To Hold and Be Held

The Therapeutic School as a Holding Environment

Daniel K. Reinstein

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135446239
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Drawing on the teachings of D.W. Winnicott and John Bowlby, who helped revolutionize thinking about relational psychology, To Hold and Be Held integrates the concepts of the 'holding environment' and attachment theory and describes how they are applied in a clinical setting. It also uses metaphor to both derive meaning from the language of the therapeutic process and to apply that meaning within a systems framework to effect significant therapeutic change.

As the number of children with complex problems increases and the facilities to treat and manage them decrease, schools are left with few resources to cope. Professionals such as teachers, psychologists, social workers, and counselors need a new framework in which to think about and advocate for services for these children. To Hold and Be Held describes the creation of a system of working that not only holds the child and his family, but also holds the larger system as well – a system in which therapeutic services are integrated at all levels and implemented in public schools in a way that supports all those involved. This is not only a unique and successful way of working with children and their families, but a timely one as well.

Part I
Philosophy and Application

In their excellent introduction to his work, Madeleine Davis and David Wallbridge quote Donald Winnicott as follows: “The nearer a worker is to the child the more difficult it will be for him or her to discuss theory without being overwhelmed by a sense of the unreal” (1981, p. 10). Although theory may at times seem somewhat removed from the practice of psychotherapy, it is always important to have an understanding of how a philosophical approach might be applied. The ability to step back and think about the work at the Community Therapeutic Day School in this way is a crucial element in the development of a language with which to communicate that work. The following section describes how the contributions of Donald Winnicott, John Bowlby and the discipline of Systems Theory have influenced the way I conceptualize our therapeutic approach and its application. These influences are considered within the context of a metaphor that, I believe, is useful in communicating what we do.

Chapter 1
Therapeutic Philosophy

The philosophy behind the therapeutic process at the Community Therapeutic Day School (CTDS) has been largely informed by the work of Donald W. Winnicott. In addition, we have borrowed significantly from the attachment theory developed by John Bowlby, from concepts developed within family systems therapy, and from the constant effort to develop language through the use of metaphor; the latter drawing on all of the former as a means to help shape our thinking about how to best meet the ever-changing needs of our child and family populations. Although all of these influences have taken root and bloom to varying degrees over the seasons, the seed that began this garden was Winnicott.

Winnicott and Holding

Winnicott (1896–1971), born in Plymouth, England, studied biology and medicine and was a pediatric house officer at Paddington Green Children’s Hospital in London in 1923. That year he began postgraduate training in psychoanalysis and completed it in the mid-1930s. He undertook study with Melanie Klein as well as proponents of the object-relations school of psychoanalytic thought who worked within the British Psychoanalytic Society. At that time, there was great interest in developing the practice of psychodynamic psychotherapy for application to children. Both Anna Freud and Melanie Klein developed this movement in Britain, while Margaret Mahler developed the child movement in the United States. Each of these figures, to varying degrees, either embraced or was directly influenced by the theories of Sigmund Freud.

Although Sigmund Freud never undertook an analysis with children directly, his psychological theories about adult functioning were rooted in ideas about child development that he gleaned from the analysis of adult patients. Freud was first a medical doctor whose specialty was in neurology, and, as such, in the early 1890s he initially attempted to develop a psychology that was neurologically based (Freud, 1954). From this perspective he postulated a biological drive theory in which human development proceeded in stages and focused on specific, developing parts of the body. According to Freud, a “drive” was a genetically determined psychic construct that, when triggered, created a state of tension. This tension state then mobilized the individual to act in such a way as to reduce the tension. Freud proposed that the stages of psychosexual development correlated with the changing foci of the infant’s developing nervous system, from the oral to the anal and, last, the genital. Thus, the infant’s initial focus on the breast and feeding as a means to reduce the tension of hunger was followed by a focus on the control of excretion and finally the mastery of sexual tension and release. To the extent that relationships developed, they did so through the association of tension and its release with an object. In the oral stage, for example, the object would be the breast and, by extension, the mother.¹ Freud later came to believe that the primary defining issue in the older child’s psychological development was the resolution of the relationship with the father, or the Oedipus complex. Thus, to the extent that any relationship was pivotal in an individual’s development, it was that of the father and child.

In the 1920s Melanie Klein attempted to extend the theories and the practice of psychoanalysis to her work with children. As she could not rely on the Freudian technique of free association with young children, she instead developed a nonverbal correlate in play therapy, believing that a child’s anxieties and fantasies could be symbolically represented in his or her play. As a result of this shift to working directly with children, Klein came to believe that relationship, rather than drive reduction, was the guiding force in the developmental process. And she believed that the integration of the genetically based, primal maternal image with the real-life mother, rather than the father, was of primary importance (Segal, 1973).

Winnicott began his psychoanalytic studies in 1923 because of his interest in Freud as a neurologist. He believed that psychoanalysis, like biology, was a science and was therefore subject to the same scientific principles. As he noted, “Psychoanalysis goes on where physiology leaves off. It extends the scientific territory to cover the phenomena of human personality, human feeling and human conflict. It claims therefore that human nature can be examined, and where ignorance is exposed psychoanalysis can afford to wait, and need not indulge in a flight to superstitious formulation” (quoted in Davis & Wallbridge, 1981). His interest in children, however, was not well served by the then current mode of psychoanalytic practice. It was only after he became aware of Klein’s work with children that he became her pupil and began to develop his own theories using child psychoanalytic techniques.

To his training and practice of psychotherapy with children Winnicott brought the unique perspective of the pediatrician. He remained interested in the vital relationship of the psyche to the soma, and much of his writing has to do with understanding psychological processes through body-oriented language. His training in the care of the body seemed to keep him rooted in the pragmatic as he explored the theoretical. A few of the key concepts that he developed that have influenced our practice of therapeutic intervention are as follows:

• the natural unfolding of the developmental process,
• the “good-enough” mother (or primary caretaker), and
• the “holding environment.”

Winnicott believed that as human organisms we were programmed to follow a certain natural course of development provided that the environment furnished the appropriate support. As Davis and Wallbridge observed, Winnicott felt that “every human being, given a facilitating environment, intrinsically contains the momentum for growth towards emotional as well as physical maturity, and towards a positive contribution to society” (1981). This natural unfolding took place for an infant within a particular relationship, usually that of the child and mother—“There is no such thing as a baby, meaning that if you set out to describe a baby, you will find you are describing a baby and someone. A baby cannot exist alone, but is actually part of a relationship” (Winnicott, 1964, p. 88).

Acknowledging that every mother–child relationship was unique and that thus there was not an ideal mother, Winnicott spoke of the particular fit of a particular pair as a good-enough fit. A mother who was providing the needed amount of environmental support for her child was then considered a good-enough mother. From Winnicott’s perspective, being a good-enough mother meant that mothers would not have unrealistic expectations placed on them by themselves or others. He was fully aware of the work involved in raising a child. “Children are a burden and if they bring joy it is because two people have decided to take that kind of burden; in fact, we have agreed to call it not a burden, but a baby” (1964, p. 131). By framing the relationship in this way, he hoped that it would help create a space in which a mother could follow her natural impulse to care for her child, what he called “natural self reliance” (1964), without the fear of being unfairly judged or overly self-conscious. He further made the distinction between what came “naturally and the things that have to be learnt … so that what comes naturally may not be spoiled” (1964). Thus, good-enough mothers were not ideal, but they had decided to take on a burden in a realistic way and had the ability to be in touch with their natural impulse as well as their willingness to learn. In this way, he emphasized the ordinariness of raising children and captured this sense in another of his phrases, the “ordinary devoted mother” (Davis & Wallbridge, 1981).

Winnicott referred to the space in which the relationship between the child and caretaker took place as the “facilitating” or “holding” environment. The basis of this was actual holding, which Winnicott felt was a form of loving. As Winnicott wrote, holding

refers to a three dimensional or space relationship with time gradually added. This overlaps with, but is initiated prior to instinctual experiences that in time would determine object relationships. It includes the management of experiences that are inherent in existence, such as the completion (and therefore the non-completion) of processes, processes which from the outside may seem to be purely physiological but which belong to the infant and take place in a complex psychological field, determined by the awareness and empathy of the mother. (1965, p. 44)

The integrity of the holding environment depended on the ability of the mother to protect the infant, to take into account the infant’s sensory experience, to provide routine care throughout the day and night, and to adjust to moment-to-moment changes. In this manner, the holding environment was constructed within the relationship and protected the infant from its fear of annihilation:

In this place which is characterized by the essential existence of a holding environment, the “inherited potential” is becoming itself a “continuity of being.” The alternative to being is reacting, and reacting interrupts being and annihilates. Being and annihilation are the two alternatives. The holding environment therefore has as its main function the reduction to a minimum of impingements to which the infant must react with resultant annihilation of personal being. Under favourable conditions the infant establishes a continuity of existence and then begins to develop the sophistications which make it possible for impingements to be gathered into the area of omnipotence. (1965, p. 47)

What then does a holding environment look like over the course of a child’s life? As children develop, they are held physically, emotionally, and psychologically within a primary relationship. For example, when an infant is conceived, he is held in the environment of the womb for approximately 9 months. After birth, the infant continues to be held in the arms of his mother, and he is in her gaze, hears the sound of her voice, and smells her body. He is also held in blankets and his crib—all familiar places associated with his mother. This holding and swaddling associated with the additional sensory stimuli of the relationship ultimately gives the infant a sense of boundary—a sense of his body as separate from the other. This leads to a sense of bodily integrity that allows the development of a self. In fact, some sense of bodily integrity is a prerequisite for the development of a psychological self. An infant’s sense of separateness is constantly challenged by the buzz and hum of the real world—the bombardment of sensory stimuli that is far too complicated and overwhelming for the infant to process and manage. Thus, this bodily integrity is being constantly assaulted and in need of regeneration. The infant is then able to return to the holding of his mother’s arms and smells—the proximal physical contact that constitutes the infant’s holding environment. As the child grows older and gradually becomes more independent, his forays into the confusion of the world become more prolonged and distant. The boundaries of the holding environment expand, and the holding is done through more distal sensory modalities. A child ventures across a room or into another part of the house and can be held by the sight of his mother’s face watching him or the sound of her voice. These verbal or visual cues then are referenced to the internalized sense of being physically held. This holding is experienced in the body and forms the foundation for psychological holding and the ability for the child to hold his own mind when away from the actual physical relationship. With age these boundaries continue to expand—outside the house, to a school setting, to college, to another state, to another country. But the sense of holding goes with the child, now an adult, who has learned to hold himself and ultimately to hold and be held in other relationships.

Abe

Abe was lost somewhere in space, and he was rapidly approaching the limits of the known universe. Within minutes of entering my office, he was speculating on the absence of color beyond the boundaries of light and time. He swiftly explored the room, moving from toy to toy as if he were an object randomly colliding into strange worlds and distant galaxies. He very briefly touched down on our planet to describe how his father’s arm had been crushed in a work-related accident and how he too could be crushed; he was using graphic detail that could rival the most violent action movie scene.

His parents twisted uncomfortably in their chairs and nervously explained that Abe was only joking. He threw himself on them suddenly, lashing out quickly, and then he bolted from the room. I ran after him as he careened off the walls in the mazelike hallways of the old farmhouse. He was a compact 7-year-old with light hair, blue eyes, and a very engaging grin that broadened as I carried him back to the office. I complimented him on his brilliant idea to test me in front of his parents. After all, if I was to help him with the difficulties he was experiencing in school and at home, he needed to know immediately if I was able to keep him safe and prevent him from spinning off into space. I said all this as I held him in my lap on the floor and tried to catch my breath.

Abe had been referred for evaluation by a special education director of a neighboring public school system. He was in the second grade and was not doing well. Abe had managed to frighten and antagonize most of the teachers in the school and was becoming increasingly isolated from his peers. His behavior in school was frequently erratic and dangerous. Whenever he walked in the school hallway, either his hand or his shoulder had to have contact with the wall. He would strike out at other students who passed by him or accidentally brushed into him. In the classroom, he could sit at his desk for only a few brief moments at a time. He constantly jumped up and down, interrupted the teacher, and called out inappropriately. If quiet, he was usually staring blankly into space. He would become fixated on fans or other rapidly circulating objects and could not be drawn away from them without significant physical effort. When he was “spaced out” in this manner, no amount of calling or yelling could get his attention.

And yet Abe was clearly a very bright boy. He was performing at or above grade level in all subjects and devoured books far above his grade level. He grasped complex abstract concepts, had a delightful sense of humor, and clearly wanted to make contact with adults and peers but seemed completely at a loss as to how to go about it. Both the school system and Abe’s parents were deeply concerned but had reached an impasse in their efforts to hold him in this world.

John Bowlby and Attachment

John Bowlby (1907–1990), a contemporary of Winnicott, began studies in medicine at Trinity College in Cambridge but soon became interested in psychology. In the fall of 1929, he began attending the University Hospital Medical School and undertook analytic training in the British Psychoanalytic Society within the object-relations field and was analyzed by a follower of Klein. Bowlby began to insert his focus on the mother–child interaction as a major influence on child development into the controversial mix of theory prevalent within the British Psychoanalytic Society in the 1930s. Bowlby had been interested in the consequences of institutional care or frequent changes of mother figure early in an infant’s life. A whole generation of children had been negatively affected by World War II and the forced sep...

Table of contents

• Cover Page
• Half Title page
• Series Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Acknowledgments
• Introduction
• Part I Philosophy and Application
• Part II The Holding Environment at the Community Therapeutic Day School
• Part III Creating a Holding Environment in Public Schools
• Part IV Case Studies
• Part V Public School Case Studies
• Appendix Systems Theory Terminology
• Endnotes
• References
• Index