Therapy Today

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
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