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Setting the Frame and Establishing Boundaries
Abstract
Setting the frame is essential to any type of psychotherapy, it establishes boundaries and sets up a safe relationship in which patient and therapist can work. The frame of psychotherapy includes: role, time, setting, money, contact information, what to do in the event of an emergency, confidentiality and issues relating to traineeship. A role is a part or function that we play in a particular situation. To set up a psychotherapeutic situation, we set aside a specific, consistent period of time during which our attention is focused exclusively on the patient. There are three major reasons why patients might need to contact the therapist outside of session time: emergencies, the need to cancel or reschedule a session and to request medication refills. A boundary is defined as the edge of appropriate behavior. Boundary "crossing" is a benign deviation from the frame that may advance the treatment and does not harm the patient.
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Effective psychotherapy builds on a strong foundation developing as early as the first session. The aim of this review is to identify clinical research related to nonspecific (i.e., common factors) treatment effects and to expand upon those findings in developing techniques for applied clinical practice. Clinicians across treatment modalities can implement these techniques that are informed by empirical evidence in an effort to develop a collaborative treatment relationship with new patients. Three therapeutic principles identified in this review are: fostering positive expectancies, role preparation, and collaborative goal formation. Research related to these factors is reviewed as are suggestions for implementing them into applied clinical practice during early treatment interventions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In simple, jargon-free language, Herbert Schlesinger sets out to demystify technique, to show how it is based on basic principles that are applicable both to psychoanalysis and to the psychotherapies that derive from it. He has little need for conventional theory; rather, he reframes essential analytic notions - transference, resistance, interpretation, regression, empathy - as processes and assigns technique the goal of promoting the patient’s activity within the treatment situation. The aim of the analytic therapist is to restore to the patient active control of his own life.
The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct. These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context. Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management.
The author argues that the use of clinical material for educational purposes or for publication presents the analyst with a conflict of interest between the protection of the patient's privacy and the educational and scientific needs of the field, and also that it places analysts in the position of using confidential patient material in the service of their own professional advancement. The strategies of dealing with this dilemma can be classified as follows: (1) thick disguise, (2) patient consent, (3) the process approach, (4) the use of composites and (5) the use of a colleague as author. Some of these options may, of course, be used in combination with one another. All of these methods have a place, and the author argues against a uniform approach. Each of these strategies is discussed in terms of its advantages and disadvantages. While no choice is without various risks, some guidelines are offered to assist analysts who wish to present or write about clinical cases.
The September 11, 2001, terrorist attack on the World Trade Center profoundly affected the population of New York City, including analysts and analysands. To study the effect of this event on the technique of psychoanalysts conducting ongoing analysis during the weeks after 9/11, confidential questionnaires were sent to all candidates and faculty at the Columbia University Center for Psychoanalytic Training and Research. Respondents indicated that in the days and weeks following 9/11 they initiated phone calls to their analysands, asked about their analysands' families, gave advice when it was requested, offered reassurance, and answered personal questions. They did not initiate physical contact, discontinue use of the couch, or give unsolicited advice. These responses suggest that these analysts made decisions to alter their technique in certain ways in the wake of a catastrophic event shared by the community.
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