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 the session recommended to the patient that 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; that is, the patient needed a period of time to hold onto her tension in order to deepen her self-understanding. The patient had been unusually restless throughout the session, and I asked her if the neck discomfort was connected to any other thoughts she might have been having.
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 in detail about her marriage and the options she was considering to deal with the tensions in her marriage. 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: the holding environment can often be deepened by the therapist withholding an intervention to lessen tension. This, of course, is a delicate matter. Part of the art of therapy is finding that balance between tension and relief that is optimal for each patient. If all goes well, the therapist will note a degree of momentum in the air. On the other hand, if the tension the patient experiences leads to emotional stagnation, or if the constructive momentum has served its purpose, the therapist then intervenes to find ways to try to lighten the patient's psychic burden.
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