Jung At Heart

Yesterday I mentioned that the boundaries of time, place, fee are elements of the therapeutic frame. These days, outside of the psychoanalytic literature, no one talks much about the therapeutic frame. But I have always found it to be one of the most important and useful concepts in the practice of psychotherapy. The frame is the container for the therapy, the fixed elements that form the boundaries for the work. The frame has three elements: time, place, fee. Optimally these three elements remain the same throughout the duration of the therapy, changed only after careful consideration, because changing one element alters the whole container. Keeping these elements fixed makes it easier to identify when either patient or therapist is acting out and facilitates working through whatever the issue is that gives rise to the acting out.

The frame is for both the patient and the therapist. It provides a structure for the basic elements of the work. There is plenty going on all the time so it is helpful to have something be stable and predictable. The weather changes, mood changes, how we look or feel changes. People in our lives change. And so on. Of course sometimes it is necessary to change the time for meeting or the place, as when the therapist moves or changes offices. But the frame as that structural skeleton still exists.

I was in analysis with my analyst for a long time. The time for my sessions changed once and he moved once within that time. The fee stayed the same the whole time. He always started and ended on time. There was something very comforting knowing that those things would stay the same -- even when I was furious with him or when my life was falling apart, that piece of my life was stable and there and reliable. It made for a space where I could explore the least explored parts of me, the parts I felt least comfortable with -- a safe space.

 In an excellent article on the frame, Robert Maxwell Young writes:

"the analytic frame is not confined to the room where the therapy is done. It is ideally tacitly in the minds of both therapist and patient all the time. It is there when you open the door or speak on the phone. It is carried with the patient (or not) between sessions: it is internalised. It is conveyed by the therapist’s demeanour, tone of voice, pauses, silences, grunts, the wording of any note or letter which it is appropriate to send to the patient. It is evident in pauses. It is all aspects of analytic space. To maintain the frame is to maintain the analytic relationship. Its essence is containment." 

So the frame is more than just the physical setting. It is the larger notion of the therapeutic space, that space in which both therapist and patient relate to each other in support of the therapy. It includes sessions on the telephone, or in writing, or in other ways that the two engage in their work together. 

"Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not relfective. The patient is acting rather than reflecting. Where acting out is, thought cannot be.

One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do — to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper."

Young writes elsewhere:

"the room, its furnishing, its stability, one’s demeanour, absolute confidentiality, the forms of abstinence dictated by professional ethics, e.g, refraining from physical, sexual or social contact –- all these are designed to facilitate speaking in an exploratory way about matters which it is difficult to reflect upon in ordinary life. Along with what the therapist says and how it is said, they constitute the containment that makes change possible, though in no sense inevitable. The therapeutic frame is a safe place to take risks, to regress, to confess, to repent, to embark upon acts of contrition. "

There are purists who hold to a highly structured and idealized sense of the frame. Robert Langs is one and there are others as well. Frame becomes elevated to an almost absurd level so that ordinary human interaction becomes almost impossible -- like offering a tissue to a patient who is crying. But within the therapeutic community there are variations in how the frame is constructed and maintained. For the purists, a letter from a patient between sessions is an instance of acting out and they would not read it but rather place it on the table and wait for the patient to talk about it. And it is acting out, because it is an extra-therapeutic contact, a kind of effort to gain more time and attention from the therapist outside of the boundaries of their time together, and it is writing rather than putting the feelings into words and speaking them in the session. But that it is acting out does not mean it is useless, meaningless or bad; what it does is signal the presence of unresolved feelings or or need. 

The actual words of the letter may indeed impart thoughts or ideas not expressed in session but it is what drives the desire to write them rather than say them that is probably of greater importance. And dealing with the fear/resistance to expressing those feelings and thoughts directly is a big part of what depth psychotherapy is about.

In this week's episodes of In Treatment we saw two examples of dual relationships in psychotherapy and I have received emails asking to to say more about this.

It might seem that it would be easy to make a clear definition and prohibition against dual relationships, but in fact it is not and how they are viewed varies some by theoretical orientation. The more the relationship between therapist and patient is the primary vessel for the work, then the less likely that such a relationship would be benign, for the therapy.

The code of ethics for psychologists states:

American Psychological Association: Ethical Principles of Psychologists and Code of Conduct

 "A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code....Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative."

The one unambiguous area of dual relationships is any sexual contact -- across the board this is seen as injurious to the patient and unethical. 

From there it becomes less clear. In a large urban area, it is possible for therapist and patient to have no contact or relationship of any kind outside of therapy. The more rural the area, the less possible this becomes. As an example, I live in a town of 6500 people. It is highly likely that I will know people who come to me or know people they are close to -- this is all but inevitable in a small population. What do we do about it? We talk about it and establish ground rules for the relationship.

It is also fairly clear that there shouldn't be any complicating financial relationship between patient and therapist. A patient could be a great accountant or plumber or attorney but should not be employed by the therapist for those skills. 

The primary consideration must always be the interests of the patient -- is the dual relationship in the best interests of the patient? And if it is not or there is doubt that it is, then it should be avoided.

In light of this, look at Paul and Mia. He knows as soon as he recognizes her that they would have a dual relationship if they proceed -- even if she did not return to see him in therapy, that that she was his patient remains the priority concern. And as they talk it becomes even clearer to him that she should not handle his case. Good decision.

Look at Gina and Paul. Their relationship is a tangled mess of personal and professional and the lines constantly shift and blur so that there has not been a clear therapeutic or supervisory contract. And though Paul asks to be in therapy with her, and Gina agrees, it is not in his best interests. He may not want to start again with someone new, but the issues between him and Gina make it highly unlikely that the therapy would be successful. And if it were to have even a chance of success, they would have to discuss the reality that their friendship needs to be set aside. Even were they able to do this, I am dubious about the outlook.

In order to have a solid container for the therapy, and for the particular kind of intimacy that can develop in a secure frame with good boundaries, sacrifice is needed on the part of both therapist and patient. No matter how much they may like each other and believe they could have a wonderful friendship, the sanctity of the therapy relationship must come first. It is sometimes very difficult to make this kind of sacrifice, but it is essential. These are feelings for the patient to put into words, and not to be acted out, by either patient or therapist.