The Frame

It has been said that what takes place within a frame is symbolic. Whether a gilded frame surrounding canvas, the curtains on a stage, the beginning and ending credits at the movies, even between the bookends of a novel — the clear demarcation in space and time create a place/thing/event set apart from ordinary reality. Even representational photographs or documentaries make a choice about what to include and what to leave out. Allan Ginsburg said, "Notice what you notice." What we attend to narrows the experience to what we consider important.

What has this to do with psychotherapy? The frame in psychotherapy refers to the setting apart of space and time, the limiting of interactions, and the creation of what the Jungians refer to as the container. When we set the time, place, frequency and length of the meeting, determine who will be there, and what the fee will be, we are creating a symbolic space, separate from the rest of one's life.
There are complications with this, of course. When a therapist lives in a small community (or even in Berkeley!), s/he is likely to run into patients everywhere from the gym to the grocery store. A patient may see you at the farmers' market with your family, or covered in paint at the hardware store, or even at a mutual acquaintance's party.

If I know that I am likely to run into patients in the course of therapy, I speak of it early on, stating that if I am with others I most likely will not even acknowledge them in public (beyond a smile or nod of my head). I explain the reasons, and then when it happens, we discuss it.

My patients say it doesn't bother them. I don't buy it. Maybe sometimes a patient will be happy to see you have a life outside of the office, but more frequently it is a disruption and even a contamination, depending on the circumstances. My advice — frequently given — to new therapists: always analyze breaks in the frame. Bring it up, even in the beginning of a session. Dig deep, and if there is still nothing there, listen for derivatives (references in other topics that are representative of the transference material), especially in dreams.

Other breaks in the frame include vacations, fee changes and requests around the fee, missed and canceled appointments and the like. Other things that we often don't think about — referrals from a patient, requests to include a family member or partner in the session, our own self-disclosures — are frequently more complicated to unravel and understand.

I don't take referrals from current patients unless the connection is remote, say, the sister of an acquaintance. New therapists often wonder how they will build a practice if they don't take referrals from patients, but I have found that I am more likely to lose the patient I have than to gain a new one, if the referral is too close to the patient.

I try not to be too rigid. Once when a patient was diagnosed with breast cancer, she arrived for her appointment with her boyfriend with no advance notice. I was flustered, but knew enough to see them both together. I think if I hadn't, I would not have helped her fully share her need and her experience with her partner.

Another time, a woman I had been seeing for a couple of years requested that she be allowed to bring her daughter in for several sessions. This had been at the daughter's request, but the mother was all for it. Difficulty with the daughter had been the presenting problem, and in the course of treatment, she had gained awareness of how her envy of her daughter, and the lack of mothering she had herself received, contributed to the painfulness of the relationship. After discussing it for several sessions (and with doubt and trepidation), I agreed to see them together. What occurred in those joint sessions was transformative. She was able to repair old wounds by her willingness to share me, "her good mother", with her daughter. The therapy continued after the sessions with the daughter, but the bulk of the work had been done.

Next blog - frame vs. boundaries.