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Debate The frame is the therapy In response to last month’s article by Nick Totton, ‘Boundaries and boundlessness’, Toby Ingham argues that well-observed boundaries are the life-blood of therapy I found Nick Totton’s article on boundaries in psychotherapy (‘Boundaries and boundlessness’, Therapy Today, October 2010) rather unhelpful. I think it might serve to confuse readers and I would like to offer a reply. Totton’s idea that the ‘therapy police’ are ‘installed in practitioners through an insufficiently examined notion of boundaries’ is a questionable statement that deserves consideration. To my mind one of the key aims of training is to enable the practitioner to internalise their own subjective understanding of the psychotherapy and counselling frame. That is, to develop a sense of one’s own therapeutic identity and an understanding of what the frame means to each of us. It is less about thinking we should behave in line with what is expected of us by an external authority or regulator (be that BACP, UKCP, BPC or HPC), and more about how we are able to internalise and develop our own sense of authority based around our assimilation of ethical codes. To my mind training should enable us to fundamentally address and examine our notions of boundaries. This should not be an insufficiently examined area in our trainings. The facts of the frame The idea that psychotherapy boundaries are in place particularly to protect the client from sexual abuse is far too reductive. Of course psychotherapy clients should be protected from sexual and ethical violations, but in my view such protection is more likely to be provided if the therapist’s training has specifically focussed on the importance of being able to work within boundaries. I think Totton’s article confuses (a) the capacity to adapt to the uniqueness of each client, with (b) boundary violation. Adaptation is essential, but so are boundaries. The idea that such boundaries are in place to meet a defensive need in the therapist is, I think again, overly reductive. Observing boundaries is a much more involved business than should be summed up as ‘risk management’. Furthermore, I think we have to be careful with notions like ‘authenticity’; whatever we think we mean by such words deserves careful clarification. The beauty of observing the facts of the frame is that it really can be observed. We can for instance be clear about whether a session has overrun or not, in a way in which we cannot as regards what we mean by ‘authenticity’. I am entirely committed to maintaining appropriate boundaries in 26 Therapy Today/www.therapytoday.net/November 2010
my work. This is not because I am overly concerned by the fear of misconduct hearings but rather because in the course of my experience as a patient, a trainee and a therapist, I have come to the conclusion that well observed boundaries are the life-blood of therapy. It is all very well to get drawn into ideas from ordinary human relationships about common kindness, care, empathy and human warmth. But psychotherapy is not an ordinary relationship, it is an extraordinary relationship, and what preserves that is the psychotherapist’s ability to maintain boundaries. If we think of ordinary conditions of unhappiness that may lead an individual to seek our help, we might think of a client who approaches psychotherapy or counselling because they never had a reliable enough experience of care. A client, for example, whose mother or father always impinged too much on them in their early days. A parent who was agitated by their baby and instilled agitation into their child. Or a parent who was too knowing, persecuting, demanding, bullying and disturbing. Our attempts to practise a reliable, predictable frame are based on the idea that the therapist/patient (or client) relationship offers quite possibly the only opportunity an individual will ever have to work through these examples of psychic disturbance and to start again from scratch. Aside from notions of disturbances in the individual’s development, we might think of the client who comes to therapy because of failures in the frames of their current experience. Perhaps they are bereaved, divorced, have been made redundant; these again are cases where a predictable part of their experience has failed, undermining their confidence. Holding and containing You could argue that there are occasions where we should respond differently, where we should follow our hearts, where we should follow the ideas that spring from the unconscious. I think more is gained from being able to think at such moments about what it is in this relationship that provokes us to want to do this. What is making itself present at this moment? It is better that we are able to notice the spontaneous idea that emerges within us and be able to reflect on it. In time we develop the capacity to hold and contain such experiences for the client, and the art of feeding them into the therapy in careful ways. Psychotherapy and counselling, I believe, provide the place where the patient/client should get one thing as a given: the frame. In my analytic training, the principle of maintaining a consistent frame was key. I have come to the opinion that the thing that is most valuable about what we offer is a fixed frame. The frame is more important than making interpretations. In many ways the frame is the therapy. Some people might not like that; they might stop coming; they might find me too rigid and inflexible; but I put being a guardian of the frame above bending this way or that. I know I have limitations. In my experience people who object to the frame are often the ones who are most in need of the secure and consistent environment it offers. In my view we do our best work when, like the DIY commercial, we do exactly what it says on the tin: we are clear about times of sessions, fees, we signpost holidays clearly. To confuse psychotherapy with any other kind of human relationship is mistaken. We will always be met with very persuasive reasons for why we should deviate from this position. Our challenge is at those most difficult moments to find a way to keep the line, to reach deep into ourselves and be able to think about the impulse that is making itself felt. These are the moments when we might say for example, ‘Thank you for your offer of healing tea; I think you don’t like finding me ill and you want to make me better; I thank you for that. I won’t take the tea, but thank you.’ I think the terms Totton quotes, for example that Jodie Messler Davies was aware of becoming ‘mesmerised’, is revealing, and as the described scene plays out it seems Davies had no way of managing this experience other than to go along with it. In psychodynamic language we might think of this as something that was acted out. It was not an event whose symbolic dimensions could be thought about. I don’t think an ‘incredible interpretation’ was necessary at the point Jodie Messler Davies was offered the tea. I think all that was necessary was that the therapist maintained a frame, a practice of working within a fixed boundary. The case is described in a warm tone but I hold that doing things because they feel like a good idea is the first step on the path towards a more serious violation of the therapeutic position. Better to be able to reflect on the wish that is making itself present. I find the notion of ‘undefensive practice’ unhelpful; it is too vague; it contains too much opportunity to legitimise all sorts of actions. I think this is an example of acting out. When you train as a therapist you never know whether you will suit the training or vice versa. I was fortunate that my second training was with the Association of Independent Psychotherapists, an analytic training which is particularly focussed upon training therapists for the demands of private practice. The AIP training fundamentally understands the value of maintaining a frame. The idea that therapists are boundary ruled should be true, but this is less to do with the therapist being overly restricted in a wilful spirit of deprivation and more to do with an attempt to provide a predictable experience of care. By attending to boundaries in this way the client may develop confidence that we are prepared to reflect on all of their experience. By doing so we pave the way for them being able to do so themselves. DW Winnicott’s paper ‘The use of an object and relating through identifications’ (DW Winnicott, Playing and Reality, 1971) is salutary reading. Amongst other things, this elegant essay argues that a therapist should be able to maintain a predictable boundary despite the provocations deployed by the patient. Winnicott demonstrates that ultimately what the patient finds helpful and which thus leads to progression and a mutative encounter (the therapeutic relationship that Totton aims at) is that the patient comes to realise that the therapist has survived despite the patient’s attempts to undermine the therapy. This proves that the patient cannot be so bad. To Winnicott’s mind, this brings a new possibility of care and love to the therapeutic relationship and thus to the client’s life. The client gets the chance to start again from scratch. So as a rule of thumb I say refuse all healing beverages and stick resolutely to the frame. Put the frame first. This does not mean that there will not be occasions when a spontaneous thought, feeling or gesture will not join the therapy, but that we commit to reflecting on it when it does. It is being able to work to these principles that make us useful. Toby Ingham is a UKCP registered psychodynamic psychotherapist, counsellor and supervisor working in private practice in Beaconsfield, Buckinghamshire. He supervises on both the Association of Independent Psychotherapists and the Manor House Centre for Psychotherapy and Counselling trainings. He trained as a supervisor with the Society of Analytical Psychology. Email toby@tobyingham.com November 2010/www.therapytoday.net/Therapy Today 27
Page 1 and 2: Therapy Today November 2010, Vol. 2
Page 3 and 4: Contents Sarah Browne Editor For se
Page 5 and 6: Mental health groups praise governm
Page 7 and 8: In practice Words and labels Kevin
Page 9 and 10: In training Walking the line Alex E
Page 11 and 12: Increasingly, counsellors and psych
Page 13 and 14: defined as the assumption that diff
Page 15: Questionnaire Jeremy Clarke A natio
Page 18 and 19: Viewpoint References 1. Wampold BE.
Page 20: Training Becoming a counsellor Surp
Page 23 and 24: ‘Trainees were primarily concerne
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Page 29 and 30: November 2010/www.therapytoday.net/
Page 31 and 32: Dilemmas The counselling-coaching i
Page 33 and 34: Kate Cunnion (counsellor, superviso
Page 35 and 36: female client and was seeking suppo
Page 37 and 38: Reviews Evidence for the economic v
Page 39 and 40: Co-creating therapeutic conversatio
Page 41 and 42: News From the Chair How are develop
Page 43 and 44: Could you write an information shee
Page 45 and 46: Case Study Research in Counselling
Page 47 and 48: skills and attitudes as a tutor to

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