I have always found the therapeutic frame 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.

“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 internalized. It is conveyed by the therapist’s demeanor, 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 (emphasis mine) Robert Maxwell Young

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. 

When is it acting out?

Young says:

Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not reflective. The patient is acting rather than reflecting…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.”

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. In a Langsian office, there are no decorations that might provide any hint about the therapist as a person. The environment is very neutral. Often not even tissues are provided as that could be construed as gratifying the patient. It isn’t being strict just to be strict but because every little thing is seen in the light of what it means in the therapy. So as many variables as possible are controlled in order to have a better idea of what is coming from the patient and what is aroused by the frame.

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 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.

Writing a letter or sharing a journal is, the strict sense of things, a way to sidestep the heart of the matter — that it takes time and effort to work through our defenses and resistances and to do so in the presence of another human being. If the entire therapy were in writing, and I know that such work does occur, then writing this way could have a place. I know of at least one Jungian therapist who works with some people via email exclusively. It is not a big step to go from that to co-blogging in a private blog.  

The boundary conditions of therapy are more complex than they seem at first glance. And we haven’t touched issues like wanting to reschedule appointments, the patient who wants the therapist to give a hug, or any of the other seemingly inconsequential things that can and do happen in any therapy. We’ll look at some of them another day.

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