What Works in Counseling, Psychotherapy, and Psychoanalysis: The Holding Environment

Sophisticated statistical analyses indicate that the working relationship between patient and psychotherapist is the most important factor in outcome – specific therapeutic techniques or “schools of thought” are much less important than the connection experienced within the therapeutic dyad. “The amount of change attributable to the alliance is about five to seven times that of specific model or technique.” Further, much of this effect is a function of the extent to which the patient has the experience of being heard, understood, and emotionally held in the relationship. Indeed, the most powerful interactions in psychotherapy and psychoanalysis are what some practitioners call “moments of meeting”, slices of time that effectively re-write some important aspect of both the patient’s and analyst’s relational ‘software’. In my view, during this moment of mutual reflection, agency, connection, and heightened emotional expression, patients experience the ability to safely try on new ways to soothe, regulate, interpret, and construe the newly emerged strong feelings, and manage such experiences in more fulfilling ways. These particularly powerful exchanges occur in the moments of what have been called mutual implicit relational knowing, where the patient’s unconscious intersects with the analyst’s, where therapeutic action occurs in psychoanalysis and often in psychotherapy.