The Therapeutic Frame in the Clinical Context

Integrative Perspectives

Maria Luca

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135443887
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

How does the therapeutic frame help therapists in their practice? The Therapeutic Frame in the Clinical Context examines some of the key issues inherent in the intimate and very often intense therapeutic relationship. It addresses and clarifies perspectives on the creation of a therapeutic environment that is conducive to therapy. The book addresses specific aspects of the therapeutic frame. How does a client feel about unexpectedly meeting her psychotherapist's son or daughter? How does a psychotherapist or counsellor practice within a 'frameless', often intrusive environment, in acute hospital wards? How does a counsellor manage the frame in the face of a life-threatening illness? Using a wealth of examples from clinical practice, The Therapeutic Frame in the Clinical Context examines these issues and more, in a range of settings including the NHS, private practice, and the workplace, and provides valuable guidelines from a range of theoretical perspectives, including Jungian and psychoanalytic.

Chapter 1

Boundary Issues in Psychotherapy

From the Literal to the Figurative Frame

Maria Luca

And yet all the qualities of a good friendship – a welcome, an acceptance, a letting be, a hospitality, an attunement, an attentiveness, a suspension of self-interest, a questioning, a criticism, a distance that does not pretend to objectivity, an engagement, a faith in the other, a commitment to truthfulness, and above all perhaps a responsibility to the other – these surely are the qualities also of an ethical therapy.

Paul Gordon, Face to Face – Therapy as Ethics

The increasing professional demands on psychotherapists to adapt to the changing culture surrounding the field, with the need for more evidence on therapeutic outcomes and tighter regulation governing the profession, have led to a climate of anxiety. As psychotherapists we are surrounded by a multiplicity of theories on what it is to be human, coupled with a plethora of ideas explaining away the human condition. Jargonizing existing ideas tends to provide temporary relief for our desire to come up with something new, something which will mark our own territory. Words become epidemics that sweep away even the most acute minds. Within a few months of the publication of Gerrard’s paper ‘A Sense of Entitlement: Vicissitudes of Working with “Special” Patients’ (2002), I have heard the term ‘entitlement’ being applied by psychotherapists a number of times. The paper encapsulates what many therapists already know from experience, and having a term to describe this provides a kind of known territory, a relief. This kind of infection is, I believe, driven by our doubts on the legitimacy of our theories, mobilizing our need to give intellectual authority to a profession surrounded by uncertainty and constant media scrutiny. The popularity of ideas against therapy, such as claims that people are better off talking to an intelligent friend (Persaud, 2003), still prevails. For psychotherapy to exist as a valued form of help in the twenty-first century we need to transgress from our conventions, let go of our theoretical orthodoxy and reach out towards a world of open debate on therapeutic forms, their value and limitations. The best teacher is clinical practice. My focus in this chapter will be on selected issues relating to therapeutic boundaries. I will attempt to tease out, from clinical experience and disguised vignettes, issues of technique as they relate to the therapeutic framework. The clinical material comes from different sources, including colleagues and therapists in supervision.

The therapeutic frame and the management of boundaries are increasingly under scrutiny. Some authors (Gutheil and Gabbard, 1993; Langs, 1976, 1992; Lazarus, 1998; Young, 1998), have attempted to define and to clarify the ‘rights’ from the ‘wrongs’ in clinical practice. The literature is replete with concepts on ideal frames, ideal conditions, ideal outcomes. Little is written on therapeutic technique that is outside the remit of these idealizations or on therapeutic failures, therapeutic mistakes and transgressions that prove valuable. Yet learning, as Patrick Casement (2002) has demonstrated, comes from our mistakes; and therapeutic failures are the result of being married to our theories, as Valentine (1996) rightly argues. These authors remind us of the value of common sense and of moments when we realize that despite our fears, a frame modification, or crossing, had been, to our amazement, fruitful.

In our zeal to be the good disciples of leading figures we employ therapeutic approaches that are more in line with tradition (for the sake of tradition) than with common sense (for the sake of fruitful, innovative knowledge). Psychotherapy would benefit from a dialogical relationship between tradition and modernity. Traditionally spontaneity (Berry, 1987) and elasticity in therapeutic technique have been frowned upon. We only need to remind ourselves of the plight of those who challenged the orthodoxy of psychoanalytic technique, such as Ferenczi (1928), to know that flexibility comes with a price. In our attempts to validate the paternalism and maternalism of our forefathers and foremothers, we perpetuate the dogmas at the expense of creativity. But therapeutic inventiveness does not have to be harmful. As Winnicott (1971) showed, therapeutic play is essential to healthy living. It is synonymous with the humane aspects of therapeutic interaction, which, in hindsight, enhances an otherwise mechanistic encounter. ‘Our confidence in our theories should be only conditional, for in every case we may be presented with a resounding exception to the rule’ (Ferenczi, 1928: 262).

It would be a mistake to assume that modifications in the agreed ground rules and flexible boundaries of the therapy do not have wide-ranging implications for practice. This would be just as naïve as to believe that a rigid framework would protect us from behaving detrimentally towards our patients. The emphasis on how a therapist should speak, how a therapist should listen and what kind of clothing a therapist should wear is a pressurizing factor on the person of the therapist. I remember as a trainee psychotherapist my bewilderment at the comment from a fellow trainee that my long hair and long ear-rings were ‘seductive devices’ and must be avoided at all costs. On reflection, it is our fears of seducing or being seduced, as well as the demand on us to work with the complexities of erotic transference and countertransference, that create the desire to control the external environment. I still wear my hair long and the long ear-rings are still a constant in my personal presentation. Being who I am evokes all sorts of reactions in my patients (see Luca-Stolkin, 1999), these becoming essential material for the work. I firmly believe that no matter how neutral we try to be, patients will have a reaction to the subjectivity of the therapist. Working with and understanding what we evoke in our patients by who we are is part of a therapeutic, inter-subjective interaction. I give the following example to highlight this point:

A therapist I supervised presented the case of a patient who persistently arrived at least fifteen minutes late for her sessions. The therapist felt increasingly irritated by this, as she felt the patient was wasting valuable therapy time. Without much exploration about the meaning of this lateness the therapist made a statement reminding her of the agreed contract and how she hoped the patient would adhere to this, as she had indeed agreed to during the initial session. She also added that they had limited time together and lateness reduced their ability to create fruitful work. The therapist felt that she tried her best not to ignore this frame challenge and was surprised that her patient missed the following session. We discussed the impact of her intervention on the patient, including the possibility that she might have felt punished and not understood by the therapist. The therapist’s focus and preoccupation with the concrete aspect of the lateness had led to a concrete management of the frame. Her need to reclaim control of the frame led to her neglecting the qualitative aspects in the patient’s expression of lateness. This meant that the understanding of the lateness had been partial, externally focused and interpreted, ignoring the underlying, perhaps unconscious communication the patient was expressing by being late. The supervisory exploration prompted the therapist to look at the deeper meaning in the patient’s use of time, including missing the session. The therapist understood her attempt to take control of the external frame as a blind countertransferential attempt to control erotization of the therapy. She related this to her increasing fear about the patient’s declarations of love and desire for her, sometimes communicated through sending her gifts. She felt that her own fears and anxieties in not managing her ‘territory’ blocked her ability to tune into her patient’s meanings.

It is underestimated how much of our character is revealed, despite all our efforts to hide. Our patients know a great deal more about us than we allow ourselves to believe. Patients’ antennae perception of their therapist often comes as a surprise to us. To this end, presenting a false self would be just as compromising to an authentic relationship as would behaving in ways that disregard the patient and totally serve our own narcissism. The highly charged energy in the interaction and the kind of intimacy that develops through the way we work can be emotionally stifling for both participants. It is important, therefore, to step outside our therapeutic frame and give ourselves respite from the confines of introspection and inward searching. The focus on what goes on inside the frame as a demarcation for the treatment leaves little room for reflection on the outside world. As clinicians we are all too familiar with the incestuous quality characterizing our profession and of the threat of litigation hanging over our shoulders each time we transgress professional boundaries. But isn’t it time we took a fresh look at this, open our consulting room windows a little and free ourselves of the frantic search for certainty? ‘Certainty can imprison the analyst just as much as it may threaten the patient’ (Casement, 2002: 16). Holding the treatment task in mind whilst situating it within the external world is likely to be more therapeutic and growth inducing than compliance to theory.

The Essence of the Frame

Without rules there would be anarchy and chaos, and exceptions to the rule are often a direct result of knowledge drawn from experience. Rules are created by humans to serve the human condition. When they cease to have this function it is important that they are reconsidered, or abolished. The frame, the setting – otherwise referred to as the therapeutic space – is a structure with rules. Just as Freud advocated the importance of ground rules, especially the fundamental rule of ‘free association’, Milner (1952) coined the term ‘frame’ to distinguish ‘the different kind of reality that is within it from that which is outside it’ (see Warburton, 1999: 80). For Milner, the area inside the frame has a symbolic function, and outside a literal function. This inside and outside of the frame has a crucial boundary function. Even though ‘Freud and Klein took a distinctly laissez-faire line concerning the frame’ (Smith, 1991: 168), the orthodoxy of some psychoanalytic practitioners is reflected in their strict, sometimes dogmatic adherence to the ground rules – an adherence that ignores the individual needs of patients for modifications to the frame that serves their therapy. Some psychoanalytic practitioners (Gutheil and Gabbard, 1993) tend to view frame elasticity as belonging to the more supportive therapies. The authors apply the language of ‘deviation’, ‘boundary violations’ and ‘boundary crossings’ to psychoanalytic practitioners who do not strictly adhere to the classical view of the frame.

Modifications, however, if indiscriminately made and without a clear rationale, can have an impact on the holding of the therapy and can lead to premature termination by the patient. If changes to the frame are made, whether deliberate or unplanned, it is important that we consider the implications to our work rather than fear that changes would damage the patient or ourselves. ‘To be healthy, every intimate relationship needs space and personal boundaries, and a corresponding respect by each person for the “otherness” of the other. Frequently, however, this space is either lacking or contaminated by intruding influences’ (Casement, 1990: 160). I imagine all psychotherapists recognize the value of establishing a secure frame; but let us be clear that this does not imply an agreement written in stone.

Some authors (Langs, 1992; Smith, 1991) emphasize the importance of the rule-abiding, abstinent therapist, whilst others (Gray, 1994; Lomas, 1987) present a more flexible notion of the frame. Lomas (1987) spoke against the analytic emphasis on discipline, reticence, toughness and control – qualities he described as masculine – and believed that creative play must prevail. There is a real risk to our creativity, that in our fears of acting out on impulse we tend to ignore the value of spontaneity as a channel of communication, that is more likely to inject the encounter with an affective connection than will measured thought.

A number of analysts (Casement, 2002; Ferenczi, 1928; Klauber, 1987, Kohut, 1978, Lomas, 1987; Resnik, 1995) have all, in their own individual ways, challenged the rigidity of psychoanalytic technique, advocating for more flexibility, spontaneity and naturalness on the part of the analyst. In reference to the therapeutic contract, Resnik argues that:

A good contract, just as in fair play, means that you can make the rules clear during implementation: it is creative, meaning that technique and schools of thought are less important than style and personal ethics. Living in a contractual society, we need to reach agreement about rules, but we have to leave some opening for inventing those most appropriate to each case.

(Resnik, 1995: 24)

Similarly, Laplanche (1989) recognizes the importance of a flexible setting, saying that it is not a ritual or a technical appliance or an arbitrary law. He argues that ‘[p]ure formalism is as meaningless as the unthinking rejection of form...’ It is essential to adjust techniques to the needs of analysands and to introduce variations, but we have to justify them’ (p. 155).

We therefore need to consider the usefulness of tentativeness in our approach and for this purpose I use the term ‘elasticity in the frame’. This is not to be confused with a poor frame that confuses the patient. In the same way that Picasso, along with other modernist painters, could do a pretty good life drawing of classical proportions and beauty before he ventured into Cubism, the therapist needs to understand the rules of the frame before employing the ‘elastic attitude’. Unless we are clear about the constituent parts, it would be difficult to be creative with the frame in its entirety.

One question that inevitably arises is ‘Who is the Frame for then, the analyst or the patient? The patient whose transference will not unfold properly without it, or the analyst who might be driven crazy with less structure in place’? (Hantman, 2000). It is hard for us to accommodate changes in structure when we know that the majority of our patients are likely to react in ways that demand more of our energy. When I moved my consulting room to another area one of my patients decided to terminate; another became curious about my personal life, wondering whether the change was as a result of a breakdown in my relationship. Some patients hated the new room, and for another patient the car parked in the driveway symbolized my financial means. It was interesting to work with the intensity of the individual responses to this structural change. Patients, each in their unique ways, expressed mixed feelings ranging from anger, outrage, empathy, envy, triumph, curiosity, loss, sadness and fear. I found it very demanding to process such intense feelings in the patients whilst trying to understand my own responses to the patients. For the first few months I suddenly found myself the object of scrutiny. Whereas before I could sink in the comfort of familiarity, continuity and therapeutic distance, I now had to deal with intensified transference and counter-transference simultaneously; not an easy task for any practitioner. What was before inaccessible was now lived out. It was precisely this accident of life that widened the therapeutic space and vitalized the relationships.

The therapeutic frame is a structure that sets the rules of therapy and holds and contains the participants’ behaviour. Most importantly, if appropriately utilized, it can create security. If play is guided by the sentiments of trust, ethical responsibility and professional care, so too creativity, imaginative exploration and mutual respect can be developed. Spontaneity is not a cardinal sin, and it does not infiltrate and damage the therapy. The principle of psychoanalytic abstinence in its extreme can sever spontaneity and block the patient from feeling free to desire and free to want. Of course therapy does not make promises to satisfy the patient’s desires and wants. Rather, it tries to create a space for these feelings to be voiced and understood. Without spontaneity, frameworks become rigid and the patient’s mind closed off. The teasing out of affects buried under the weight of defences requires an affective relationship between client and therapist. As I mentioned earlier, a structural change whether planned or accidental can mobilize affects buried under the weight of ‘normality’. As Nicole Berry (1987) puts it: ‘the analyst learns how to make the patient accept rules and limitations, but at the same time he learns how to act naturally’ (p. 107).

Ms B completed her therapy two years before I met her on the tube one morning. ‘Hello’, she said, with a big smile. ‘The weather is not so good today, is it?’ she continued. ‘Yes, it has changed this week’, I replied with a smile of acknowledgement. She then buried herself in her newspaper. As it was time for me to get off at the next station, I said, ‘Goodbye, Ms B, have a nice day.’ Her face lit up and she replied in a similar manner. As I walked up the escalator I thought about our exchange. Our sense of being in those moments was in attunement with each other. Although we both felt uncomfortable, as the context meant that for the first time we were thrown into a new frame, we sensed the unease in each other. I tried to behave naturally and to acknowledge her existence, but without intruding into her social envelope either. Having used her name to say goodbye, she felt remembered and acknowledged by me. Intuitively I knew that in its ordinariness, the encounter was extraordinarily healing. As simple as this may sound, by referring to her by her name she felt remembered and not ‘just a patient’. I saw no harm in serving the patient’s need to be special and human in my eyes.

Technical tools, ethical ideas and knowledge of what the common therapeutic factors are, are some of the elements that inform practices and influence the nature of the frame. There is no question in my mind about the importance of having a clear frame at the start of the therapy that specifies the conditions within which therapist and ...