An Introduction to the Therapeutic Frame

Anne Gray

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134702824
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Designed for psychotherapists and counsellors in training, An Introduction to the Therapeutic Frame clarifies the concept of the frame - the way of working set out in the first meeting between therapist and client. This Classic Edition of the book includes a brand new introduction by the author.

Anne Gray, an experienced psychotherapist and teacher, uses lively and extensive case material to show how the frame can both contain feelings and further understanding within the therapeutic relationship. She takes the reader through each stage of therapeutic work, from the first meeting to the final contact, and looks at those aspects of management that beginners often find difficult, such as fee payment, letters and telephone calls, supervision and evaluation.

Her practical advice on how to handle these situations will be invaluable to trainees as well as to those involved in their training.

Chapter 1

The frame

Throughout this book the concept of a frame is used, and I will begin by discussing what I mean by this term and how this meaning has been reached. Although the idea of a framework for therapy has long been understood, Marion Milner was the first to apply this concept using the metaphor of an artist’s frame (Milner 1952). When an artist completes a piece of work, it is usually framed and the choice of frame is important. If a decision is taken not to have a frame then the edge of the canvas will tell us where the imaginative work ends. When a frame is used, then it is this that performs the function of containing; the artistic creation has a boundary. Some artists have experimented with the idea of containment by letting parts of the picture spill over on to or beyond the frame, and it is only then that most of us become aware of its more usual function. A picture that has stayed in my mind is of a man with a chain round his ankle; a real piece of chain with a ball attached to it is fixed on to the painting and dangles down beyond the frame. This serves to remind the viewer that what is seen is a representation of a particular condition the man may find himself in. The ball and chain which is attached draws the eye so that attention is focused on the device. We are con fronted with a complex set of images: something contained within a frame, the man, and something uncontained, the ball and chain, which keeps him imprisoned. None of the images is real – in the sense of a flesh and blood human being in manacles – and yet the way in which the artist has presented us with his creation shocks us into looking at his picture in a new way. In this example the artist wants us to experience feelings about imprisonment, and the way in which he achieved his effect was by shocking us into thinking about frames, about reality and artistic depictions of reality. It is interesting that most artists prefer to have their work contained and when it is not the effect is disturbing; the eye concentrates more on what is not being contained than what is. Thus we might say that not to have a frame draws attention away from the main body of the creative work and simply functions to remind us that it is aesthetically more pleasing when it is contained.

Now the idea of a frame in terms of artists and their creations cannot be taken wholesale and applied to the therapeutic process. Nevertheless, it is this idea of containing that lies behind the thoughts of having a frame, or framework, for what happens between the therapist and the client. Robert Langs, the American analyst, has written extensively about the therapeutic framework, its importance for containment and how breaks in the frame are accurately perceived by the client, although often ignored by the therapist (Langs 1976; 1978; 1988). He shows how errors are experienced unconsciously, and then through what is talked about in the session cues are given to the therapist to remedy these. David Livingston Smith’s book, Hidden Conversations (1991), gives a learned account of Langs’ contribution, as well as a damning indictment of what both of them see as the established conventions for the practice of psychoanalysis. New ideas are invariably seen as threatening and it is often necessary for their exponents to state them didactically, otherwise they would not get any attention at all. However, the counsel of perfection which is expounded can be daunting to therapists at the beginning of their careers, as well as threatening to those with an already established way of working. My intention in later chapters is to give examples of work using the concept of the frame to understand important aspects of the therapeutic process, and although suggestions are made for what constitutes good practice, more will be learnt from mistakes, from what happened when there were errors or breaks in the frame, than accounts of cases where everything went well.

Defining the frame

Before we can start to think about the frame we have to decide what its constituent parts are, and to do this I am going to use the concept of rules, which will be discussed further towards the end of this chapter. If we think about an individual contacting a therapist and then arriving for an initial consultation, we can see that at some point in this meeting both parties need to agree on what happens next. Should regular meetings be offered by the therapist and accepted by the client, it is necessary for them both to agree on how the work will be conducted: the framework. The therapist will state the location for the meetings, the duration of each session and the charge made, as well as explaining what happens should the client miss or cancel any appointments. Clearly there is no legal sense in which this agreement can be seen as binding, or any part of it seen as a rule, but unless the basic framework is made clear, muddles, misunderstandings and misconceptions are bound to arise. It may seem difficult at this point to see why such prosaic details should be given so much stress, but I am going to suggest that the framework has connections with the way in which we were cared for in the past. However, I also want to stress its importance in the present, in the here-and-now relationship between therapist and client, where it is essential for there to be congruence between the therapist’s words and actions. We all know how confusing it is when people say one thing and do another. We do not know where we are with them. On one level the frame can be seen in terms of a contract, an honest and clearly stated offer of professional help, setting out how the work is to be conducted. In this sense it is similar to any other agreement between two people, whether therapist and client, doctor and patient, or builder and customer. Where it is different is that the agreed way of working is going to be understood as an essential factor in the therapy. Should there be a deviation from what has been agreed then we are going to try to understand what this means to the client, both in the here-and-now relationship and how it may relate to past events. It is important to point out that there is no consensus regarding the frame or which particular elements can be included under this term. However, for the moment I am going to propose that the frame comprises: a private setting in which therapist and client meet; fixed times and duration for the sessions; vacation breaks which are clearly stated by the therapist; a set fee for all sessions reserved; and an internal concept on the part of the therapist that what is talked about is not talked about with anyone outside the therapeutic relationship. I am now going to discuss how the frame is connected with the past and how we might understand what each part of this agreed way of working may mean or represent.

Early experiences and the frame

Individuals seeking therapy do so because they have problems in living; these problems have arisen through their experiences of life and the expectation is that the therapist will be able to help them overcome their difficulties. Psychotherapists and counsellors do not have any answers to the problems of living but they do have a body of knowledge regarding the way in which psychological difficulties arise. We might say that through our knowledge of the ways in which human beings are treated in infancy and childhood, we can make predictions about their future development. These predictions will not be exact; there will always be divergence because of the different circumstances that go into the making of each unique human individual, as well as genetic factors which are also part of our inheritance. Psychological understanding is not deductive but observational. We cannot predict or conclude with certainty what we know from one example of human behaviour about another. But we can observe, and the more we begin to understand the motives underlying behaviour the more we understand the action.

We know, both from research and perhaps from remembering our own experiences as children or as parents, that infants require continuity and consistency. The new-born baby enters a confusing world in which initially it is aware of nothing other than the sensations in its own body. Unpleasant sensations such as hunger, pain or loneliness are modified or eliminated through the care of the mother or mother-substitute. A tiny infant has no concept of time; hunger is not alleviated by an internal sense of lunchtime or teatime, something that will happen when the appointed hour is reached. Nor does a baby have an internal concept of a mother who will come to pick it up in ten minutes, or an hour, or even tomorrow; the longing for contact exists in an eternal present. Slowly, with enough good experiences of a mother who responds, the infant is increasingly able to wait with hope. Baby smiles, gurgles, chuckles and meets with delight the mother, who, in turn, delights in her infant. The baby is learning to give and to receive – it is becoming socialized, the first steps to becoming part of a human society. Of course at times all babies experience frustration, for their needs are not responded to instantaneously, and in this way all of us have had to learn about time, about waiting.

It should be said here that devastating early experiences can result in breakdown later in life, which may result in hospitalization. And although it may be beyond the skills of most therapists to offer help to clients who are severely ill, it is useful to think about some of the factors involved when individuals become unable to look after themselves. If we believe that early experiences can be one of the causes then this can help us to think about all the people we see, since many people fear breakdown even though their fears are never realized.

For those who have never experienced good-enough parenting it may be that they have failed to internalize, to take into themselves, the idea that they are of worth and that their needs are capable of being met. Tiny babies need to be cared for by someone who responds reasonably quickly. If this does not happen despair sets in, trust is destroyed and hope lost. They may survive rather than live, and mental health remains precarious. We all need inside ourselves the sense that we have been loved, and it is this feeling that we can draw on in times of stress. It is often a major life event such as marriage, bereavement or the birth of a child that triggers memories of the individual’s own losses in infancy and childhood. Keeping this in mind can help the therapist to understand both the need for a firm frame, and to appreciate how much the person who feels that they have never had enough care may long for more than the therapy gives. We want to provide a setting in which past failures can be re-experienced so that our clients are able to work through their feelings about these failures. This process is facilitated by an understanding of how past events are connected both with the client’s present life and with the specific relationship that is made with the therapist. Moreover through clients’ emotional experience of being accepted and understood by the therapist, ego strength is built. In other words, because clients are able to internalize the therapist as someone who is able both to respond to their needs and to contain them, their sense of self becomes stronger.

If we continue to think about mothers and babies we can see that it is the mother who gradually introduces to her child the idea of a containing framework for care. This is not done by explaining to the baby that she will be there when the next hunger pangs strike, or that she is handing over care to father for the day but will be back tomorrow; it is done through actions. The baby experiences over and over again the actions of the mother and it is through these actions that the child builds up its expectations for other relationships. The therapist offers the new client a framework for care which has connections with what the mother provides for her child but is of course not the same. We are therapists, not parents.

Without a framework of care the infant may find itself unable to experience its own feelings and emotions. Instead the baby may adapt itself to fit the mother’s needs, thus retaining her love but losing a sense of self in the process. There are many motives for wanting children of our own, and for those of us who have had difficulties in our own childhoods, one of these may be to assuage deprivations vicariously, by trying to give to others what we felt was lacking in our own past. There is nothing wrong in this – indeed it is an honourable intent – but the problem lies in its subjectivity. We may be filtering everything through our own experiences, a subjective position which will blind us to the needs of the particular individual in our care. Should we work with clients whose difficulties touch closely on our own, we may be in danger of seeing in them the child we once were, rather than the people they are now. The frame provides the holding environment in which individuation (recognizing oneself as separate from the other) can take place. In the best of situations it provides a safe space with secure foundations, one in which clients do not have to manage the therapist’s anxieties but are able to develop their own authentic emotional lives.

In most societies, in their first few months of life babies are usually cared for by their mothers. If this is not the case then it is generally accepted that constant changes of personnel in the primary care of infants will be detrimental. It is with this knowledge that therapists think about their prospective clients and the arrangements that will provide the optimum setting for the working through of difficulties. We can infer from what we know about infants that we should provide a model of care which is consistent, that continuity is ensured, and, like the feeding pattern which is gradually established, a regular period of time set aside just for the client. Therefore, in the first meeting the therapist states very clearly the arrangements for the therapy. Keeping in mind the idea of continuity and consistency, we say where we will be available, at what time, and for how long. Because we know that interruptions to care are upsetting we also state when breaks will occur due to vacations, and try to give good notice of any cancellations that may become necessary.

The frame as a practical reality

We now come to the fee which, although it may have many meanings for both therapist and client, is primarily concerned with the reality of the therapist earning a living. Clients need to know how much they will be charged and what happens should they miss or cancel any appointments that are arranged for them. I am going to suggest that once the initial agreement is made clear and clients know that a specific time is going to be reserved for them then they should be charged for all sessions.

Here I think it is worth pausing for a moment to think about asking the client to pay for missed or cancelled appointments, because it is something that causes great difficulty for both trainees and their clients – and indeed for many more experienced practitioners. What I want to emphasize is that although this arrangement has a symbolic element, representing the mother who is available, it does of course have a much more down-to-earth meaning. The therapist has to earn a living and when part of the working day is set aside for a client then this contract is a serious one. Should we adopt a laissez-faire attitude and charge only for those appointments the client decides to keep, then there are consequences for the therapist, and an implicit message is given to the client. The therapist will be in the position of holding open a time that has been reserved for a particular individual and yet will receive no payment. Clients will feel that little importance is attached to whether they come or don’t come to their appointments, and of course may wonder whether the therapist knows about the practicalities of life. Of course clients can decide to stop coming whenever they want to and no further charges are made once the therapist is told of this decision. However, if they are expected to keep the time available then even if some appointments are not kept a charge is made. All of us have to find out for ourselves how to manage the arrangements for fees but it is important to recognize that this aspect of the frame, like all the others, is not there simply to serve the interests of the client but is concerned with the therapist as well.

Implicit in the offer of regular meetings is the idea that continuity is important but the fact that there is only a specific time made available may well prove frustrating. Babies do not always want to feed according to schedule. Sometimes they want the breast or the bottle before the appointed time, sometimes they do not want to feed when the mother is ready. Therapy on demand is not normally a possibility and the frustrations experienced because of this may be said to represent the reality principle – the fact that we cannot have all that we desire instantaneously. The reality is that therapists have needs of their own: they have to earn money in order to live; they have interests outside the therapeutic encounter; they have other clients; they need rest and relief – just as parents have needs of their own which may conflict with the needs of an individual child. In the therapeutic situation this will have different meanings for different clients, and the way in which the firmness of the frame – or lack of it – is experienced becomes an important factor in the work.

We could say then that the offer of regular meetings represents the therapist’s willingness to be available (to offer sustenance) to the client during stated times. Unavailability at other times represents the therapist both as frustrating but also as containing. What I mean by this is that the mother who tries always to be available to her baby is attempting the impossible and is not containing the anxiety of having to wait. By not providing sessions on demand therapists demonstrate their belief in clients’ ability to manage without them. Asking clients to pay for all the sessions that are reserved underlines the therapist’s belief in the importance of regularity, but also leaves clients free to come or not come to meetings, knowing that the time is theirs whatever they decide to do. The therapist is available, like the mother who offers the breast and accepts that there may be times when it is rejected. The task is to understand the reasons for the rejection. The frame remains firm and is not altered, because this would allow strong feelings to dissipate and will be experienced as an abdication of authority. Should we go along with demands to alter our practice and not understand the feelings behind the demands, we may create the sort of anxiety that is experienced by children who feel that they are able to control their parents. While it may be important for them to rebel, children also need to know that parents are able to withstand attacks on their authority.

Unlike the situation with mother and child, the therapist has to state clearly what the arrangements for care are. But, rather as with the mother, the framework is not going to be talked about in detail; it is going to be experienced directly. It is through observing what the frame means to each individual client, what mental occurrences are associated with which particular actions, that the unconscious can be made conscious. In other words, the therapist provides a setting in which clients can bring into consciousness thoughts and feelings which previously had been outside their awareness. Past experiences can be understood in the immediacy of the present and clients, through firmness and consistency, are able to re-enact and thus understand, in an emotional rather than an intellectual way, how their difficulties are manifested. I am not suggesting that it is through the frame alone that problems are solved. There is a wealth of understanding to be found in the more general discourse that is part of the therapeutic process, but some of the basic realities of life are contained in the frame.

The reality of not being the only person the therapist sees is inferred from the limited time offered; any sense of omnipotence is undermined by the therapist determining the length of sessions; the offer of regular meetings represents the therapist’s love; feelings of hate may be experienced through the fee; having to accept that others have needs is manifested in breaks between sessions; limitations of the care provided become apparent through therapist errors – all these realities are there to be worked with and understood. But above all, and most poignantly, is the reality of the passing of time. Each session that draws to its close, every break in the therapeutic relationship, and eventually its ending – all these factors reinforce the painful reality every human being has to accept, that life is finite. The therapeutic relationship becomes the microcosm in which this fact of our existence is faced.

Here a note of caution should be added to what is being suggested. I am arguing that the frame should be seen as a container but it is important to bear in mind that for some it might not be experienced as a safe place, but instead could feel like a prison. Discussing adolescents and anti-social behaviour Winnicott wrote the following:

When a deprivation occurs in terms of a break-up of the home, especially an estrangement between the parents, a very severe thing happens in the child’s mental organization. Suddenly his aggressive ideas and impulses become unsafe. I think that what happens is that the child takes over the control that has been lost and becomes identified with the framework, the result being that he loses his own impulsiveness and spontaneity. There is too much anxiety now for experimentation which could result in his coming to terms with his own aggression.

(Winnicott, quoted in Davis and Wallbridge 1981: 90)

In this instance Winnicott is referring to a specific occurrence in a child’s life, the break-up of his family, a tragedy for any child. But what Winnicott is suggesting, quite apart from the obvious upset this disruption causes, is that the child now feels himself responsible for managing all his aggressive impulses, rather than having the containment that hitherto had been provided by a stable environment. I think this idea has implications for the frame. In understanding what the framework for therapy may mean, or represent, it is important to have ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction to the Classic Edition
• Introduction
• 1 The frame
• 2 Transference, countertransference and interpretation
• 3 The first contact
• 4 First meetings
• 5 Letters and telephone calls
• 6 Third-party communications
• 7 Ongoing work
• 8 Money matters
• 9 A brief intervention
• 10 Supervision
• 11 Ending and evaluation
• Afterword
• Glossary of terms
• Select bibliography
• Suggested reading
• Index