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Monday, October 16, 2017

The Holding Environment in Therapy: Maintaining a Safe Environment for the Client

In a prior article, I began a discussion about the holding environment in therapy (see my article: The Creation of the Holding Environment in Therapy).  As I mentioned in that article, the idea that the psychotherapist creates a safe therapeutic holding environment for the client was developed by British psychoanalyst, Donald Winnicott (for more on Winnicott, see my article: Books: "Tea With Winnicott" at 87 Chester Square).  In this article, I'm focusing on a particular aspect of the holding environment, which is the therapist's ability to keep the work emotionally manageable for the client.

The Holding Environment in Therapy: Maintaining a Safe Environment for the Client

As an example, it's often the case that clients come to therapy because they're not feeling good about themselves.  This can be a lifelong problem or a new development for a client.  Either way, the client might focus on the aspects of himself that he is unhappy about and miss the fact that he has many strengths.

A skilled psychotherapist will usually see the client's strengths, even when the client is unaware of these strengths.  

The challenge for the psychotherapist is when to talk to the client about his strengths.

Timing is everything.  If the therapist brings up the client's strengths too early in therapy, the client, who has a particularly negative view of himself, will often minimize or dismiss the idea that he has these strengths (see my article: Overcoming the Internal Critic).

Some clients, who are focused on what they perceive as emotional deficits in themselves, might even think the therapist is being disingenuous when she tries to talk to them about their strengths (see my article: A Strengths-Based Perspective in Psychotherapy).  

In many cases, on an unconscious level, these clients are too afraid to consider the possibility that they have strengths.  Rather being overwhelmed by their fear, they protect themselves emotionally by remaining stuck in their denial.

It's important that the psychotherapist not interpret the client's reluctance as "resistance."  This comes across as judgmental.  It would only make the client feel uncomfortable and it's not helpful to the work.

If the therapist doesn't know how to handle the client's fear,  this could lead to the client leaving therapy prematurely to avoid dealing with uncomfortable feelings (see my article:  When Clients Leave Therapy Prematurely).

So, the skilled psychotherapist, who is aware that it would be premature to talk to the client about his strengths, must keep these observations to herself until the time is right.  This requires the therapist to be emotionally attuned to the client (see my article: The Psychotherapist's Empathic Attunement).

Even with self critical clients who are willing to explore the possibility that they have strengths, they might perceive their strengths on an intellectual level but not on a deeper emotional level.

For these clients, the therapist might broach the topic of the client's strengths, let the client know that she (the therapist) sees these qualities and will hold a space for them until the client can accept this on an emotional level.

This is a way for the therapist to create a safe holding environment for the client because the client knows that the therapist holds onto these observations until the client is ready.

Let's take a look at a fictional vignette that illustrates these points:

John had been in and out of therapy for many years.

He usually attended a few sessions with a therapist, and then he aborted therapy because he felt the therapist didn't understand him.

John struggled with depression, including low self esteem, since he was a child.  He grew up in a household where both parents were mostly preoccupied and paid little attention to John, who was an only child.

John's father often criticized him and told John that he would never amount to anything.  His father's critical comments were so frequent that John internalized them and, over time, believed them.  John's mother was depressed and withdrawn, and she was emotionally unavailable to him.

When he was in school, his teachers often told John that he had a lot of potential, but he was not trying.  From John's depressed perspective, he didn't see a reason to try since he believed his father that he wouldn't ever amount to anything.

As an adult, John drifted from one job to another.  Since he never expected to do well, he put little effort into his work, which resulted in disappointment for him.

John also had very low expectations about relationships.  He had a few close friends, but his romantic relationships didn't last beyond a few months.

He would go through long periods when he didn't even try to meet anyone, but then his loneliness caused him to try again with the same low expectations.  It was an ongoing cycle.

By the time John came to therapy again, he felt he was at a low point.  He was already in his mid-30s and he felt he had nothing to look forward to in his life.

The Holding Environment in Therapy: Maintaining a Safe Environment for the Client
He told his current therapist at the start of therapy that he left his prior therapists because they were unable to see him as he was.  He felt that each of them saw him as they wanted him to be, which frustrated him.

He appreciated that his former therapists were "nice people" and they tried to speak to him about his personal strengths, but he didn't believe what they were saying.  He wasn't sure if they were mistaken or if they were intentionally trying to boost his confidence in a false way.  

Either way, whether the therapist was well-meaning but wrong or whether the therapist was only trying to boost his confidence and didn't really believe he had strengths, John found these discussions intolerable and he would abort therapy.

John's current therapist could see how self critical he was.  She also saw that he had many strengths.  But she also heard John loud and clear that he was unable to even consider that he had strengths, and she knew, based on what he was telling her, that if she tried to broach this with him, he would leave therapy, as he did in the past.  So she waited until he was ready.

Until then, his therapist remained attuned to John's experience and reflected back to him what he told her.  In doing this, she showed John that she understood how he felt about himself, and for the first time in his life, John felt that he was finally seeing a therapist who understood him.

In the meantime, his therapist held onto her perception of the many strengths she saw in John over time.  She waited until she saw a possible opening to explore this with him.

Gradually, as John felt more comfortable with his therapist, he opened up more with her, and she continued to let him know that she understood how he felt by mirroring back to him.

One day, John came to therapy in an agitated state.  He told his therapist that his new supervisor complimented John on a project.

John's first reaction was to get angry because he thought his supervisor was lying to him or he was trying to manipulate John in some way.

But as he thought about it, John said that he knew his supervisor wasn't a manipulative person, so he doubted that this was the reason for his compliment.  He said that maybe his supervisor was just trying to make him feel good--like some of John's prior therapists.  

Whatever the supervisor's intentions, John found it difficult to sit there and listen to his supervisor's compliments.  He said nothing to his supervisor but, for some reason, John realized, it brought up a lot of shame and sadness for him.

During the next several sessions, John continued to talk about this because his supervisor came to him again and told him that he really liked his work.  This continued to baffle John.

Over time, John became more open to exploring this issue and his own sadness and shame.  He was able to connect his negative feelings about himself to his critical father.

During that time, his therapist continued to maintain an open and empathetic stance with John, allowing John to draw his own conclusions (see my article: Why is Empathy Important in Therapy).

She knew that if she intervened prematurely, John would shut down emotionally and he might leave therapy.  She had to wait until he was ready.

Then, one day John came in and told his therapist that his supervisor took him to lunch.  John was surprised that he enjoyed talking to his supervisor over lunch.  He was also surprised to realize that his supervisor liked him and that his praise really was genuine.

As John opened up more emotionally in therapy, he allowed himself to feel his sadness about being a disappointment to his father.  He wished he could have had a father who was more like his supervisor--a kind and generous man.

As he continued to discuss this in therapy, John became aware that his father was a disappointed, bitter man, and his father didn't feel good about himself.

As he looked at his childhood from an adult perspective, he realized that his father was projecting his own negative feelings about himself onto John (see my article: Looking at Your Childhood Trauma From an Adult Perspective).

This led to John questioning whether his father's perceptions about him were accurate, "Maybe I'm not such a loser after all.  What do you think?"

At that point, his therapist realized that John created a small opening for them to be able to discuss the possibility that he wasn't "a loser" and he might have positive qualities.  She also knew that this was a tentative opening that could shut down if she rushed in because John might get overwhelmed, so she had to be cautious.

His therapist said she observed positive qualities in him, and she explored with him whether he would be open to discussing this.  John responded by shifting in his seat and telling her that it felt uncomfortable but, at the same time, there was a part of him that wanted to talk about it.

Gradually, John was able to explore his feelings.  He trusted his therapist enough to know that she wasn't going to lie, hurt him or try to manipulate him.

His therapist relied on John to tell her whether their discussions about his strengths felt too uncomfortable, and he told his therapist when he felt uncomfortable.  In this way, his therapist was able to maintain an emotionally safe environment for John in their sessions.

The Holding Environment in Therapy: Maintaining a Safe Environment for the Client
Over time, John developed the emotional tolerance to discuss seeing himself in a positive light.  This was new and scary for him at first, but he was starting to feel better about himself.

By being attuned to John, his therapist was able to provide him with feedback about his positive qualities in "manageable doses" for him.  She respected his feedback when he told her that he was beginning to feel overwhelmed, and she would not push him beyond where he could go emotionally.

Working with John in this way, over time, his therapist was able to help John to mourn what he didn't get as a child and to develop more self confidence (see my article: Psychotherapy and Compassionate Self Acceptance).

There are many ways for a psychotherapist to create a therapeutic holding environment for a client.

One way, as I have discussed in this article, is to keep the therapeutic work manageable for the client.

To create a holding environment, the therapist must be emotionally attuned to the client and intuitively sense when the client is ready to explore uncomfortable issues.  She must also ask the client for feedback.

When the client provides a tentative opening, a skilled therapist doesn't rush in.  She helps to facilitate an exploration that is manageable for the client.

In this way, by being attuned and titrating the work, the therapist helps the client to make progress in therapy.  In other words, going slowly in these particular cases, is more effective than trying to get under the client's defenses and overwhelming the client.

From the outside, it might appear that the work is going too slowly, but with regard to the client's internal world the client is developing the internal resources for more in-depth work.  

Not every client has these particular problems, and in many cases the therapist senses that she can make observations early in therapy without jeopardizing the work.  But for clients who aren't ready, premature explorations often lead to premature endings in therapy because the client aborts therapy.

Getting Help in Therapy
Many people, who could be helped in therapy, never come to therapy and struggle on their own without success.

Finding the "right fit" with a particular therapist might be a matter of trial and error as you interview various therapists (see my article: How to Choose a Psychotherapist).  

I usually tell prospective clients to follow their own instincts when choosing a therapist and not to remain with a therapist if their gut feeling is telling them that it's not working out.  However, if you have a long history of aborting therapy prematurely, it might be worth considering that you're avoiding dealing with certain issues in therapy.

Rather than struggling on your own, you could benefit from seeing an experienced therapist who can help you to work through the problems that are keeping you stuck.

By working through problems that are keeping you stuck, you can lead a more fulfilling life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who works with individual adults and couples.

I work in an empathetic, attuned and respectful manner with clients to help them to overcome their problems and maximize their potential.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.