To the Editor: We very much appreciate the comments of Drs. Shapiro and Plakun and endorse their ideas. It is indeed difficult to construct a holding environment that provides meaningful continuity of care for severely ill patients, given the attitudes and constraints of many managed care protocols. What is just as troubling, however, is the impact of the absence of a holding environment on the clinician attempting to do this work. Without this, the clinician cannot find the financial or emotional support to deal with either his own or the patient’s sense of helplessness. The therapist may begin to "identify with the aggressor" in seeing the patient as only manipulative and insatiable. Inevitably, the identity of the therapist is fragmented and diffused so that she can only see herself as a "part object" in the role of "med manager," or "treatment planner"; the doctor-patient relationship, so central to the treatment of the severely ill patient, is compromised to the extent that it, too, becomes meaningless.