Techniques of psychotherapy :The Function of the Frame: It is how a Good Therapist makes their Patient Feel Safe!

Freud’s 1911 model suggested setting a consistent frame or  background from which the patient could develop a plan for working in their treatment (testing). First and foremost is the concept that the therapist’s task is to create a safe holding environment. To attend to and infer for each individual pt what this might be. My basic job is to be an ally to my patient. To be that container from which digestion, metallization and metabolizing can occur.  This process of creating a safe space in which therapy can take place is at times referred to as building a secure frame, or in my metaphor, “the dance”. A structured frame is most important for patients who were intruded upon or violated.  It may not be as important for patients who are very rejected. There is no magic number of sessions needed per week (1-4) or specifically perfect length for a session. The use of a couch or chair can be pt. specific. Pts. can be comforted by consistency but again flexibility can show strength and comfort with your authority.

I will be helping my patients disprove their pathogenic beliefs in order allow them to be free to pursue the goals forbidden by the beliefs.  The patient and the therapist have the same purpose, disconfirmation of these beliefs.  The efficacy of my techniques is judged by whether it disconfirms or confirms a pathogenic belief. I can judge my success by whether my patient becomes less anxious, more secure, more insightful, or bolder  – which may lead to increased testing.

I have been taught to act polite and friendly.  It’s not a manipulation; it will not gratify dependency needs, which might prevent the patient’s facing dependency needs.  Patients will not lose their motivation for work in treatment because they feel good. I do not need to worry about patients externalizing their problems via blame.  Requests for changes do not have to be seen as hostile acts; rather they can be rejection tests, or invitations from our patients to blame or humiliate them.

In psychotherapy, one makes oneself deeply vulnerable to another human being, and may allow many disturbing feelings and thoughts to be expressed. This is absolutely necessary to healing. But to allow himself to do it, a patient will need to have a strong feeling of trust in their therapist; they will need to feel safe. This is the central component of Control Mastery theory.

The “frame” is the environment of therapy. It includes the physical surroundings, the emotional environment, the psychotherapeutic structure, and the relationship (or dance) between patient and therapist. A secure frame is a private psychic space in which the patient feels safe, “held” and supported. A secure frame is an environment in which every detail reflects structure, containment, safety, and support. Psychodynamic therapists believe that the secure frame is a vital element of the therapy. Others disagree about its place in the scheme, but certainly if the frame is not secure, you will find it difficult to accomplish much that is meaningful, whatever type of therapy you pursue.

Psychotherapists now know that boundary violations in the therapeutic setting are problematic, but most can’t tell you why. Therapists will say it is because of the loss of objectivity and potential for exploitiveness. True, but there is so much more to it.

One perspective, returns to our image of the child and its mother and is developmental in nature: a child needs to be in a protective boundary within the family, within the symbiotic boundary with the mothering object, and feel protected within the self-boundary. If the boundary is violated with too much stimulation, aggression, seduction or exploitation, the child will have traumas and developmental arrests. They can, as Bion would remind us, lose the capacity to symbolize. When a therapist uses his or her patient for personal needs, the patient loses a healing therapist, just as a child loses a parent. The world doesn’t feel safe, and the damage sticks to the patient’s personality.

The question of what should be included and excluded in the therapeutic frame is not an easy one to answer. The frame itself is to some extent determined by a clinician’s theoretical framework and work setting, along with serious consideration of the client’s needs and ego strength. For example, a traditional psychoanalyst may view a therapist’s self-disclosure as something that negatively impacts transference, whereas an existential therapist may see it as essential to the therapeutic process. Control Mastery therapists will use the patient’s plan to guide what kind of frame will be needed to create a sense of safety.

Flexibility in the therapeutic frame can be an important component of successful psychotherapy. In using the term “flexibility”, I am referring to measured and well-considered self-disclosure, and a willingness to alter various aspects of the traditional therapeutic frame when it is deemed to be in the patient’s best interest, with an understanding of how it is likely to affect them, and a willingness to observe and correct with the real data from your relationship with your patient. I am not referring to inappropriate self-disclosure, touch, or dual relationships, or any illegal act. If done mindfully and safely, alteration of the therapeutic frame in the service of a client’s progress and healing can produce potentially profound outcomes.

Patients adapt to the therapist’s approach, style, and personality.  Patients who feared challenging authority would be particularly helped by the 1911 model, as would patients who have trouble protecting themselves from the intrusiveness of others or fear seducing the therapist or overwhelming and worrying the therapist. So another way to consider the issue that I like is using the term “Boundary Crossing” instead of “violation”. (From Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings –Thomas G. Gutheil, M.D. & Glen O. Gabbard, M.D). (http://kspope.com/ethics/boundaries.php#copy)

“Boundaries are not intended to create a remote and rigid way of relating between therapist and patient. On the contrary, external boundaries are established so that psychological boundaries can be crossed through a variety of mechanisms common to psychotherapy, including empathy, projection, introjection, identification, projective identification, and the interpretation of transference. Langs’s concept of the frame and Winnicott’s notion of the “holding environment” address similar concerns.”

Gutheil & Gabbard have suggested that boundary transgressions can include a “boundary crossing,” a benign variant where the ultimate effect of the deviation from the usual verbal behavior may be to advance the therapy in a constructive way that does not harm the patient. Some of these may be fully appropriate human responses to unusual events that might involve physical contact. One should consider the way in which cultural differences, timing, and transference combine to create a context for an action, which may be felt as a boundary transgression by the patient or the therapist.