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"Psych 101 -
What you didn't learn in nursing school."


by Kathi Stringer
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Holding Environment

Written by Kathi Stringer

This paper will attempt to discuss the analytic components of the holding environment and extrapolate theory to give meaning towards a syncretic result. First lets disassemble the codification of targeted principles to create a clear topographic model in this highly abstract concept.

Winnicott, a British object relations theorist and pediatrician originated the "holding"(1960) and Bion (1967) the "containing" concepts. Stone (1981) goes on to say;

"The "love" implicit in empathy, listening, and trying to understand, in nonseductive devotion to the task, the sense of full acceptance, respect, and sometimes the homely phenomenon of sheer dependable patience, may take their place as equal or nearly equal in importance to sheer interpretive skill. [p. 114]"

The holding and containing elements are particularly useful when treating regressive individuals with underdeveloped and disturbed object constancy common in the borderline. These clients employ infantile defense mechanisms, splitting, projective identification, denial, idealization and devaluation (Kernberg 1967). Integral of this process transferences will shift abruptly and so do their introspective of self (Mahler).

Boundaries

Writers (Scharff & Scharff, 1988) postulate the establishment of the holding environment must consist of boundaries. These include showing up for appointments on time, prompt payment and strict start and stopping times. Scharffs empathize these boundaries are needed to create a safe space in which the patient can feel protected, yet free to communicate, explore and experience. This modern psychology would seem self-defeating since to terminate a client due to trespassing over boundaries would allude to a presdo-holding environment since in truth the parallel would be to terminate a small child from the family relationship. Surely, exploration for alternate consequences for these regressed, self-sabotaging clients would prove advantageous for the therapeutic relationship. It would be imperative the treater not only be educated, but skilled and creative.

Containment

Lipthrott states that Bion (1967) developed concepts of the container and the contained both in therapy and in parenting. These terms of parenting, infants often become overwhelmed by affect because they lack the internal controls. The mothering caretaker pays attention, listens, takes in these communicated feelings whether they be cries, coos, laughter of facial expressions, transforms them, gives them meaning and returns them to the child resulting not only in necessary physical care for the child, but also an empathic soothing.

Holding Environment

Lipthrott also states that Winnicott speaks of a holding environment in which the infant is contained and experienced. The mother assists the child in the task of self-integration by reflecting back the child expression of him or herself. In his later writing, Winnicott describes mother functions as a mirror which provides the infant with "a precise reflection of his own experience and gestures, despite their fragmented and formless qualities."

Incomplete Therapy

Ninety percent of borderlines drop out of therapy (Kreisman 1991, p122). It is their primary nature to execute self-defeating behaviors and sabotage the therapeutic relationship. Like the toddler who runs from mother, expecting to be swooped up by her, she will instinctively test the safety capacity of her environment.

Self-defeating

The anaclitic quasi-symbiosis relationship with the therapist and treatment team will be under the scrutiny of the patient. In hopes to ameliorate her perception of the holding environment she will run like the toddler and dismiss those who are in a position to help her (such as case workers). Not game-playing but rather attempting to substantiate a consistent platform of trust and safety searching for the parental object. On the other hand, a patient may be so anaclitic depressed that the strength escapes her to proceed with therapy since she is incased with a shroud of helplessness and hopelessness. And finally, the patient when at odds with the world, who’s behavior manifests negative transference will project her anger since she is unable to fulfill her notions, wishes and fantasies. Her fragile ego incapable of effectively using her previously maladaptive defense mechanisms will unconsciously elicit the same behavior she is projecting onto the therapist hoping to destroy the therapeutic stance and validate her perceptions of reality (the world is bad). In this instance the therapist should monitor her countertransference as a barometer to gage how the patient relates and responds to her internal structures and with others rather then in retaliation.

At any rate the therapy should continue as an open case for a period of supervision (telephone if necessary) to determine a definitive solution or hospitalization in a patient’s failing mental health. A procedure short of this would damage the holding environment substantiating the patient’s precarious fears of the vicissitudes of rejection and isolation.

Telephone strategies are a viable option to create and maintain an intrapsychic prophylaxis and a spatial element of the holding environment for the severely affected patient who is not able to operate. I formulate this conjecture to expand the therapist’s modalities to reach beyond the static office climate into the patient’s world of the here-and-now. This therapeutic tool may mitigate and stifle the growing anxiety of rejection and abandonment, giving rise to object constancy, bringing escalating emotions into manageable proportions. Such tactics will inhibit the neurotic rapture of desperation in the borderline.

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