Winnicott famously coined the term 'holding environment' to describe the experience of safety and support that constitutes a good therapeutic alliance with a patient. Psychological space is a phrase I have been using in recent years to capture the capacity of a patient to bear psychological tension long enough to resolve or find creative pathways to deal with matters that are troubling him or her.
The following is a little vignette that emerged during a Ketamine-enhanced therapy session. The patient had participated in a number of ketamine sessions with us and was finding them very helpful for depressive symptoms. In this particular session, the patient was not quite her usual self. Characteristically she would be very still in her session in deep meditation. On this occasion, however, I noticed that she seemed mildly restless. When she began to massage her neck I lowered the music and asked what she was experiencing. She reminded me of her previous neck surgery for a pinched nerve and said her pain was acting up a bit.
At this point my well-intentioned sitter who was attending in the room recommended she might try a lotion she had found effective. The patient looked her way and seemed receptive to the advice. However, I was concerned that therapeutic space might inadvertently be narrowing. The patient, after all had seemed unusually restless the entire session and I asked her if the neck discomfort connected with any of the other thoughts she might have been having during her session.
At this point, Ms. T remarked that she had been thinking of her marriage. She teared up remarking that when she mentioned her pain to her husband he would often roll his eyes and seem detached. Well into the session as she was becoming more lucid we had the chance to talk a good deal about her marriage and options she was considering to deal with its tensions. There was a marked feeling of connection with the patient who seemed greatly relieved to be in a space where she could talk about her marriage.
This vignette illustrates a paradox: we often encourage the holding environment by withholding. This of course is a delicate matter. When it is done well, the therapist will notice an immediate deepening of the therapeutic connection. During the period of withholding the the therapist will note a degree of momentum in the air. If the tension the patient experiences is leads to a psychic stalling, or if the constructive momentum has served its purpose, then it's time to pass the tissue.
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