The Coherent Treatment Frame and the Role of Therapeutic Boundaries in Effective Psychiatric Treatment

The Coherent Treatment Frame and the Role of Therapeutic Boundaries in Effective Psychiatric Treatment

The “frame” of a social interaction was defined by Goffman (1974) as consisting of the spoken and unspoken expectations defining meaning and involvement in a given situation. For ex-ample, patients seek out psychiatrists based on a tacit assumption that the doctor is a reliable and experienced clinician who has the ability to assist them in finding relief for distress. However, many patients tend to frame their treatment in pathological ways. For example, some will attempt to pressure the psychiatrist into the role of a magical wizard who will confer unconditional love and pleasure. Whatever method the patient employs to frame the rela-tionship, any abrupt disappointment or rupture of these unspoken expectations often results in intense and disruptive feelings of mortification and betrayal. A sudden breach of a social frame can lead to the dissolution of one’s sense of meaning and connection, and is often accompanied by intense feelings of shame. By exam-ining verbal and behavioral responses following violations of the treatment frame, Langs (1984–1985) was able to document that patients usually perceive the offending therapist as an unreliable and mentally unstable person – someone seeking perverse pleas-ure at another person’s expense.

The psychiatrist’s task is to provide a coherent therapeutic frame within which to contain the patient’s illness. The psychia-trist’s frame makes it secure to proceed with the specific therapeu-tic modality, just as the surgical suite provides a safe environment for operative techniques. The treatment frame enables the patient to maintain a feeling of trust and connectedness while learning to deal with the unrealistic nature of his/her expectations. The frame comprises various boundary factors that include acting in a reliable way, showing respect for the patient’s autonomy by ex-plaining the potential risks and benefits of the treatment method, maintaining confidentiality, avoiding exploitation of the patient’s sexual feelings, and resisting the patient’s manipulative efforts by explaining the maladaptive nature of such behavior (Epstein, 1994; Simon, 1992).

Frank and Frank (1991) conducted an extensive review of the literature concerning psychotherapy outcome. They deter-mined that there were four basic factors common to all success-ful psychotherapies (see Table 5.4), and that treatment efficacy relied upon the ability of the therapist to form a structured, mutu-ally trusting, confidential and emotionally arousing relationship. Their findings sustain the argument that maintaining a coherent treatment frame is an essential part of all psychiatric treatment, regardless of the therapeutic paradigm being employed. These issues are important whether the patient is being treated solely with psychotropic medication management, cognitive–behavio-ral therapy, or psychoanalysis.