The Therapeutic Frame: an illusion of the past?

The therapeutic 'frame' refers to the fixed elements of the relationship that provide the context for therapeutic work. It was described by Marion Milner (1952) as a boundary distinguishing the separateness and incompatibility between the therapeutic relationship and other social relationships in the client's life.

As a trainee, I often find myself questioning my own stance to 'the frame', and what feels necessary in my own practice as a novice therapist. I seem to get caught up in a dilemma between what feels right for the therapeutic relationship and what is possible in the practice of the NHS.

Physical space and confidentiality are the two aspects of the frame that most often lead me to question the ideal practice. Are they even achievable in today's age and modern practice? Time and time again I reflect on the discrepancies and contradictions between the ideal frame described in literature, and the stark reality when practicing in the modern working conditions of the NHS.

Reliable, consistent and unobtrusive

This concept of psychoanalytic origin was once considered to be the cornerstone of a strong therapeutic relationship, referring to a set of practical and symbolic boundaries that contain the therapeutic space and the process of therapy (Bass, 2007). A reliable, consistent and unobtrusive therapeutic environment symbolises the care we offer, allowing the client to internalise the therapist as a 'good enough mother' and instil trust in the therapeutic process (Winnicott, 1965).

It does feel like we have drifted quite far from the views of psychoanalyst Robert Langs. Langs advocated for a 'secure frame' to mean, amongst other things, total confidentiality, total privacy, predictability and consistency. With his somewhat rigid ideas of an ideal frame, Langs (1978) believed that these optimal conditions allowed for the unfolding of the transference phenomena, and that any adaptations to these rules would lead to 'frame deviation', resulting in the insufficient containing of the client's anxieties.

I often find myself questioning my own stance to 'the frame', and what feels necessary in my own practice as a novice therapist.

Echoing to the more recent past, some see all breaches of the frame to communicate untrustworthiness of the therapist (Warburton, 1999). The intrusions are seen to generate mistrust, regression and impairment of intimacy – inviting defensiveness into the therapeutic relationship that can hinder the movement towards insight and the potential for progress (Hoag, 1992).

In psychoanalytic and psychodynamic schools of thought, the frame was (and I guess still is) believed to provide the sense of maternal 'holding' – acting as a protective boundary of the therapeutic endeavour from external intrusions that might have a detrimental effect on the emerging transferential exchange.

Breaching the frame

This ideal of providing a room that is free of impingements can be problematic when working within the NHS, where the available rooms are often not suitable for purpose (Howard, 2012; Price & Paley, 2008). From personal experience, the rooms provided for therapists working as part of the NHS community mental health teams are often in buildings that have shared waiting areas, non-soundproof rooms, sometimes containing phones that ring, alarms going off and even at times intrusions from other professionals interrupting in search for an available room.

Recently, I was working with a client who found it difficult to admit they needed therapy. They had always been "the strong one", often implying that only their nearest and dearest knew about the sessions. One day the therapy session was in full flow when suddenly someone stuck their head around the door to ask if the room was free.

I was stunned into silence. A million thoughts ran through my head. "Really!?", "What is the client thinking?", "Do they feel exposed?", "Do they feel like I have let them down by not providing a secure space without intrusions?". I was also thinking about how I should react to what was unfolding. Do I follow the intruder and tell them how inappropriate their behaviour was – especially as the sign on the door said 'engaged'. Or, do I smile awkwardly and apologise profusely to the client?

I think I ended up doing all of the above. Thankfully, the client reassured me that they were OK. What has stayed with me though, was the feeling that somehow the session was contaminated and we had lost the secure frame.

More harmful than helpful

Gold and Cherry (1997) argued that adherence to the very strict rules of the frame invites maladaptive counter transferential reactions. These reactions are likely to be more harmful than helpful for the client and the outcome of the therapy. While recognising the importance of the frame, they argued that the fixed frame omits the uniqueness of individual clients – leaving them feeling controlled, misunderstood and potentially reinforcing unhelpful patterns relating to the past.

Gray (2014) also draws importance to attending to the needs of each individual client. She believes that what one person may experience as safe and containing, may be seen as cruel and uncompromising by another. Therefore, the frame should not force someone to follow strict rules but simply provide a safe space allowing for therapeutic endeavour.

Elsewhere, Cooper (2008) considered it important to maintain the naturalness of the therapist. Believing that the therapist remains authentic in responding to the client's needs, rather than simply adhering to the strict boundaries of the frame. It has even been suggested that the occasional breach of the frame is necessary to allow the client to learn to tolerate anxieties (Gray, 2014).

Absolute confidentiality

Adequate setting alone was described by Howard (2012) as the foundation for therapy, as without it the rest of the 'frame' would be challenged. Personally, I consider the physical setting (i.e., the room) and the absolute confidentiality to be the most important practical aspects of the frame.

The ideal of absolute confidentiality is believed to be redundant in today's UK society due to ethical and legal implications (Howard, 2017). As neatly summarised by Hudson-Allez (2004), the many statutory laws have eroded confidentiality ethics through the need to find the balance between confidentiality to the client's material, and the legal duty to disclose information in the interest of the public. This is especially evident in the Managed Care Services like the NHS, where the client's notes become the property of the service providing Trust (Bollas & Sundelson, 1995).

Working as part of a multidisciplinary team implicitly holds five people in the 'frame': the client and therapist but also their General Practitioner (GP), care coordinator and often the consultant psychiatrist.

Anything but absolute confidentiality by many is still believed to lead to alterations in the therapeutic relationship (Grey, 2014). Its importance is noted in the development of therapeutic boundary where the deepest layers of one's psyche can be discovered (Hudson-Allez, 2004).

For me, working as part of a multidisciplinary team implicitly holds five people in the 'frame': the client and therapist but also their General Practitioner (GP), care coordinator and often the consultant psychiatrist. The client's information is shared with the team of professionals, different parts of the service and their GP on a regular basis. Their notes are accessible electronically Trust wide. The clients, and their care needs, are discussed in supervision, group reflective practice, multidisciplinary team meetings and cross-agency working. While anonymity is practiced majority of the time, the client material is not treated with total confidentiality as advised by Langs (1982). As Bond (1992) highlighted the shift, the therapist's primary responsibility is seemingly now to the institution rather than to the client.

Consequences of inconsistency

McLoughlin (1995) argued that a lack of consistency in physical environment and the failure to apply the 'frame' can break the integrity of the 'container'. Lack of predictability in the physical setting has been evidenced to have an impact on both the therapists and the clients (Howard, 2012). The therapist is left to compensate for the inconsistencies of the environment by relying more on their internal resources.

The distractive and unsupportive NHS setting has even been reported to affect the therapist's ability to offer containment to their clients, resulting in doubting the integrity of one's own professional practice (Price & Paley, 2008). This can have a detrimental impact on the felt sense of safety for the client who is left feeling uncontained, destabilised and lacking the secure base (Howard, 2017).

Moreover, the inconsistent and unreliable setting can be experienced as a repetition of past experiences and lead to increased distress. McLoughlin stated: "without clearly defined container… there can be no therapeutic disclosure and no counselling relationship". Ultimately, the lack of a sense of safety provokes resistance in the client and their withdrawal from therapy completely (McLoughlin, 1995).

Moving on, this somewhat illusive promise of confidentiality hinders the therapy effectiveness from the start. People who are offered 'conditional' confidentiality might feel silenced through the fear of legalities and breaches to confidentiality (Hudson-Allez, 2004). Some clients might find it comforting to know that more professionals hold them in mind (Howard, 2017), yet for others, a breach of confidentiality can feel as a betrayal (Kahn, 1997) and destroy any potential for successful therapy (Warburton, 1999). Bollas (2001, as cited in Hudson-Allez, 2004) even advised therapists to admit to non-existence of confidentiality as he believes it no longer exists in the Western countries.

Compromise?

The evidence seems to indicate that the very core of the frame; the secure, consistent, containing space and complete or even sufficient confidentiality are further slipping into an illusion of the past, making the frame somewhat fractured. It is undoubtedly not always considered within NHS practice as much as the theoretical literature would like us.

Holding on to the therapist's professional Code of Ethics and Conduct (BPS, 2018) and its principles of integrity and respect, we need to be able to create the therapeutic space that respects the needs of the individual client in front of us. While limited in our choice, reminding the service developers of the importance of the containing space should help advocate for what we need to be able to provide evidence-based practice.

Furthermore, owning and naming the true nature of confidentiality and its limitations in NHS practice would help us communicate transparency and give people the informed choice to whether they want to engage in therapy that is perhaps less contained than it is idealised in the literature.

There are clearly aspects of the service delivery that have shifted over decades to meet the needs of the service more than the needs of the therapy clients. There are areas that are perhaps overlooked, but definitely under-practiced when it comes to applying the therapeutic frame in the NHS.

As therapists of the modern world, it is our job to figure out how to adjust the frame to the best we can while we remain limited by the constrains of modern ways of healthcare provision.

About the author

Ave Kotze - Counselling Psychology Doctorate student at UWE, undertaking placement as a Trainee Counselling Psychologist with Herefordshire and Worcestershire Health and Care NHS Trust

References

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British Psychological Society (2018). Code of Ethics and Conduct. Author.

Cooper, M. (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. Sage.

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Winnicott, D. W. (1965). The maturational process and the facilitating environment: Studies in the Theory of Emotional Development. The International Psycho-Analytical Library, 64, 1-276. The Hogarth Press and the Institute of Psycho-Analysis. http://doctorabedin.org/wp-content/uploads/2015/07/Donald-Winnicott-The-Maturational-Process-and-the-Facilitating-Environment-1965.pdf