Patient Education and Counseling 97 (2014) 299–300
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
Reflections on the holding environment in health-care counseling§ David Kealy a,*, Eunjung Lee b a b
Department of Psychiatry, University of British Columbia, Vancouver, Canada Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
A R T I C L E I N F O
Article history: Received 9 November 2013 Received in revised form 29 May 2014 Accepted 3 August 2014 Keywords: Holding environment Counseling
Health-care counseling is often aimed at helping a patient change: to promote healthier lifestyle choices, to address maladaptive behaviors, or to work through ambivalence regarding health-care decisions. Although attentive, empathic listening is at the core of such interventions, we are sometimes unprepared for a kind of ‘‘being with’’ to be the intervention itself. In our work as social workers attached to a primary care clinic, we occasionally wondered how – indeed whether – we were helping patients who seemed unable to make use of typical counseling interventions.1 I first met Leon after he was referred by one of the clinic physicians. Leon was a 54-year-old computer network technician who had repeatedly presented with complaints of gastric pain and discomfort. Multiple medical examinations, tests, and specialist referrals had produced no confirmation of medical illness, nor any information regarding the etiology of his symptoms. It was thought that some counseling might help him deal with some vaguelydescribed stress thought to be fuelling his somatic complaints. Leon politely, but dubiously, agreed to meet with me to discuss his situation. He felt frustrated at the lack of medical progress in addressing his persistent physical discomfort, and plainly told me that talking was unlikely to be of any help. Nonetheless, he was game to try whatever his doctor suggested. Besides, he reckoned
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Corresponding author at: Psychotherapy Program, Department of Psychiatry, University of British Columbia, Suite 420, 5950 University Blvd., Vancouver, BC V6T 1Z3, Canada. Tel.: +1 604 953 4995x763033; fax: +1 604 953 4901. E-mail address: [email protected] (D. Kealy). 1 Because we have both encountered this phenomenon, and cases similar to this vignette, the rest of the paper is written in the first person.
http://dx.doi.org/10.1016/j.pec.2014.08.002 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
that he could talk about some stress related to his work, feeling some pressure to cut corners as his employer sought to maximize profits. Leon felt this was an affront to his professional and personal values, and he reasoned that perhaps venting about it could help him to ‘‘reboot’’ and feel less stressed by this workplace tension. In response to my questioning, Leon provided a factual sketch of his personal history. Leon revealed – with few details and minimal emotion – that he had been placed in foster care as a schoolboy after having been abandoned by his parents. He had managed to identify with his foster parents and succeed in his studies, eventually proving himself to be technically adept and gifted with computer operations. He went on to establish a stable career, form a loving marriage, and raise two children. Tragedy struck again when his wife died suddenly from a surgical complication. Although Leon had since remarried, I wondered about the cumulative impact of abandonment and loss: how had these experiences shaped his emotional development? Despite Leon’s matter-of-fact account of his background, I was struck by the adversity and pain that I imagined him to have struggled with. Although I was able to glean bits and pieces of his personal history, Leon was reluctant to discuss his traumatic losses at any length. He had never done so previously – ‘‘so why start now?’’ Instead, he filled each session with lengthy, emotionless descriptions of the technical details of his work. On other occasions, he simply canceled or missed his appointments, though he duly rescheduled them for the following week. I felt somewhat bewildered: what could it mean that Leon had almost nothing ‘‘psychological’’ to say? How could he possibly find it helpful to fill an hour a week with the minutiae of his job? Although no ready answers to such questions were apparent, I silently hypothesized that Leon had long suppressed painful affects, images, and
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D. Kealy, E. Lee / Patient Education and Counseling 97 (2014) 299–300
memories, only to have recently found them seeping out somatically. Leon spoke about ‘‘stress’’ in the most vague and superficial manner. Efforts to turn his attention toward an inner emotional life seemed to go nowhere. I eventually accepted his communications, reasoning that they likely reflected a learned effort to avoid being flooded with painful affect. Occasionally, however, I verbalized some recognition of Leon’s disrupted childhood attachments, or the painful loss of his beloved first wife. During a few such moments, Leon paused, his eyes welling up, before continuing along on a soliloquy about network routers or internet security issues. When this happened, I did not press on. I had the feeling that these moments were critically important; that they should be allowed to stand on their own. Perhaps Leon was telling me that my acknowledgment was enough: his traumas needed to be known about and recognized, and then left at that without further elaboration. One day, after having met together for several months, Leon announced that he was eligible for early retirement and that his ensuing travel plans would likely prevent him from coming to ‘‘chat’’. He also felt that retirement would relieve him of the stress he had felt in connection to his work. He thus felt little reason to continue with regular sessions, and shortly thereafter he ceased attending altogether. I initially felt dismayed regarding what I thought was a premature termination of therapy. Leon’s selfdisclosure had remained limited, as had his ability to talk about relationships, loss, and other emotionally charged issues. I had a sense that much more therapeutic work was left to be done, and I was concerned that perhaps Leon had given up on therapy ever being helpful. However, at a subsequent clinic meeting, Leon’s physician inquired about his status: ‘‘What did you do with him? Whatever it was, it was like a miracle: he used to be in my office every week, asking for this test or that one. Now, I rarely hear from him. It’s as though his symptoms just evaporated.’’ In working with Leon, and with other patients with psychosomatic problems, I had anticipated a need to actively explore the underlying meaning of his symptoms, to develop insight into the role of past traumas and losses, and to directly facilitate inhibited emotional expression. Leon’s steadfast disinterest in these standard psychotherapy processes was somewhat disconcerting. He nonetheless achieved a level of recovery that he seemed pleased with, and which his primary care physician felt was substantial.
In reflecting on my involvement with Leon, I thought about Winnicott’s [2] idea that early developmental trauma results in a walled-off core self, inaccessible to verbal counseling interventions. Indeed, exploratory or cognitive interventions might further impinge on some patients’ sense of safety and cohesion. Winnicott instead recommended the provision of a holding environment2 – a setting in which the self can convalesce and gradually strengthen. With repetition, this basic kind of ‘‘being with’’ is thought to result in the patient’s internal sense of having been recognized and responded to, fostering a capacity to face both the challenges of the external world and the inner experiences that threaten one’s emotional equilibrium. In retrospect, my awareness of the inimical conditions of Leon’s background caused me to refrain from pushing him into clinical processes that might have overwhelmed him. This stance, oriented around Leon’s sensitivities, may have conveyed a sense that he was being held – psychologically – in my mind. My reservations notwithstanding, I ultimately accepted Leon’s need for superficial soliloquy, rather than active exploration or emotional expression. Perhaps it was simply enough to engage in ‘‘being with’’ him, holding in mind his emotional unrest. This seemed to free him from locking up his body with somatic symptoms. Although Leon might have benefitted from further therapy, he seemed to accomplish some unconscious psychological work [1] by coming to ‘‘shoot the breeze’’ with me (as he put it), perhaps feeling slightly more integrated and less constricted than before. Our work had an impact on me as well, impressing upon me the importance of patience, acceptance, and respect for each individual’s unique approach to the handling of adversity and pain. Leon’s therapy showed me that a holding environment may not always conform to the conventional expectations of the counseling situation. Ultimately, it is the patient’s distinctive sense of process – even an apparently non-psychological one – that must be prioritized in order to facilitate psychological work. We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. References [1] Ogden TH. On holding and containing being and dreaming. Int J Psychoanal 2004;85:1349–64. [2] Winnicott DW. The maturational processes and the facilitating environment: studies in the theory of emotional development. London: Hogarth Press; 1965.
2 The terminology of ‘‘holding’’ in the clinical setting is metaphorical and does not indicate actual physical holding of the client or patient.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
Reflections on the holding environment in health-care counseling§ David Kealy a,*, Eunjung Lee b a b
Department of Psychiatry, University of British Columbia, Vancouver, Canada Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
A R T I C L E I N F O
Article history: Received 9 November 2013 Received in revised form 29 May 2014 Accepted 3 August 2014 Keywords: Holding environment Counseling
Health-care counseling is often aimed at helping a patient change: to promote healthier lifestyle choices, to address maladaptive behaviors, or to work through ambivalence regarding health-care decisions. Although attentive, empathic listening is at the core of such interventions, we are sometimes unprepared for a kind of ‘‘being with’’ to be the intervention itself. In our work as social workers attached to a primary care clinic, we occasionally wondered how – indeed whether – we were helping patients who seemed unable to make use of typical counseling interventions.1 I first met Leon after he was referred by one of the clinic physicians. Leon was a 54-year-old computer network technician who had repeatedly presented with complaints of gastric pain and discomfort. Multiple medical examinations, tests, and specialist referrals had produced no confirmation of medical illness, nor any information regarding the etiology of his symptoms. It was thought that some counseling might help him deal with some vaguelydescribed stress thought to be fuelling his somatic complaints. Leon politely, but dubiously, agreed to meet with me to discuss his situation. He felt frustrated at the lack of medical progress in addressing his persistent physical discomfort, and plainly told me that talking was unlikely to be of any help. Nonetheless, he was game to try whatever his doctor suggested. Besides, he reckoned
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Corresponding author at: Psychotherapy Program, Department of Psychiatry, University of British Columbia, Suite 420, 5950 University Blvd., Vancouver, BC V6T 1Z3, Canada. Tel.: +1 604 953 4995x763033; fax: +1 604 953 4901. E-mail address: [email protected] (D. Kealy). 1 Because we have both encountered this phenomenon, and cases similar to this vignette, the rest of the paper is written in the first person.
http://dx.doi.org/10.1016/j.pec.2014.08.002 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
that he could talk about some stress related to his work, feeling some pressure to cut corners as his employer sought to maximize profits. Leon felt this was an affront to his professional and personal values, and he reasoned that perhaps venting about it could help him to ‘‘reboot’’ and feel less stressed by this workplace tension. In response to my questioning, Leon provided a factual sketch of his personal history. Leon revealed – with few details and minimal emotion – that he had been placed in foster care as a schoolboy after having been abandoned by his parents. He had managed to identify with his foster parents and succeed in his studies, eventually proving himself to be technically adept and gifted with computer operations. He went on to establish a stable career, form a loving marriage, and raise two children. Tragedy struck again when his wife died suddenly from a surgical complication. Although Leon had since remarried, I wondered about the cumulative impact of abandonment and loss: how had these experiences shaped his emotional development? Despite Leon’s matter-of-fact account of his background, I was struck by the adversity and pain that I imagined him to have struggled with. Although I was able to glean bits and pieces of his personal history, Leon was reluctant to discuss his traumatic losses at any length. He had never done so previously – ‘‘so why start now?’’ Instead, he filled each session with lengthy, emotionless descriptions of the technical details of his work. On other occasions, he simply canceled or missed his appointments, though he duly rescheduled them for the following week. I felt somewhat bewildered: what could it mean that Leon had almost nothing ‘‘psychological’’ to say? How could he possibly find it helpful to fill an hour a week with the minutiae of his job? Although no ready answers to such questions were apparent, I silently hypothesized that Leon had long suppressed painful affects, images, and
300
D. Kealy, E. Lee / Patient Education and Counseling 97 (2014) 299–300
memories, only to have recently found them seeping out somatically. Leon spoke about ‘‘stress’’ in the most vague and superficial manner. Efforts to turn his attention toward an inner emotional life seemed to go nowhere. I eventually accepted his communications, reasoning that they likely reflected a learned effort to avoid being flooded with painful affect. Occasionally, however, I verbalized some recognition of Leon’s disrupted childhood attachments, or the painful loss of his beloved first wife. During a few such moments, Leon paused, his eyes welling up, before continuing along on a soliloquy about network routers or internet security issues. When this happened, I did not press on. I had the feeling that these moments were critically important; that they should be allowed to stand on their own. Perhaps Leon was telling me that my acknowledgment was enough: his traumas needed to be known about and recognized, and then left at that without further elaboration. One day, after having met together for several months, Leon announced that he was eligible for early retirement and that his ensuing travel plans would likely prevent him from coming to ‘‘chat’’. He also felt that retirement would relieve him of the stress he had felt in connection to his work. He thus felt little reason to continue with regular sessions, and shortly thereafter he ceased attending altogether. I initially felt dismayed regarding what I thought was a premature termination of therapy. Leon’s selfdisclosure had remained limited, as had his ability to talk about relationships, loss, and other emotionally charged issues. I had a sense that much more therapeutic work was left to be done, and I was concerned that perhaps Leon had given up on therapy ever being helpful. However, at a subsequent clinic meeting, Leon’s physician inquired about his status: ‘‘What did you do with him? Whatever it was, it was like a miracle: he used to be in my office every week, asking for this test or that one. Now, I rarely hear from him. It’s as though his symptoms just evaporated.’’ In working with Leon, and with other patients with psychosomatic problems, I had anticipated a need to actively explore the underlying meaning of his symptoms, to develop insight into the role of past traumas and losses, and to directly facilitate inhibited emotional expression. Leon’s steadfast disinterest in these standard psychotherapy processes was somewhat disconcerting. He nonetheless achieved a level of recovery that he seemed pleased with, and which his primary care physician felt was substantial.
In reflecting on my involvement with Leon, I thought about Winnicott’s [2] idea that early developmental trauma results in a walled-off core self, inaccessible to verbal counseling interventions. Indeed, exploratory or cognitive interventions might further impinge on some patients’ sense of safety and cohesion. Winnicott instead recommended the provision of a holding environment2 – a setting in which the self can convalesce and gradually strengthen. With repetition, this basic kind of ‘‘being with’’ is thought to result in the patient’s internal sense of having been recognized and responded to, fostering a capacity to face both the challenges of the external world and the inner experiences that threaten one’s emotional equilibrium. In retrospect, my awareness of the inimical conditions of Leon’s background caused me to refrain from pushing him into clinical processes that might have overwhelmed him. This stance, oriented around Leon’s sensitivities, may have conveyed a sense that he was being held – psychologically – in my mind. My reservations notwithstanding, I ultimately accepted Leon’s need for superficial soliloquy, rather than active exploration or emotional expression. Perhaps it was simply enough to engage in ‘‘being with’’ him, holding in mind his emotional unrest. This seemed to free him from locking up his body with somatic symptoms. Although Leon might have benefitted from further therapy, he seemed to accomplish some unconscious psychological work [1] by coming to ‘‘shoot the breeze’’ with me (as he put it), perhaps feeling slightly more integrated and less constricted than before. Our work had an impact on me as well, impressing upon me the importance of patience, acceptance, and respect for each individual’s unique approach to the handling of adversity and pain. Leon’s therapy showed me that a holding environment may not always conform to the conventional expectations of the counseling situation. Ultimately, it is the patient’s distinctive sense of process – even an apparently non-psychological one – that must be prioritized in order to facilitate psychological work. We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. References [1] Ogden TH. On holding and containing being and dreaming. Int J Psychoanal 2004;85:1349–64. [2] Winnicott DW. The maturational processes and the facilitating environment: studies in the theory of emotional development. London: Hogarth Press; 1965.
2 The terminology of ‘‘holding’’ in the clinical setting is metaphorical and does not indicate actual physical holding of the client or patient.
