Therapeutic Frame

Keeping the 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 as it did when I left my husband, 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.

Robert Langs, a psychoanalyst, has been the most vocal advocate of the very tight therapeutic frame. 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 kleenex is provided as that could be construed as gratifying the patient. It isn't being anal just to be anal 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.

According to Langs and his followers, the therapist's office is supposed to be in a neutral medical office type building. A bill is to be sent at the end of the month with a check sent in by the patient for the sessions covered by the bill. No physical contact at all with the patient, including a handshake. If the patient brings a gift, it is not accepted but remains unopened and the offer of it discussed for meaning. If the patient sends the therapist a letter, the envelope remains unopened and is there the next time the patient comes.

In the late 80's, Langs published a number of books illustrating his ideas about analysis. They are essentially transcripts of seminars and supervision sessions he conducted with psychiatric residents. This was how I first encountered his ideas.  I worked for three years with  a clinical supervisor who was supervised by Langs. He helped me to look in detail at all kinds of things like when the patient gives me the check and how we greet at the door.

All of these things can be useful but the rigidity doesn't work for me. Sometimes it is important for a patient to be able to give to the therapist. Thanks to the work in Langs approach, I know how to look at the gift giving and make sure it comes into the therapy and is understood.

When the patient comes in and says "I was thinking about the time I went to buy a car and the car dealer really cheated me", in the Langsian model, the therapist will hear this as a communication about the therapy, what we call a derivative. And will listen and collect the derivatives and then might say "I can hear that you are feeling cheated somehow in our work together and I wonder if you could tell me more about that." Also useful. But I am not convinced that *every* communication is about the therapy.

So the method is valuable to learn.

A brief word of caution -- Langs is not the easiest writer to read, but if you are interested in the process of therapy, the effort is worth it. He tends to same the same things in many of his books, though, so reading one or two of them will likely give you more than you need.

© Cheryl Fuller, 2018. All  rights reserved.