to think about what might have triggered Tony's stated resistance to talking and coming to the session. Here, I note that his not wanting to come to the session may have only come to his mind once he arrived and did not find me waiting for him, as was usually the case. Given Tony's early history of loss and discontinuity in his carers, I hypothesise that my lateness was most probably a trigger for his silent rage towards me.

Through his complaints about work and people not meeting deadlines, I hypothesise that Tony is giving expression indirectly to his infuriation with me for having missed our "deadline". His choice of the word "deadline" makes me think about his parents' death and I speculate that, given his traumatic history, my lateness has also aroused terrifying anxieties about whether I would ever arrive and whether he would be left, once again, orphaned.

This hypothesis was supported by a question Tony had put to me in a previous session about what would happen to a patient if his therapist had to move to another country. My attempts to explore the meaning of the question had been met with resistance. At the time of asking this question, Tony had insisted that he was simply curious about this and rejected my interpretation that he was worried about what would happen to him if for some reason I could no longer see him. It now seems important to return to the anxiety that I thought had fuelled this earlier question, namely, the anxiety arising from his growing dependency on me and his fear that I might also leave him, just as his parents had done. Although Tony had rejected my earlier interpretation, the theme of being abandoned is recurring and therefore needs to be pursued. I therefore hypothesise that Tony's rejection of my first interpretation may have been a sign of resistance to thinking about the possibility of my leaving him and the painful affects this gave rise to.

In my interpretation, I decide to reflect back to Tony, not only his rage about my lateness but also to acknowledge what the rage defends against. However, rather than giving the interpretation all at once, I start with the most conscious feeling, namely, the rage. This way Tony may be more receptive to what I have to say than if I offer him an interpretation that confronts him too quickly with feelings that he would rather not think about. Bearing this in mind I begin by interpreting: "You start off telling me that you don't have much to say today and in fact you did not really want to come to the session. You also express infuriation with work colleagues who do not meet deadlines. I think that you are saying to me that my lateness has made you feel infuriated with me. It's like you experience my lateness as me not doing a very good job and keeping to our deadline. But we both know you find it hard to express such angry feelings directly.''

Tony is able to think about this and acknowledges that he had been angry as he had made a real effort to get to the session on time and was angry when I did not arrive. He then falls silent. He resumes speaking and reports an upsetting dream he had a few days earlier in which his cat ran out into the street and Tony waited for a long time but he did not come back. He could not remember anything else about the dream. This dream is thematically consistent with feelings of loss and abandonment; it reinforces my hunch about the underlying anxiety of being abandoned and I therefore decide to share with Tony the second part of my interpretation: ''I think that your anger with me when I did not come to get you on time today covers up the anxiety you felt as if inside you feared that I would never arrive.''

Adhering assiduously to the boundaries of the frame is not a question of being pedantic or inflexible - accusations often levelled at therapists who are very strict about their boundaries. On the contrary, such an attitude of respect for boundaries reveals an appreciation of the importance of stability and reliability for the patient's psychic development. For patients such as Tony who have experienced early losses, unsettled childhoods or grew up in an unpredictable family environment, the safeguarding of the boundaries of the analytic relationship may represent for the patient the very first experience of a person who can be trusted and depended upon. It creates a safe psychological space in which the patient may explore his deepest longings and fears. The importance of this frame cannot be overstated. It is a concrete expression of the containment we can offer the patient - an indication of what the patient can expect from us and can therefore rely on.

The boundaries of the therapeutic relationship ensure that anxiety provoking phantasies and feelings about the self and others can be explored and expressed in the context of a non-retaliatory relationship that will carry on being irrespective of the feelings the patient may need to voice. This does not mean, however, that ''anything goes''. Being truly containing requires knowing when understanding is not enough, that is, when words simply cannot contain the patient. There are clearly behaviours that undermine the therapeutic process and have to be managed, for example, arriving to sessions under the influence of alcohol or attempts to self-harm during a session. Such behaviours need to be addressed promptly and understood as unconscious communications. In many cases, this will defuse the need to act out.

An important part of our role is to allow ourselves to become the receptacles for the patient's projections and his need to act out feelings that cannot be verbalised. However, it is also our responsibility to keep the boundaries and to remind the patient of this if his behaviour threatens to undermine the therapy. Lending oneself to the patient's projections involves knowing when the enactment of a projection is too concrete for it to be of any use. Not retaliating does not mean passively accepting that the patient is abusive towards us because of what has happened to him. The therapeutic relationship may well be subjected to familiar patterns prominent in the patient's interpersonal repertoire, but it also has to be one with a difference, namely, one where these patterns, and their consequences for relating, are made explicit and can be thought about. The survival of the object that Winnicott spoke of results from our ability to use our own mind when under interpersonal pressure to abandon thinking and to act. Where understanding is not enough to defuse the need to act out, the therapy may, in rare situations, need to end.

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Responses

  • Aamu
    What is a holding environment in therapy?
    11 months ago
  • costantino
    How do therapist create a holding environment?
    10 months ago
  • andrea
    What is a safe holding environment?
    10 months ago
  • Genoveffa
    What are the theories of the hilding enviroment?
    9 months ago
  • RIIKKA
    What is a disadvantage the holding enviornment in treatment?
    9 months ago
  • semret
    Where did 'holding the space' originate in psychotherapy?
    8 months ago
  • FAITH
    What is a sage holding environment in therapy?
    5 months ago
  • Polo Whitfoot
    How to create a holding environment in therapy?
    5 months ago

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