Quote 1

Boundary Marker by the Jeker by Willem van Konijnenburg. 1943. Wikmedia Commons

“The frame is the context in which psychotherapy occurs and all the arrangements that go with it. Think of the frame as the “rules of engagement” for treatment. Elements of the frame include privacy, confidentiality, a consistent appointment schedule, starting and ending sessions on time, maintaining boundaries (e.g., doing therapy in therapy sessions only, avoiding dual relationships, exercising care about self-disclosure), the fee and missed appointment policy, the physical arrangement of your office, and even how you greet the patient in the waiting room. If therapy is online, the video technology also becomes part of the frame.”

Jonathan Shedler. Beginning Therapy: The “Frame”

The function of a frame – any frame – is to surround, give shape and show a delineation. It may mark out the borderline between outer and inner, as in a painting; the frame provides a boundary, a limit, a structure. Within the frame, is the freedom to express oneself.

In therapy, the invisible frame forms a kind of contract, an agreement made at the beginning of therapy between therapist and client that certain ‘rules of engagement,’ as Shedler puts it, or ground rules, are necessary for the therapy to begin and progress.

Each new therapy requires a unique and thoughtfully designed frame, to reflect the individuality, identity, concerns and needs of the client:

“The therapist must strive to create a new therapy for each patient.”

Yalom

The therapeutic frame is not only for the client’s benefit; it is a mutual safeguard. As Shedler says, the contract between therapist and client includes, amongst other aspects, starting and ending times and the fee and cancellation policy, which are there to protect the therapist, too.

Quote 2

Lucifer – Jackson Pollock. 1947. Wikioo.

“A therapist’s capacity to provide a patient with this analytic holding is discovered through the real (and recognised) survival of that which the patient experiences as the worst in himself or herself. (Winnicott 1971)”

Patrick Casement: On Learning From The Patient

The above painting does not have a frame…or does it?

In actuality, the frame is very much there, in terms of the edges of the painting. Without this canvas edge, the ‘devilishness,’ the wildness, in this abstract expressionist painting, would have no boundaries and would totally ruin the wall, gallery, or exhibition in which it is situated.

There would be no control, no limits, no demarcation, and the spattering paint would spoil everything.

The artwork was created by dripping, splashing and pouring paint onto the blank canvas support, in order to express aspects of the artist’s own inner world, his ‘demons’ and his disturbed state of mind.

There is the ‘support’ of the canvas, the boundaries of its edges, inside which the artist can safely express his inner feelings and ‘demonic’ sides. How powerfully does this reflect the therapy situation!

The therapeutic frame enables the client to feel contained and secure enough to express and give voice to less ‘acceptable’ parts of themselves.

The mutual establishment of a containing, boundaried, therapeutic atmosphere is an important feature of every effective therapeutic endeavour. The creation of the frame, discussed and planned between therapist and client from the start, can help the client slowly gain strength and an ability to cope with life.

The mutually established frame itself is there to create security and a feeling of comfort and containment. It is about much more than the physical setting; the frame has a powerful emotional function, in that, within it, a client can feel able to let go, and be safe enough to allow unconscious material to slowly emerge into consciousness.

Emotionally, the therapist contains the client’s feelings and fears through empathy, self-confidence, faith in the process, reliability, and a strong sense of boundaries, professional care.

There is containment in the ongoing maintenance of the therapeutic frame, which represents the stable and largely unchanging aspects of the therapy, both emotionally and physically. This surrounds and ‘holds’ the therapy in a way that provides a reassuring sense of security and continuity.

Mother and child – Kuzma Petrov-Vodkin. 1927. Wikioo

The concept of ‘holding’ was introduced by the child psychoanalyst Winnicott in the 1950’s, in terms of the importance of the infant’s experience with the mother. Something of the essence of this kind of support is needed in therapy, too, and the frame helps the therapist provide it.

As the quotation says, the therapy needs to feel contained enough for the client to risk showing what they may regard as the worst parts of themselves. Discovering that they can do this, and still have the therapist ‘survive’ and be there for them, remaining compassionate, is a huge part of the work of therapy.

The client will also have learnt that, having faced what they felt was ‘monstrous’ inside themselves, they, too, have survived their worst fears.

Whilst the therapist in psychodynamic psychotherapy usually does not physically hold the patient, there is created an environment in which the client can be helped to explore feelings of longing and their unmet childhood needs.

Many schools of psychotherapy have differing thoughts about boundaries. For example, most psychoanalytical psychotherapists would consider that hugging a client is unprofessional, whereas some others might not.

Quote 3

Kazimir Malevich.”House in a Garden” (1906). Wikimedia Commons.

“The paradox of psychotherapy (and not just psychotherapy) is that the more secure the boundaries, the more freedom there is within them—and the deeper the work can become.”

Jonathan Shedler, ibid.

This quotation extends the ideas in the previous quotation.

Whatever the therapeutic approach, it is crucial for all therapists to have clear professional boundaries, in order to work ethically and responsibly.

Boundaries in psychotherapy delineate the ‘rules’ that therapists set and maintain with the client, to protect and care for both of them. In addition, the client will have their own boundaries, which will also be discussed and must at all times be respected and honoured.

The therapist will be aware that the therapeutic frame very much includes the setting, the way the room is arranged. For example, it is important to have chairs that are the same height, so that one person is not above or below the other.

Therapy may be asymmetrical in terms of the differing roles of therapist and client, but it is a relationship of equals, not of one-up, one-down.  It is important to underline the fact that the therapeutic frame is not about power; it involves mutuality, a working-together. The setting of the therapy room needs to symbolise and underline this equality.

“Therapy requires a collaborative working relationship in which both partners act on the basis of their implicit confidence in the value and efficacy of persuasion rather than coercion, ideas rather than force, mutuality rather than authoritarian control.”

Judith Lewis Herman

The chairs must not be too far away from each other, nor too close. If too close, it can be awkward if feet clash and get in the way. The chairs also need to be placed at an angle, so that therapist and client are not face-on to each other, and each can look away at times. This angle also facilitates reverie and fantasy.

In addition, it is important that there is no furniture between therapist and client, such as a coffee table. This forms a very definite and physical barrier and may reduce trust and feelings of being empathised with. A small table at the side of the chairs , on which to put a lamp, a box of tissues or a glass of water, is certainly acceptable and often necessary.

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Image: Elica Coaching and Counselling. Sander van der Wel. Flickr.

Quote 4

• Elastic boundaries

Boxing ring at Gleason’s Gym. Carlos Pacheco. 2012.Wikimedia Commons

Beginning therapists often misconstrue boundaries to imply rigidity. The notion of a “frame” is perhaps problematic because it often conjures up a visual image of an inflexible picture frame. The flexible ropes of a boxing ring might make a better image (although an analogy with boxing is problematic in other ways!), whereby the frame an be extended or reshaped for various reason. Boundaries are designed to create an envelope within which the therapist can be empathic, warm and responsive…”

Glen Gabbard

Whilst boundaries need to be firm and clear, there also needs to be a sense that they can sometimes be ‘stretched,’ that they are elastic and somewhat flexible. Otherwise, a model of rigidity and lack of humanity may be set, which can inhibit the client.

Glenn Gabbard, in his book Long-Term Psychodynamic Psychotherapy underlines this fact and refers to any departure from the established therapeutic frame as  “...boundary crossings rather than violations.” (pp62)

On the other hand, it is important to explain to the client that there are some boundaries that are certainly not to be altered, such as confidentiality, respect for personal boundaries, timings and attendance.

Gabbard also mentions the need to examine one’s own counter-transference responses to the client when’ boundary crossings’ occur. These are often benign breaks in the frame that may not be harmful and can sometimes help.

He quotes a case where a therapist allowed the session to run 15 minutes over time. (pp 62, Gabbard) The beginning therapist had a counter-transference response to the client, feeling sorry for her.

When this was explored with the client after the therapist’s supervision, it was found that the client’s mother had never made her feel special, as the therapist had done by going over time. The subsequent discussion led to some beneficial links and understandings.

Quote 5

• Boundaries in online therapy

Egan Snow.Sunday morning in Sausalito.Flickr

Let us begin with a cautionary tale…an example how not to set the frame in online therapy…

Martin Beek. Kitchen Sink Realism. John Bratty, (Tate Britain)www.flickr.com/photos/oxfordshire_church_photos/galleries…

Some time ago I tried having some brief online therapy to help with grief after losing a dear friend. The therapist was obviously unused to working online, and it showed. The background to the therapy offered was their rather drab kitchen, with an old vacuum cleaner slowly expiring in a corner.

I had a clear view of a bottle of Fairy Liquid and fraying pan scrubs as I looked at the screen. On a shelf was a tin of mustard powder and something that looked like a medical specimen in a jar.

In addition, for some reason, they kept lifting up the laptop, obscuring my view of their face. The experience was depressing, unprofessional, distracting and far from conducive to a feeling of containment and safety. It was awful, and, needless to say, I did not continue.

It is crucial that in online therapy the therapeutic frame is negotiated  and maintained. Boundaries in online therapy are as necessary as those in face-to-face work; the screen itself forms a very real frame and it is important that the therapist studies the image projected online to the client, ensuring that it is professional and appropriate.

Some therapists place their laptop on the client’s chair in their therapy room. This means that a client who has had face-to-face therapy before switching to online, can feel that there is something familiar about their view of the therapist in their chair and their usual room.

If online therapy is offered from the beginning, the therapist can ensure that they themselves are not too near the screen by again putting the laptop on the client’s chair, or backing off from the camera a little. Staring at the client close-up can feel intimidating and intrusive.

(For further information on online counselling and the therapeutic frame follow this link.)

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To my mind the frame in therapy expresses true loving care, in that it acts as a vital, secure container for the expression of a wide spectrum of feelings… from hate, to ambivalence, love, anxiety, rage, and all kinds of emotional disturbance. Without it, there can be no real therapy.

“Psychoanalysis in essence is a cure through love.”

Freud

“The therapeutic frame is like the artist’s frame and like the framework for care provided by parents for their children. It is something that both initiates and curtails the interaction of the two people contained within – it is both a source of anxiety and a container for anxiety. Without a framework neither participant in the therapeutic relationship will feel safe enough to experience the complex emotions that are part of all deep and lasting relationships.”

 A Gray. An Introduction To The Therapeutic Frame.

© Linda Berman