Many children who have suffered traumas early in their lives have also experienced profound losses of relationships. They may have lost or been separated from family members, experienced war and displacement, and/or lived in multiple placements. Because children with developmental trauma can show difficulties with cognition, emotional regulation and behavioral control (Spinnzola et al., 2021), they often cannot articulate their struggles, instead demonstrating them through behavioral responses. When children with histories of developmental trauma and loss enter treatment, the therapist must create an environment that offers protection and containment so that the child feels safe enough and can regulate sufficiently to explore thoughts, feelings and memories. Creating that therapeutic space is not always easy.
The concept of a holding environment was introduced by D.W. Winnicott to signify a secure and protective relationship, similar to that which parents offer infants as they begin to explore the world (Altman et al., 2002). The therapeutic holding environment enables expression and exploration of strong affects that would otherwise feel too overwhelming. When the COVID pandemic brought loss, both due to illness and death but also because of safety and isolation mandates, just about everyone experienced a need for more security. The challenges the pandemic introduced offered a new perspective on what therapists need to create a holding environment for clients with developmental trauma.
The pandemic brought the experience of suddenly being separated from others, isolating each person from the interactions and connections that had been part of everyday life. “These years have affected how we think, feel, imagine and connect with each other” (Levy-Warren et al., 2023). As a global phenomenon, the pandemic forced us to grapple with our needs from a new perspective, uncovering the defenses that protect us, forcing us to experience raw feelings alongside our clients and the opportunity for greater empathic connection. The challenging situation of being emotionally vulnerable for therapists and clients at the same time is an opportunity to examine the role of holding relationships needed for therapists to be able to offer therapy. “We cannot provide our patients with a sense of safety and reassurance if we are not able to identify and reach out for help to contain our own anxieties” (Malberg, 2023).
For therapists to offer clinical holding to their clients, they must also experience it for themselves. Listening to clients’ expression of trauma, loss and ongoing struggles can evoke strong reactions. Therapists' emotional responses can include fear, anxiety, anger, frustration and sadness, as well as empathy and compassion (McNellie and Rose, 2021). Managing these feelings, at the same time as therapists are trying to help their clients, can be difficult, sometimes leading to burnout or therapeutic mistakes (Fixsen et al, 2019).
Consultation groups for therapists provided by the nonprofit organization, A Home Within (AHW), which focuses on meeting the long-term therapeutic needs of children and adults who are or have been in the foster care system, offer an example of a framework for concurrent management of the experiences of both client and therapist. AHW therapists commit to seeing one foster youth pro bono in their private practice for “as long it takes” (from the mission statement of A Home Within) and are supported by peer consultation groups. During the pandemic, this two-tiered system was uniquely suited to hold therapists and help them reflect upon themselves and their cases. For a period of time, these bi-weekly peer consultation groups were the only contact some therapists had with others outside of their homes. It was through these connections that the therapists experienced the significance of feeling seen and recognized amid the storm of isolation.
Nancy McWilliams describes her experience in a small supervision group: “Participation in this intensive experience expanded my knowledge, kept me honest about my struggles and blind spots with patients, reduced the loneliness endemic to private practice and extended my range as a therapist via the opportunity to identify with other professionals” (McWIlliams, 2021, p 91). Group consultation as described by McWilliams and provided by the AHW therapists offered crucial opportunities for therapists to learn about themselves and their clients. The space that these groups offered during the pandemic highlighted the necessity of relationships that create holding environments. Having the space to explore one’s own feelings and vulnerabilities with peers in the same position enabled the clinicians to revisit their fragility with the scaffolding that enables growth.
One way to conceptualize the experience of children and adults who have sustained developmental trauma is that of trying to grow from a ground that repeatedly shifts without warning. In a precarious situation, it is difficult to find a solid, nourishing base. During the pandemic, therapists and clients alike were trying to remain upright as the world shifted and real experiences of and threats of losses were magnified. The parallel moment of experience highlighted the role of the holding relationships for therapists as they offer therapy, particularly in a time of vulnerability for both sides of the therapeutic relationship.
About the Author
Sarah K. Abel, LICSW, has a psychotherapy practice in Western Massachusetts and is a consultation group leader for A Home Within. She is the co-author of Calming stormy feelings: A child’s introduction to psychotherapy.
References
Altman, N., Briggs, R, Frankel, J, Gensler, D, & Pantone, P. (2002). Relational Child Psychotherapy. New York: Other Press.
Fixsen, A., Ridge, D., & Evans, C. (2019). ‘Momma bear wants to protect’: Vicarious parenting in practitioners working with disturbed and traumatised children. Counseling & Psychotherapy Research, 20, 680 – 688.
Levy-Warren, M. & Tuber, S. (2023). A Snapshot of development and treatment during the time of COVID-19. Journal of the Society for Psychoanalysis and Psychoanalytic Psychology, 40, 147-151.
Malberg, N. (2023). The monster outside the door: A Developmental-psychoanalytic exploration of the impact of COVID-19 on the lives of children and adolescents. Journal of the Society for Psychoanalysis and Psychoanalytic Psychology, 40, 172-181.
McNellie, N., & Rose, J. (2021). Vicarious trauma in therapists: A meta-ethnographic review. Behavioural and Cognitive Psychotherapy, 49(4), 426–440.
McWilliams, N. (2021). Psychoanalytic supervision. New York: The Guildford Press.
Spinazzola, J., van der Kolk, B., & Ford, J. (2021). Developmental trauma disorder: A legacy of attachment trauma in victimized children. Journal of Traumatic Stress, 34, 711 - 720.