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The Frame, Part 4 (Privacy)

Did you tell your own therapist everything?

Assume that you are thinking of doing something bad. It’s probably too hard to imagine that you are thinking seriously of shooting up an elementary school, but I will say that the public health problem is not just identifying and providing services to potential mass killers; it’s how to provide services that would actually induce a shooter to share his thoughts. Possibly you are considering embezzlement, marrying someone primarily for his or her money, or cheating on your taxes in a big way that could get you into real trouble but with great reward. You would benefit from the chance to reflect if you shared this with someone, but with whom? Your reputation with that person, and with anyone they told, could be damaged forever.

The same consideration applies to more normal troubles, like anxiety and depression. These problems are easy to divulge to a therapist, and your therapist prompts you for good examples. You report truthfully that you often experience intense anxiety when the phone rings. Now the therapist wants to know what goes through your mind when the phone starts ringing. You know perfectly well that the therapist’s question makes you think of your pregnant sister miscarrying, but you either think that this cannot be the problem—you love your sister—or you think that the therapist will be disgusted with you if you report this image. Instead, you make up something sensible but false about bad news you once got over the phone, wasting months of therapy on the wrong focus, but saving face. Again, the question is, what would the therapist and the therapy space have to be like to induce you to report what actually occurs to you?

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We develop one set of guidelines for producing honesty and authenticity in the abstract and quite another set when we are justifying and supporting our own specific therapists and parents, because out of for love or fear we want to make them feel good. The abstract set has much to recommend it, because it escapes this desire to make the therapist feel good. And you can double the effect when we are trying to make ourselves feel good about the therapies and childhoods we provide. This difference is why so many therapists, starting with Freud, agree that certain practices are desirable and then proceed to ignore them. So the question is, “What ought the frame to be?” and not, “How can I justify the frame I provide?” “What’s keeping me from living up to the highest standards of practice?” and not, “Oh, I don’t think there’s any harm in it.”

An important component of the therapeutic frame, known since 1915 or so, is privacy—what happens in therapy stays in therapy. You would be more likely to divulge your sordid plans or your embarrassing thoughts to someone you will never meet again, someone who doesn’t even know who you are. You would not then benefit from the relational acceptance offered by therapy, but you can see that the online chat room offers certain frame elements that can facilitate honesty. These used to be called confidentiality, but that term has been appropriated by legalisms so that nowadays, therapists think they are providing privacy if all the intrusions on privacy are either legally required or consented to.

As much as possible, the therapy relationship should be out of time, out of place—a special world of its own that intersects only obliquely with the rest of life. (The therapist must take steps not relevant here to facilitate transfer of learning to other situations.) The patient should have an ironclad sense that nothing leaves the room. The therapist undermines that sense by taking notes and promising to report threats and child abuse, even though these intrusions are legally required. The therapist further undermines privacy by mentioning other patients, by “taking a history,” and by giving advice. Anything that ties the therapy province to the rest of life (after the goals are established) reduces the patient’s willingness to take off the social mask and examine the psychology of the situation. Don’t even get me started on casual, status-enhancing or entertaining disclosures to the therapist’s friends and spouse.

But please don’t take my word for it. Instead, we need a method for determining which of the many things we do actually benefit the therapy and which don’t. We can’t rely on our instincts, because these will typically tell us what we want to hear. We can’t ask our patients, because they will (generally) tell us what we want to hear (or what feels good to them in the moment rather than what is good for the therapy). Instead, we can listen for what our moves and speech acts remind the patient of. If telling the patient about another patient reminds the patient of breaches in privacy or sibling rivalry, we should stop doing that; if it reminds the patient of good role models, we can keep doing that. This turns the rules of frame management into empirical questions rather than a competition among personal preferences. It also ensures that the focus is on the meaning of what the therapist does and not so much on whether it was right or wrong. Most patients are struggling with collisions between the way they were raised and the way things are, between their loyalty to schemas and their schemas’ poor utility. The cure is not to provide schemas that are correct; the cure is to provide schemas that are not arbitrary, self-serving, unquestioned, or unhealthy. The therapist furthers this cure by treating his or her own rules (the frame) as subject to change, not because the therapist feels uncomfortable about upholding them, but because the therapist is genuinely curious about the patient’s reaction to them.

All therapists should ask themselves if they told their own therapists everything, and if not, why not. All therapists, instead of imitating their own therapists, should try to rectify the frame elements that they know from personal experience put a damper on honesty and authenticity.

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

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