Feeling Our Way

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The Therapeutic Frame Part 2

A good frame is rigid.

After considering which implicit rules of conduct support taking off the social mask and authorizing the therapist to comment on the patient’s behavior (which I wrote about here), and after considering the essential task of therapy (welcoming the marginalized) here, I want to look at the reasons for having rigid ground rules in therapy that support these imperatives. I know that most therapists and some patients balk at the word, rigid, because it is the opposite of flexible, and they think flexibility is somehow inherently good. But rigid is also the opposite of weak, unreliable, and arbitrary. Ground rules in therapy are best applied rigidly, but warmly and with curiosity about their impact, to reduce the impact of caprice and superstition on the situation. For example, the only way to keep the patient from wondering why you end sessions when you do is to end them on time. Now sometimes, the ground rules are found to be unhelpful (but much less often than needy patients and delicate therapists would have us think); if so, they should be changed, not bent. If a patient can’t seem to discuss the rule, or seems likely to overreact to it, the therapist can discuss it before applying it (usually in the form of acknowledging that the therapist has been put in a lose-lose situation). Rigid application of rules also frees the therapist to be entirely curious about the patient’s experience; any possibility of breaking the rule is bound to distract the therapist with thoughts about whether to do so.

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Besides facilitating authenticity and integration of what’s marginalized, the frame of therapy is designed to enhance the client’s engrossment in the experience. After all, if the relationship with the therapist, lasting for only an hour or maybe two a week, is supposed to counterbalance all the problematic relationships in the client’s history, it had better be an important relationship. This needed importance is enhanced by engagement in the process. Tight frames can engross people in even trivial experiences, such as board games, quiz shows, and sporting events; when the matter at hand is the client’s most personal self, a tight frame can empower the therapy enormously.

Almost all psychologically-based pathology can be construed as a framing problem on the part of the patient. An obvious example of a framing problem would be to mistake an overheard play rehearsal for real life; you think a couple are having a fight, because you are using the wrong frame to contextualize what you are hearing. Hysterics tend to impose a sexual frame on nonsexual encounters, and some narcissists frame interactions as if they are between royalty and their subjects when most people would say they are between, say, restaurant patrons and wait-staff. We all develop framing devices from our exposure to different relationships in childhood. The therapist speaks (or refrains from speaking) as a therapist speaks to a patient (and not as a health care professional speaks to a client and not as one social being speaks to another), but the patient misconstrues the speech by framing it according to some familiar expectation. Only a therapeutic frame that highlights predictability and ambiguity can underline these framing errors and address them in real time; otherwise, the therapy just talks about the problem.

The frame of therapy can usefully be analogized to the ground rules in a movie theater. Sure, there may someday be a movie that benefits from starting late, but the vast majority of movies benefit from starting on time, so the audience knows what to expect and can get engrossed in it. The theater should be set up so as to enable audience members to see the screen; the speaker volume should be within a certain decibel range; cell phones should be turned off; the house lights should go down; the curtain should part; and so on. These ground rules enhance absorption in the movie, partly because they frame the movie tightly and partly because their implementation communicates that the management is competent and that the audience is in good hands.

No movie patron has ever left her seat at the beginning of a show and sought a manager to express gratitude for turning down the house lights or opening the curtain. Instead, patrons seek out management to complain about any deviation in the frame, because a deviation dominates the patron’s experience of the moment and interferes with engrossment. Similarly, therapy patients don’t sit there appreciating the fact that you designed your office so as not to intrude yourself unnecessarily into the space; instead, they wonder why you are wearing an outfit that calls attention to itself.

Because of what I call therapeutic privilege, it is very difficult for therapists to find out what patients make of frame deviations. Asking them is like asking students if they are annoyed at you for not knowing how to run the powerpoint projector. What are they going to say, knowing the power you have to define them as disturbed? It’s also like asking children if letting them stay up late is good for them. There are indeed ways to get this information, either by listening to metaphorical representations of the deviation or by establishing a textured and multifaceted dialogue around the patient’s reactions to the therapist. The point for now is that the ground rules of therapy did not develop from a theoretical hypothesis but from an understanding over the years and decades of which ground rules facilitate therapeutic progress. But these are just a starting point, and any particular therapist-patient dyad may develop different rules based on analysis of what works in their relationship. Still, all such analyses are suspect when the suggested rule change makes things easier or immediately more gratifying for either party.

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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