Engl. original article:
Correcting the Analytic Frame in Practice:
Comments on Clinical Material Involving Payment of the Fee*
(Copyright U. Berns, 2001)
Psychotherapeutic frame corrections are generally of utmost importance for the process and outcome of psychotherapy. Context-bound and derivative-related listening to the patient leads psychotherapists to an understanding of the optimal frame components. At the beginning of therapy, the therapist should offer these ideal frame components to the patient. Establishing these optimal basic frame conditions is not a prerequisite, but the subject of, and reason for, therapy. Regarding intervention technique of the management of the frame it is suggested, that the therapist should neither demand nor enact changes in the frame but should formulate interpretations on the firm basis of the derivative communications of patients and then should leave it to the patient to correct the frame or not. This intervention technique is exemplified with case material of a whole session concerning the frame component of the fee with the change from reimbursement to paying for oneself. Finally, some basic principles regarding frame interventions are summarized.
Human beings tend to regulate their ways of living together with the help of AN interpersonal frame. Laws, orders, and regulations, might also be called frame preconditions, - facts or -agreements. The social frame preconditions are a function of cultural development: Laws as frame preconditions are constantly amended, in certain social phases rapidly, slowly in others. Some frame specifications are particularly resistant to change; these are superordinate frame specifications, e.g. the famous specification of the constitution of the United States which says that all human beings are created equal has existed for more than 200 years.
The social area of psychotherapy has its frame, too. The various psychotherapeutic schools hold different frame components to be important. Even within the psychoanalytic schools there is no agreement as to which of the basic frame conditions are favorable for the patient. In particular, there is no agreement concerning the relevance of a frame for the psychoanalytic-psychotherapeutic process. At the same time, many psychoanalysts stress special frame components as condition sine qua non, for instance lying on the couch or, a certain number of sessions per week.
In my opinion, the psychoanalytic frame should offer the most favorable developmental conditions for the patient and I assume that every therapist would like to offer therapeutically helpful conditions to patients. But how can we know which of the frame components are favorable? How can we find out the specific frame components favorable for psychotherapy? What are the possibilities?
On the one hand, we can make use of on the experiences other analysts have made with certain frame components and whose suggestions seem plausible. Thus, for decades, the frame components that S. Freud recommended were accepted by psychoanalysts. Freud (1912) developed the psychoanalytic technique essentially on the basis of trial and error, rather than guided by theory (Fonagy, 1999). He acknowledged this when he wrote: “the technical rules which I am putting forward have been arrived at from my own experience in the course of many years, after unfortunate results had led me to abandon other methods” (1912, p. 111).
Another road was taken by R. Langs. He pointed out that the psychoanalytic method of free association can be used as an instrument to find out, with the help of patients, those frame components that are favourable for the psychotherapeutic process of healing. He clinically found out that patients
a) relatively constantly react to frame interventions of all kinds not only consciously but unconsciously, i.e., by communicating derivatives and
b) to his surprise, rather constantly point out derivatively which specific frame components are favorable for the healing process, and which are usually contrary to their conscious preferences of frame components. Thus, by the consistent application of the psychoanalytic method every therapist can find out which frame components are favorable frame offers, recommendations etc. for patients. Using the method of free association therapists can let themselves be guided by patients in their therapeutic efforts to arrive step by step at those frame components that are therapeutically most favorable. Therapists can use the patients' free associations, in order to find out, piece for piece, which frame components are favorable in general and also for a specific patient.
Considering the relevance of the frame in everyday life it is conceivable that the frame specifications, - recommendations, - expectations, -agreements and – management, might be a crucial part of any therapeutic management of relationships. Managing the frame becomes the crucial work of any psychotherapy.
Establishing a therapeutic frame does not, from this perspective, have to be done before, at the start of, or at the end of therapy. Rather, it is a task to be done in the course of the therapeutic process and is an essential part of the healing process.
Concerning the intervention technique the question is: how is the managing and – if necessary - the changing of the frame brought about in a way so that one of the most frequent reason for which patients leave communicative psychoanalytic therapy might be avoided?
One thing is clear from a communicative psychoanalytic perspective: As Langs (1976, 1982, 1988, 1995, 1996) has shown, for more than 25 years now, the indispensable prerequisite for the correction of the psychoanalytic frame is that the patient has given derivative hints to the therapist that the frame should be corrected. As David Smith (1991, p. 208) puts it: „The basic rule for the management of the frame in such situations is that the frame is to be structured according to the patients unconscious behest. If the patient unconsciously addresses a deviation and derivatively informs the therapist that this should be rectified, the therapist should interpret the material and, if possible, alter the frame accordingly“.
I assume, moreover, that the helpful frame management and correction crucially depends on the manner in which it is executed. In principle there are two different issues at stake:
1.Who, in fact, is able to correct the frame and
2. Who should do it, patient or therapist?
Bonac (2000, p. 20) comments: „The therapist‘s interventions which change the analytic frame from ‚broken‘ to ‚secure‘, which Langs calls the ‚management of the frame‘ can only be applied to the corrections of the therapist‘s own errors in technique - but no further. If one can create a situation in sessions where there is no coercion from outside of the patient, where the therapist neither demands nor enacts changes in the frame, when the patient is left free to follow the therapist‘s interpretations at his or her own pace and ability, only then is the patient left autonomous and unrestrained“.
I would like to expound how this correction can, as far as intervention technique is concerned, be carried out in such a way that it is of optimal benefit for the patient by giving a clinical example:
The female patient I will be talking about in the following material took it for granted from the outset that, as is usual in Germany, her therapy would be financed by her insurance. When I offered her, in her first session, the ideal frame components (e.g., regarding the fee, I told her, „My fee is xx Marks per session“), she insisted on claiming reimbursement from the health insurance company. At that time already she indicated derivatively to me, in the course of her free associations, that unconsciously she perceived my collaboration with any reimbursement as infantilization of her, nevertheless she was consciously completely decided to go on with the therapy only if I, too, was ready to support reimbursement. I did this, i.e. I wrote a report on the basis of which the patient was refunded the fee that she paid me for the first 80 sessions. I presented her with a bill every month.
Regarding the question of my remuneration of sessions for which she was absent, the situation was slightly different. I had indicated to her that the insurance does not refund vacant sessions. At the same time I pointed out that I was convinced that I was entitled to a fee for such sessions. That was all I said in this matter. The patient commented briefly on the manifest level with the remark that she found it unfair. I remember very distinctly that at the time I listened carefully trying to detect from her derivatives how she had perceived and processed this intervention unconsciously, but I found nothing in the material, which fitted thematically. In particular I did not find validation to this intervention.
For half a year the patient came to every session, but one day she cancelled a session. When, consequently, I did not give her any bill for this missed session, intensive work followed; on the basis of the patient‘s manifest feeling that she felt pressured, because she knew that I felt entitled to a fee. In her derivatives there were on the one hand images of inadequate dependency, childishness and claustrum, and on the other hand appropriate and important demands as they are made on children to clear up their rooms etc., because otherwise they will not become independent. Appropriate interpretations were unconsciously validated by the patient, yet the patient did not pay me for the vacant session. This did not occur until she had cancelled a second session some months later. After further interpretations during which I could take up her derivative images again, she also consciously accepted that I was entitled to a fee from her. She now gave me the money for both vacant sessions.
Generally, it has been my experience that these situations must be activated several times by relevant triggers and have to be worked through several times, before it becomes possible for patients to say consciously „yes“ to their own, derivatively expressed hints at correction as they are pointed out to them by interpretations. Also, it generally becomes possible for patients to detect consciously the harm they do to themselves, and to which they had pointed derivatively, only after repeated working through. I think, one should assume an integration of derivatively expressed, deeply unconscious wisdom, only if patients consciously affirm derivatively validated interpretations carrying out the frame correction on their own. Congruence of the conscious and deeply unconscious believes held before, is the result of validated interpretations. This may enable patients to make a behavior modification, i.e. frame correction, by themselves.
Except for interpretations, any other attempt to induce patients to frame corrections by suggestion or action, generally blocks the possibility of integrating consciously the unconscious process of analyzing and ascribing meaning. Furthermore, it can even lead to a rejection of the interpretation or to complying. Both reactions are not helpful to the patient and complicate the total situation tremendously.
Returning to the patient’s material: In the meantime the reimbursement for the first contingent of 80 sessions had run out and the patient took it for granted that I would support her request for further reimbursement once again. This time, the derivatives of how unhealthy this procedure would be were impressive and illuminating. I interpreted a connection between my former action of providing for her reimbursement which resulted in her expectation that I would support her once again and the symptoms which occurred: her material showed that the patient was again in a situation of substantial dependency on her father. In particular, I used her derivatives hinting at the necessary correction of this whole unhealthy situation. Nevertheless she was consciously determined not to continue the therapy if I did not support reimbursement by her insurance. I did what she requested and the therapy continued.
I wish to point once again to a very important principle of intervention-technique: every time this context is activated, the therapist has the function not simply to take up the patient’s manifest wishes not to pay the fee but to have an open mind to a revision of the far from ideal frame conditions and to adapt his or her intervention technique in this regard. If patients then give derivatives to correct the frame modification, the therapist should neither try to delegate the correction function to the patients nor to move patients to make the correction themselves. As these forms of interventions contain in themselves aggressive and penetrating implications, which put to lie the well meant correction of a frame, which, at this point, is anything but ideal. Such coercion can lead a patient to abort therapy, or as mentioned above, to comply, which is more frequently the case.
These implications do not arise if therapists restrict themselves to realizing what is their part in offering the ideal frame components. But in addition, boundaries are set in this regard, too, if one wants to prevent patients from aborting the therapy before they have had the opportunity to resolve their relevant unconscious conflicts regarding the matter in question.
The situation to be mastered concretely is as follows: After offering therapy I tell patients my expectation concerning fees. After that they usually ask, whether this is not covered by their insurance. I react to this by telling them I would like to listen to them, listen to what comes to their minds. After thinking it over on a manifest level patients sometimes give derivative hints at how to deal with the frame. I use these for interpretation. If I then get the impression patients would rather not go on with therapy if they should have to pay for it by themselves, I am ready to play my part in making reimbursement possible, perhaps temporarily.
One restriction must, however, be made here: I think it is possible for patients to perceive unconsciously and/or consciously that I am basically not ready to do therapy without a fee. Patients may thus unconsciously perceive that I am not ready to leave the frame correction totally up to them, inasmuch as I am not ready to take the full risk of eventually not being paid by them at all. In my experience this applies only to the financing of the therapy as a whole, and not to the question of single vacant sessions. Here patients are generally able to bear the consciously felt pressure, as soon as I let them know that I am entitled to a remuneration fee, but I do nothing further at the time to urge them to pay me, as I am ready to take the risk not to be paid.
To me, this seems indeed essential and it brings into play the new technique for carrying out intervention tasks. As Bonac (2000) said in her article, I also think it is not the analyst‘s task to carry out frame corrections except regarding his or her own errors. Rather I think it is the therapist‘s task to safeguard the frame and to offer patients consistently those frame components which patients themselves, unconsciously wise, consider to be healthy for them and by that helping them to optimize the frame themselves.
Excursus on counter-transference
How can the analyst achieve this, how can he safeguard the frame in the above mentioned sense? Just like the patient, the analyst is a human being with conscious and unconscious attitudes. It is crucial for analysts to have methods at their disposal allowing them to see whether their own practiced attitudes are contaminated with their own unconscious attitudes which counter their conscious intentions. In principle there are two methods regarding this issue:
1. The analyst could put his own derivatives to good use, i.e. he or she could admit them to come up in her or his mind, pay attention to them and decode them in a context-related manner.
2. She or he could analyze and evaluate the implications of their own interventions. Let me turn to the first point: Context-related decoding of one‘s own derivative reactions is the communicative counterpart to what is usually called counter transference analysis. Here I would like to make a short remark regarding the concept of counter transference. This concept is at present in a quite open status. On the one hand Bions’ remarks still apply, that "one of the essential points about counter-transference is that it is unconscious. People talk about making use of their counter-transference; they cannot make any use of it because they don‘t know what it is. There is such a thing as my emotional reaction to the patient; I can hope that through my awareness of the fact that I have human characteristics like prejudice and bigotry, I may be more tolerant and allow the patient to feel if my interpretation is or is not correct." On the other hand, it is today quite common to understand each feeling and each fantasy as counter transference reaction without submitting it to a further evaluation process. Merten (2001) has shown that what psychoanalysts said they felt in a special therapeutic situation did not significantly correlate with their emotions expressed by their facial expressions. This shows that it is at least very difficult to get adequate knowledge even concerning the meaning of such manifest experiences. Further, Merten (2001) found out that the feelings of therapists predominantly had the function to regulate the relationship with the patient, which makes it even more difficult to use their feelings as a reliable diagnostic instrument regarding the patient. The analyst‘s feelings have a predominantly final-functional aspect and are less clearly indicative of the therapist‘s internal affective state. The latter is readily regarded as relevant by therapists, possibly because the final-functional aspect is not so easily noticed. Hence, it will be still more difficult to use one‘s own feelings as a diagnostic instrument to assess the patient‘s emotional status reliably. Let me remark here that a significant correspondence between the feelings of both therapist and patient often correlates with negative therapeutic outcome.
One possibility for communicative psychoanalysts to grasp some of the unconscious aspects of their own counter transference could consist in trying to decode their own derivative reactions to the information coming from the patient. Psychoanalysts could try to decode their derivatives context-bound in order to get access to their unconscious reactions in this way i.e. counter-transference proper in Bion‘s sense of that term. This, however, is very difficult during therapy sessions; I can only state that I for one am not able to decode possible derivative reactions during therapy sessions, and consequently I am not able to use this possibility for grasping some of the unconscious aspects of patients‘ experiences.
The second point: Context-bound psychoanalysis has found a further important method of providing access to one‘s own counter-transference reactions. This consists in analyzing the implications of the therapist‘s interventions. There are two ways to achieve this.
1. The direct method by evaluating the implications of an intervention, and
2. The indirect method: Robert Langs has submitted abundant clinical evidence, proving that it is especially the implications of our interventions that are veridically and unconsciously perceived and expressed derivatively by patients and only then unconsciously processed further. Helmut Thomae (1996, p. 239) might have something similar in mind when he writes, "from a psychoanalytic point of view ... subliminal effective stimuli are of special interest".
By decoding the patient’s narratives in the light of the emotional relevant implications of our interventions, the important part of our counter-transference reactions that we put unconsciously into our interventions, can therefore at least be grasped. If the insight gained from this direct and indirect methods fit, it is indeed highly probable that we have - at least a posteriori - understood a part of our own counter-transference reactions.
However, by this procedure counter-transference reactions will not become automatically a diagnostic instrument of the psychoanalyst concerning the patient's emotional condition. A further differentiation, as to whether the reaction is more a reflection of the patient's condition or rather the therapist‘s madness, is not possible with this method. After all our total dependency on conscious fantasies and emotions stemming from the first system of the mind no longer exists. In view of the above mentioned research results by Merten (2001), i.e. their finding that manifest emotional reactions are not reliable, it is a relevant finding.
Examples formulating frame-executing versus frame-safeguarding interventions concerning vacant sessions
Let me now return to the issue of frame correction concerning the fee. Here are some examples of specific interventions to give you an indication of the different implications of all these interventions.
If the therapist regards it as his or her task to correct the frame of the vacant session or to move the patient to correct the frame, then he or she might be inclined to say, for example:
• You owe me the fee for...
• please, give me the fee...
• You still have to pay for the cancelled session.
• It is placed in your responsibility...
• I expect you to give me the fee for the cancelled session.
• I see you as responsible for the remuneration of cancelled sessions.
• Or as an acted intervention to give or to send a patient a bill
The implications of all these confronting interventions, in which interpersonal pressure is exerted and projective-identifications are made, are aggressiveness, encroachment, forcing the other, etc.
However, if the therapist does not regard it her or his task to correct the frame, but rather to leave this to the patient and believes in her or his task just to clear up his position in this affair, he might be inclined to say, for example:
• In my opinion I am entitled to the fee of those sessions you cancelled.
• I am convinced that I am entitled to a fee for the session you did not turn up for.
• I am convinced that I am entitled to a fee because I was ready for the session.
• I find that it is not my job to bear the costs for sessions, which I did not cancel.
• I do not want to bear the cost of the fee for this session.
Presentation of the 166th and 167th session with the above mentioned patient
Let me now present the 166th and 167th session with the above-mentioned patient in condensed form:
After about 2 years of analysis, toward the end of the 166. Session, the above mentioned female patient said her health insurance company had sent her the forms to apply for further reimbursement and so she now brought them along. She asked me then, how that was to be handled now. I felt a slight pressure to handle the affair on a manifest level, i.e. to accept the forms and to tell her I would write the report. I said I first would like to go on listening to her and then see whether an answer as to how it should be handled would result from it.
comment: This is the situation specified above, in which the patient tries consciously to go on with therapy within a not ideal frame. It is up to the therapist to live to his commitment for healthy frame correction efforts once again.
I would have liked to take the emotionally easiest way for me with the patient, instead of considering the emotionally strenuous frame correction, as it was possibly hinted at derivatively by the patient again. Neither did I know whether this time she would find a way to integrate conscious and unconscious convictions. I decided to try to be open minded.
The patient then said then that the evening of the day before yesterday had just come to her mind. That evening she had visited a friend, who played in a band, and who said he would like to drive her home afterwards. She was pleased about it and wanted to buy him two drinks, and did so. As it was the end of the session, taking leave she said, "Would you like to take the forms?" and reached into her bag to take them out. I felt now a much stronger pressure to act, i.e. to take the forms. Impulsively I wanted to take them, resulting from a feeling like: "Okay, I take them, write the report and have my peace. I am not in the mood to stand that, to stand up to you." But then I thought it over and said: "I would like to wait and see what will come up." I managed not to stretch out my hand to take the forms.
The 167th session that followed is presented here complete:
After the patient lied down on the couch she kept silent for a short time, which gave me the time to adapt to her presence.
Patient (1): "This week I dreamed three times "
(I know, on the one hand this is a lot, on the other hand I know from experience that when she has something important to process, she may dream a lot; so I am prepared for hard work).
"In the first dream I saw - well I was there but had nothing to do with it - how someone was not able to decide in favour of two people, or was it two things? I do not know that for sure. Perhaps it was a woman in favour of one man or another? No, it was a woman. This was really horrible for her, real anguish; she had to suffer so much. I saw it and yet I was not really involved. This was at the beginning of the week.
Two nights later I dreamt that I let a homosexual couple have my flat. They wanted to have it for themselves. At first I did not object to it, but the more I felt ready to do it the harder it seemed to me. It turned out later that they wanted to have the flat until noon on Sunday. That, I felt, was really terrible. I knew I would have had to go back to my parents for that time. Really terrible. I don't now how it ended.
The third dream, this time I was together with my friend. - It was the first time since we have been so neutral to one another. And then I told her some very intimate sexual matters. I felt it was so very wrong that ..., I felt so awful about it, I should not have said these things, especially as there was someone else there. But I must say I do not know who it was."
Patient is silent for some time. She says she has nothing to add to these dreams. She does not know what to do with the dreams, has no ideas about them. All her dreams are very strange to her. She is silent again.
After some time she says: "The end of the last session is on my mind now. During the last week I felt strange when I remembered this session. I wish the whole money and the insurance thing was behind me."
(I think: so you feel just like I did at the end of the last session, when I wished the whole thing with the forms and money and all, was behind me; if I had taken the forms and so on.)
Patient is silent again. 20 minutes have passed.
Therapist (1): "The uncomfortable end of the last session still bothers you. You offered me the forms and I did not accept them. You would like to have the whole matter over and done with. Two issues might be connected with it: you have an agreement with your insurance. It regulates the conditions, which have to be met, in order to get the fee repaid.
The other issue might be what it means to you that once again I did not spontaneously accept the forms. Perhaps you expressed what this means to you in your dreams. In the first dream you realize that a woman has to decide in favour of two people or two things and that was tormenting for her. This was a really anguishing thought. I did not accept the forms and in turn you might have experienced during last week the same kind of anguish having to decide to whether to take money from your insurance or not, which could make you feel as if you had to decide in favour of me or against me. It‘s been a really tormenting situation to you.
The second dream is about whether you should let your flat to a homosexual couple for such a long time, which would mean having to live with your parents again. You experience this as rather bad. You might express the following: if I turn to your insurance by not accepting the fee directly from you - and this is still possible - you might feel abandoned, thinking I wasn't sexually interested in you and preferring to be together with a homosexual. This could drive you back to your parents. To you it could mean you are not mature enough to live without your parents.
In the third dream you might have picked up another thread: you tell your friend something, which is much too intimate and even overheard by a total stranger. You are ashamed and it is embarrassing, perhaps as embarrassing as it might be to you if I told an expert of the insurance company your most intimate matters."
I will restrict my comments to the theme of frame corrections, although there is certainly a lot to be said concerning my interventions from other points of view. I was not absolutely sure I understood the patient's most urgent issues. It is, for instance, my impression that I was hardly able to grasp the derivative meaning of the dream of the homosexual couple. However incomplete my understanding might have been, I would like to point out now that I took up the patient's derivative hints of her need for a frame correction without any demand on her. I would have openly contradicted the principles I clinically consider to be valid, by taking the derivatives and tell the patient that the frame should be corrected and that I no longer should and will take the forms. At that time I was still ready to take the forms and fill them in as I had done twice before, or leave it to the patient herself to correct the frame accordingly.
"On Sunday a friend called me and asked me to have dinner with him. I did something, which took me by surprise. I said 'no', because I suddenly thought, he is just looking for someone to be with to kill the time. Until now I have always said 'yes'. I pushed this to the limit and said I would have time next Sunday. I just wanted to know if he really wanted to be with me or if he was just calling up everybody he knows and in the end got stuck with me. He must have realized something. But he said 'okay, next Sunday'. I did something else. Until now I have always paid for him, since I knew that he is short of money. This time I at once told him on the phone - and I did it very well - that each should pay for themselves. I wouldn‘t have dreamt of that before. It feels so good. Really good. Like - I thought - one might and should feel at my age, quite secure and independent and important."
The patient became silent and so was I.
"Last week at breakfast break I came into our common rooms. There my former friend was sitting in that part of the room which signals that you are prepared to meet other people, where one signals ‚I would like you to take a seat near me‘. In the end I went to my own seat where I am able to work. But I really got the impression she was ready to contact me. But I knew for certain it was better not to take a seat beside her. After all it’s really up to her to take the first new and correct step."
"What you said just now might reflect your attitude and your feelings regarding the fee: all of a sudden you liked to find out, if this guy was really interested in you. If he is really interested, then you are not just someone for him to kill the time. Also, you felt so good insisting on his paying for himself instead of paying for him just because he earns less money than you. To your surprise he was ready to pay for himself. Now you are looking forward to that dinner, as you feel independent and secure, since for the first time you dared to ask for equality in your relationship with this friend of yours.
Perhaps you are saying something similar regarding you and me and the fee: our dinner, too, should be better balanced regarding the fee. You might have expressed something like: if each of us is responsible for ourselves each of us might feel good. It seems possible that you express by this an underlying conviction regarding the issue of fees: if I am paid by the insurance you could feel like the friend you paid for all the time, if it was you who paid me you might feel as good as when you dared to take responsibility for yourself. At the same time you are interested in my being paid by the insurance company, since you offered me the forms to be filled in."
Obviously there are some unclarities concerning my intervention. While listening I realized that there were the themes in her free associations, which I found in the implications of my intervention of filling in the forms. Nevertheless I was not able to remove the unclarities in my understanding. I said to myself, silently: "You better tell her what you do understand even if you are mistaken, than to keep silent, since the patient – in her unconscious wisdom - might be able to draw something good out this partially incorrect interpretation. So I did my best.
Reacting to my intervention (1) she tells two narratives, reflecting important personal developments. It is doubtful whether the narrative of the man on the phone can be evaluated as an upcoming positive introject, since this man turned into a positive image only after she herself had made progress concerning her ability to structure their relationship for the better. Anyhow, I understood this as another hint that the frame should be corrected. I restricted myself to pointing this out. I even mentioned both her convictions: her conscious one, according to which she does not want to be responsible for paying the fee and an unconscious one, expressed in the derivatives, suggesting the very opposite. As I have said, I restricted myself to pointing at it, and did not suggest any course of action.
It seems important to me that patients find a way to integrate conscious an unconscious convictions and I take the coexistence of contradicting conscious and unconscious convictions as a sign of lack of integration. I trust in patients to change the frame to its ideal state or at least for the better once they have found integration. Regardless of whether this is a correct supposition, i.e. my trust in the patient; it might be of great importance. As long as such contradictory beliefs persist, any frame correction proposals on part of the therapist perhaps will probably not be put to good use by the patient.
Back to the patient once again:
I did not use the narrative of her former friend in my intervention because at that time I was sure that my understanding of it was deficient. Only after the session did I have the idea that she could have told me derivatively that the frame correction really should be done by the one who had deviated from it. And as it was her who had not accepted my ideal offer concerning the fee at the beginning of the therapy, it was evidently up to her to take the first step at correcting this. The other person, in this case it was me, simply will have to wait until the person responsible for this, and in this case it was her, takes the first step on her own initiative.
For four months now I have had to lead a group of girls. Okay, I said, I'm going to take one of the groups and my colleague will take the other. She did that and she did her job, but I dragged on with it. I don’t know, why I didn’t deal with it properly. This week, well, I have really had a good week, this week I have done it. I called up all the places and discussed the issue with them. It went off quite smoothly, as if by itself. Now, that I have done it, I have a feeling for what else can and should be done. I wonder how this will go on.
- Silence -
After the last session, when I came home, I felt uneasy. Well, I had not carefully read the letter of the insurance company. I had just taken a glimpse at it, shortly before the last session. Then I put it in my handbag and I somehow thought I would just give it to you. Back home I read it carefully and then it seemed quite clear to me: on the one hand they say I should hand in another application, on the other hand they wrote they will not repay for more than 160 sessions (in fact, they do repay for a maximum of 300 sessions). I checked this; I have already had more than 160 sessions. They don’t know what they mean. It reminded me that I still see my father in all-important financial matters. That‘s strange.
You seem to say that things will only work, if you take your own affairs seriously, if you really take charge of the things you have agreed to carry out. This might be the case with your therapy and the fee. Otherwise it will remain as puzzling as that thing with your father.
I wanted to go on carefully, I did not want to take the first step. For instance, I did not want to say: "... and your therapy perhaps will not be your own therapy unless you yourself take over responsibility in financial matters, too, like you took over responsibility with the group of girls only after four months, during which you let it drag on. You seem to be saying, if you carry on like this, you will really stay dependent on your father, and this seems to be no good to you.“ And of course, I did not want to say: „So it would be good, that from now on you pay me directly and I should no longer should give you a bill for your insurance."
Regarding the other girls, (not the group just mentioned) it is my turn now. We have a pretty good relation, but then I thought I would like to go to the opera with them. But I know girls of that age don’t like to go to the opera and I didn’t want to push them. Then, one day there was a favorable occasion to suggest it to them. And you won’t believe it: they really liked the idea! And I was so afraid to press them; I don’t like to be pressed, either. But sometimes I am like that myself.
She seems unconsciously to have perceived my carefulness or caution or anxiousness. Yes, she even seems to know unconsciously why I am so reserved concerning my interventions: What she is saying corresponds to my cautious anxiousness: I might be inclined to pressing her. Therefore I might have been especially cautious and reserved, more than was probably necessary.
Up to now, the mode of payment is still open. This could be on your mind. A suggestion would be okay, but without any pressure.
I believe, now I am one of the girls. It has just turned around.
(The patient is silent for 5-7 minutes.)
I see clearly now. I feel so..., I am clear about it. It is really surprising. I feel good, and I want to pay you. Yes, that’s it. (She says something more in this astonished, almost amazed manner).
Okay, then you and I are going to handle it in this manner.
(The session ends.)
During the session I got the impression that the patient was on the verge of correcting the frame. Therefore as the end of the session drew near I was worried about running out of time. This was the reason that intervention (4) was difficult for me. It was difficult to stay close to the material of the patient and NOT to say to her: "If I don‘t tell you how to handle this fee issue, you might perceive me just as inadequately anxious as you felt towards those girls. Therefore I propose you should pay me directly in the future."
Yet I trusted her to find the best solution i.e. the ideal frame, in good time, either right now in this session or perhaps in one of the next sessions. This trust in her and the firm conviction that genuine autonomy in this case will be lived out only if the frame correction is done by the patient herself was the reason for my ability to be patient.
It’s been a long way for over 167 sessions with repeated working-through of deep unconscious separation-anxiety and separation-guilt. These feelings could be worked through particularly at times when the patient applied for my payment by the insurance company and in those sessions when vacant sessions were at stake.
Some basic principles concerning frame-safeguarding interventions
1. At the beginning of a therapy the therapist offers those frame components, which, due to his experiences, he considers optimal. Psychoanalysts working communicatively will take these from their practice, which is always context-related, and they pay attention to derivatives.
2. It might well be the case that patients do not consciously accept some components, in spite of their identifying them derivatively as desirable. This may be taken as one indicator of the suitability of therapy.
3. Establishing the optimal basic frame conditions is not a prerequisite, but the subject of, and reason for, therapy. This does not apply to components that can‘t be rectified, e.g. familiarity between patient and therapist.
4. Whenever an adaptive context is activated, there is the possibility of offering again the optimal basic frame condition in question.
5. Listening to derivatives leads analysts to an understanding of the optimal frame components. They commit themselves to these optimal frame components. This self-obligation is to be strictly separated from the patient‘s obligation to these frame components on part of the therapist.
6. If patients act against this self-obligation of analysts and if analysts remain faithful to their self-obligation, which rules out any obligation to patients, patients will be in a position to realize the analysts‘ esteem for their unconscious wisdom.
7. I differ from Bonac (1999) and consider this as transference, too, as it fulfils the following criteria: Patients express their unconscious wisdom. They act contrary to this unconscious wisdom, although the therapist does not put any disrespectful pressure on them. Therefore their manifest action is determined by their deep unconscious anxiety, guilt and / or shame affects, i.e. by their deep unconscious pathogenic beliefs. These are the consequences of the internalization of aspects of the relevant relational figures, which in childhood did not respect the child's personality.
8. If patients stick to the frame modification, and analysts accept this modification this means in effect that analysts act contrary to their attitude.
9. To the therapist this basic attitude means getting into a state of tension, which results from his self-obligation concerning the patient‘s unconscious wisdom and his taking part in the modification of the frame. This state of tension remains until the patient rectifies the frame, thus possibly up to the end of therapy.
10. Analysts who are exclusively self-obliged safeguard the frame but do not forcibly execute the frame. Taking over the part of safeguards in this sense they offer patients the chance - by way of interpreting the context-related derivatives - to understand their enactments, to resolve their conflicts and also to correct the frame on their own.
11. A transference-reaction in Bonac‘s (1999) sense** does not always occur after patients corrected the frame by themselves after a validated interpretation. Generally this reaction may not be observable if therapists function as safeguards and not in any way as executers of the frame. By that patients might get the opportunity several times to work through their deep unconscious pathogenic believes. It might be interesting to find out, if transference-reactions in Bonac's sense and in the way I just described it, exclude each other, or if they might occur consecutively.
Bion W (1980 ) Bion in New York und Sao Paulo. The Roland Harris Trust Library, Nr. 10, Clunie Press Pertshire
Bonac, V.A. (1999) Perception or Transference? A New Clinical Theory of Transference. The International Journal of Communicative Psychoanalysis & Psychtherapy, Vol. 11, Nos. 3-4 (Reprinted from Electronic Journal of Communicative Psychoanalysis, 1998,Vol. 1)
Bonac, V.A. (2000) Communicative Psychoanalysis with Children. Whurr Publishers, London
Fonagy, p. (1999) The relationship of theory and practice in psychodynamic therapy. Journal of Clinical Child Psychology, Vo. 28. No 4, 513-520
Freud, S. (1912) Recommendations to physicians practicing psychoanalysis. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 109-120). London: Hogarth Press
Langs, R. (1976) The Bipersonal Field. New York: Jason Aronson.
Langs, R. (1982) Psychotherapy: A Basic Text, New York: Jason Aronson
Langs, R. (1988) A Primer of Psychotherapy. New York: Gardner Press
Langs, R. (1995) Clinical Practice and the Architecture of the Mind. Karnac Books, London
Langs, R. (1996) The Evolution of the Emotion-Processing Mind. International Universities Press
Merten, J. (2001) Beziehungsregulation in Psychotherapien. Maladaptive Beziehungsmuster und der therapeutische Prozess. Kohlhammer, Stuttgart
Smith, D.L. (1991) Hidden Conversations. An Introduction to Communicative Psychoanalysis. Tavistock/Routledge, London and New York
*A version of this paper first appeared as oral presentation at London the conference of the European Society of Communicative Psychotherapy, April 2001.
**Bonac (1999, p. 54) defines transference as follows: „Transference proper is an intra-psychic phenomenon which becomes observable in the bi-personal field of therapy as a response to the patient‘s own intent to secure the analytic frame in the absence of pathological contributions from interpersonal sources, all this within the context of the therapist‘s constant offer of an ideal analytic frame“.
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