New York Institute for Psychotherapy Training in Infancy, Childhood and Adolescense

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NYIPT faculty Hannah Hahn has written and presented an interesting paper on how child therapists create and provide a therapeutic environment for their patients. She gives us a wonderful case example of her work with a child who was being pulled apart by his warring parents.

Much of what we do in child psychotherapy, both with the patient and with the patient’s parents, involves “holding." The metaphor of the holding environment was first used by Donald Winnicott (1960; 1965), who was referring to the “model of the protective and soothing maternal holding of a needy infant” (Meissner, 1999, p. 18). In psychotherapy and psychoanalysis, holding has to do with the therapist’s “reliability,” that he or she constantly attends to, listens to, understands, and, in addition, accepts “what is obnoxious without retaliating” (Modell, 1988, p. 98). The holding environment can be thought of as providing both safety and attunement, or “optimal availability” (Pulver, 1991, p. 76). The psychotherapist empathically senses what is important to the patient, “actively” adapting his or her “mind” to the patient’s “needs” (Lanyado, 1996, p. 428).

Because with child patients we rely more on the noninterpretive, nonverbal aspects of the therapeutic endeavor, with children “holding” constitutes an important avenue for therapeutic change. The holding environment can also be a useful therapeutic stance in working with parents. In this paper I will describe the case of Fritz, a five-and-one-half year old whose separated parents treated him like “Solomon’s baby.” For this case “holding” proved a helpful approach not only in working with a disturbed child, but also in working with his difficult, estranged parents.

In psychotherapy sessions with young children, we are affectively present (affirming, accepting, attending to, and understanding); at the same time, we process the meaning of their play. Doing so enables us to know how to understand them, and to respond to them in a therapeutic manner. (B. Berk, personal communication, December, 2004). The verbal interaction which occurs is sometimes about interpretation or insight, but is more often about understanding or attunement, aspects of holding.

Working with child patients and their parents requires that in some way we split our allegiances. In order to work effectively and empathically with a child patient, we must temporarily identify with him or her. Moreover, in order to form a working alliance with the child’s parents, we must be able to put ourselves in their shoes. Realistically, we know that, whatever their intentions, these parents have made some mistakes which contributed to the child’s psychological difficulties (Gardner, 1993). Because of this, we are very likely to have countertransferential feelings about the parents.

Siskind (1997, pp. 49, 51) believes that in order to form a working alliance with parents, the therapist should assume an “even and disciplined but not unfeeling . . . stance,” behaving in a “quietly attentive” manner. I suggest that, in addition, the use of the metaphor of the holding environment with difficult or hostile parents can be of crucial importance. Working with the parents of child patients can be compared to “holding” eggs in a basket. It is a way to help parents who at some level feel themselves to be in a painful emotional predicament to feel safe.

Fritz’s separated parents had opposite styles as individuals and as parents, and could agree on nothing for the good of their child. Fritz experienced immense rage and acted out physically due to the intolerable bind in which he found himself, a bind which was the result of parents pulling him in different directions. His parents had separated when he was two-and-one-half. When he began treatment, Fritz spent several days with each parent every week (he had to switch homes at least twice a week).

Fritz's father, Morris, was precise, obsessional, demanding, and controlling with everyone. His mother, Hetty, was rebellious and characterized by low self-esteem and a "laissez faire" attitude. With me, Fritz's father noted that he and Hetty could not talk at all. The two had not yet—and would not be able to—agree on the terms of a divorce. One important factor in this case was that—because Fritz’s mother was a student, his father paid for the entire treatment, as well as for many of his former wife’s expenses.

In their interactions around Fritz, Morris would say, “it’s this way” or, “I won’t pay for it.” Hetty would then strike back, refusing to give in to Morris’ demands or giving ultimatums of her own. Morris behaved provocatively toward Hetty and she, in reaction, became more and more irrational. Much of Fritz’s anger arose from being caught between his parents’ opposite ways of doing things: if, for example, his father were to say, “change your clothes,” his mother inevitably told him not to do so.

During the early months of the treatment, Fritz’s energetic wars continued. He repeatedly said, “I’m tough,” reflecting his fierce attitude. [In an attempt to turn his passive position into an active one--]* he soon began to order me around, telling me how to set up his games. Sometimes he ran around the clinic.

In sessions Fritz began to describe himself to me as “tricky,” as well as “tough. During one session he made “powerful” balls from playdoh, announcing that they were so powerful that they could “do anything.” He then threw them very hard against the wall. Next he emptied a whole can of yellow playdoh, flattened it, stepped on it, and threw it. During many sessions, he cheated at games, a pattern that continued throughout the treatment. In one session he stated, "I'm special. I'm fast at games. I win most of the time."

My countertransference during my initial sessions with Fritz included worries about my ability to handle him. Did I have enough energy for him? Responding to the aspect of sadism in his aggression, I wondered whether he would attack me. I knew my job was to live with and process these worries so that I could provide an “affectively responsive presence” (Slochower, 1996, p. 19), a safe and secure holding environment, for Fritz. By doing so, I allowed him to expose the feelings and conflicts generated by living with his parents’ war. My attempt was to provide a safe space in which Fritz could order me around and in which his wildness would be accepted and contained. This was, however, very hard work; it was at times overwhelming. I sometimes felt angry at Fritz, as I absorbed his sadistic aggression. It was a challenge to process both Fritz’s rage and my angry reactions so that I could continue to “hold” him.

Fritz tried to find ways to behave powerfully in sessions. During one session, we played basketball (the waste paper basket was our basket); when it was my turn with the ball, he turned “tricky” and moved the basket; later he moved the basket by putting it on his head and dodging whenever I threw the ball.

In being receptive to Fritz’s play--for example, with the “superhero” “powerful” playdoh balls--I allowed his fantasies about himself as powerful to unfold and to be made known; I could also infer his probable feelings of powerlessness. In addition, I was able to “facilitate [his] expression of rage” (Slochower, 1996, p. 24).

As our work progressed, Fritz and I began to have some therapeutic verbal interaction, much of it in connection with the “Talking, Feeling, Doing Game.” He told me that he did not like his father yelling at him. Later, in response to a game prompt about a child hearing fighting, I said, "a child's mother and father are fighting about what days they'll have him, and the child feels bad." Fritz agreed that his parents argued about that.

Throughout the treatment. Hetty and Morris acted out. For example, in working on a custody agreement, Hetty refused Morris joint custody—which she actually wanted—because he would not pay for a summer program for Fritz which she had chosen (he preferred a different program). This type of disagreement was, in fact, routine between Morris and Hetty.

As I worked with Fritz, I also met with his parents individually. At times the sessions were peaceful. During such sessions, I was able to contain my many difficult** feelings about Morris and Hetty so that I could provide an “affectively responsive presence” (actually during these peaceful sessions, I felt sympathetic toward each of them).

Morris must have felt at a disadvantage with me, as he perceived that Hetty was more likeable than he. During one early session, Morris complained that he had so many problems because of Hetty: she was consummately and continually political, he said, and he felt she manipulated everyone else into paying for her.

In one difficult session with Morris, he demanded that Fritz stay with him, rather than with Hetty, for one extra day a week: he felt that it was absolutely crucial that he put Fritz in an after-school enrichment program on that extra day and that Hetty would refuse this program on her day. He angrily stated, “I’ll take it all the way to the Supreme Court.” I tried to point out that Fritz was being torn apart by such battles. I felt furious at Morris at that moment, but did my best not to respond angrily to him. Because of Morris’ frightening degree of anger, “holding” with him meant using a great deal of discipline to exclude my subjectivity. Yet, at the same time, “holding” with Morris dictated that I provide a space in which he could expose his hate and his rage.

During one session, Hetty told me that she felt criticized for not being firm enough with Fritz, countering, “But I am firm.” At this point I needed to hear her feelings on this issue, rather than to help her provide more structure for Fritz. She continued that she had learned to make Fritz walk to school by grabbing his wrist “with an iron grip” if he wouldn’t cooperate. She then asked me whether she could punish Fritz without first giving him a warning. In order to work with Hetty, I needed to walk a fine line between excluding my subjectivity and offering much-needed reasonable parenting advice.

During the first year of the treatment, Fritz did better both at home and at school. This did not continue, however, as this was a situation in which--as Siskind (1997, p. 57) wrote--"parental pathology [was] such that the case [was] doomed no matter how wise and skilled the therapist.” When Hetty threatened to move to an unsafe neighborhood in order to lower her rent (this was an attempt to loosen the financial strings which kept her tied to Morris) the process began which would both pull Fritz apart and prove disastrous for Fritz, Hetty, and Morris. Morris was determined that Hetty not move to this unsafe neighborhood.

When Hetty indeed went forward with her move, Morris became increasingly anxious, controlling, and angry; the situation between the two of them worsened and Fritz began to deteriorate. My memory of the last few months of the two-year treatment was that Fritz was generally more out of control both in sessions and outside. At school one day, he inserted a metal clip into an electrical outlet; fortunately, although he received a shock, he was not hurt. In sessions, [we were able to have therapeutic interventions using--omit] he did respond to my comments as we played the Talking, Feeling, Doing Game. In answer to the question, “Why is the boy sad?” I replied, “because his parents argue a lot.” “I’m the boy,” he said.

When the situation between Hetty and Morris had reached a crisis (Morris was threatening to end the treatment because he felt all Fritz’s problems had to do with Hetty's move), I decided to meet with the two together one more time. Although the two were able to cooperate somewhat on a plan to reward Fritz for good behavior at school, the session did little good.

Finally, because he could not force Hetty to leave her new neighborhood and could not get me to do so, Morris ended the treatment by refusing to pay for it. In our last session, Fritz and I had a good interchange. [Once again--omit] while playing the Talking, Feeling, Doing Game, [on my turn--omit] I said, “This girl is crying because her parents fight all the time.” “Like me,” he responded.

It is my hypothesis that in child treatment, providing a “holding” environment --rather than offering interpretation—is important to the therapeutic action. In child psychotherapy, holding functions both as a mode of receiving what it is that the child is trying to communicate and, in addition, as a mode of responding therapeutically to the child.

The use of the holding environment is also crucial with difficult or hostile parents of child psychotherapy patients. “Holding” with a parent aims to maintain the treatment relationship with the child, rather than provide therapeutic change for the parent. With a parent, the therapist wants to be empathic and attuned, sensitive to the often painful emotions the parent brings to the situation of his or her child’s needing help.

As mentioned above, working with the parents of child patients can at times be compared to “holding” eggs in a basket. This is true not only because of the parents’ feelings of vulnerability and narcissistic injury in having to bring their child to treatment. Thus, “holding” with parents proceeds on several different levels. 1) The therapist "holds" the situation in its totality, trying to be attuned to the treatment relationship with all of its participants (child, parents, and therapist). 2) The therapist "holds" the parents as individuals and/or as a couple. 3) Finally, the therapist "holds" his or her own countertransference.

What distinguished the case of Fritz from other child psychotherapy cases was the level of anger that Fritz, Morris, and Hetty all experienced toward one another and in the treatment room. I have found pervasive anger in child patients to be relatively common. However, the degree of anger that these parents experienced toward one another—which both caused them to treat Fritz like “Solomon’s baby” and contributed to Fritz’s own intense anger—was unique.

Attunement was certainly one important factor in Fritz's therapy. During his infancy, Fritz’s parents may have been able to provide true responsiveness or attunement for him only for short periods of time. As a therapist attuning to this insecurely attached, enraged child, I began to help him to "reshape" relational patterns so that he would be better able to let in those in his world—his teachers for example—who wanted to reach him (Greenberg, 2002, p. 676). In addition, I tried to provide a safe space in which Fritz could expose his rage, his powerlessness, and his fantasies. Of note is that, in holding Fritz’s intense emotions, I had to at times hold “more or less unexpressed” my own intense reactions to them (Slochower, 1996, p. 8).

That I accepted, understood, and validated Fritz’s rage, rather than punishing it, was important. That I could “experience his anger with him” and communicate to him that I understood its source in his life with his parents, I hope helped him to feel “supported” and “vindicated” (Loewald, 1988, p. 59). In addition, my indestructibility and refusal to retaliate in the face of both Fritz’s rage and his parents’ demands made me a “good and protective container” in providing, for both Fritz and his parents, a “safe context for emotional discharge” (Meissner, 1999, p. 22). What helped therapeutically with Fritz? I believe that the holding environment played a role in three interrelated functions that led to therapeutic change: the experience of a new object (the therapist); attunement, or optimal responsiveness; and the feeling of safety.

Gardner, R.A. (1993). Psychotherapy with children. Northvale, NJ: Jason Aronson.

Greenberg, J. (2002). Psychoanalytic goals, therapeutic action, and the analyst’s tension. Psychoanalytic Quarterly, 71 (4), 651-678.

Lanyado, M. (1996). Winnicott’s children: The holding environment and therapeutic communication in brief and non-intensive work. Journal of Child Psychotherapy, 22 (3), 423-443.

Loewald, H.W. (1988). On the mode of therapeutic action of psychoanalytic psychotherapy. In A. Rothstein (Ed.), How does treatment help (pp. 51-59). Madison, WI: International Universities Press.

Meissner, W.W. (1999). Notes on the therapeutic role of the alliance. Psychoanalytic Review, 86 (1), 1-33.

Modell, A.H. (1976). The “holding environment” and the therapeutic action of psychoanalysis. Journal of the American Psychoanalytic Association, 24 (2), 285-307.

Modell, A.H. (1988). On the protection and safety of the therapeutic setting. In A. Rothstein (Ed.), How does treatment help (pp. 51-59). Madison, WI: International Universities Press.

Pulver, S.E. (1991). Psychoanalytic technique: Progress during the past decade. Psychoanalytic Inquiry, 11 (1), 65-87.

Siskind, D. (1997). Working with parents: Establishing the essential alliance in child psychotherapy and consultation. Northvale, NJ: Jason Aronson.

Slochower, J.A. (1996). Holding and psychoanalysis: A relational perspective. Hillsdale, N.J.: The Analytic Press.

Winnicott, D.W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41, 585-596.

Winnicott, D.W. (1965). The maturational processes and the facilitating environment. New York: International Universities Press.

* Talking about turning passive into active in this case may be a bit confusing without further elaboration: he was not a passive child either with me or with his parents.

**Saying "my many difficult feelings" about the parents seems to me to convey a tiny bit of the flavor of the countertransference with them; to me saying that I contained "a gamut of feeings" seemed a bit self-congratulatory.