Safety and a Flexible Frame

Early in my medical training I recognized that a large majority of patients sought medical help for behavioral (overeating, excess alcohol, lack of exercise) and other psychological (anxiety, depression, psychosomatic illness) problems. I gave up Family Practice in favor of Psychiatry, but early in psychiatric residency training I entertained the notion that accurate diagnosis and appropriate medication-- while perhaps dampening psychosis, vegetative symptoms, and autonomic responses-- may not fix a bad marriage, undo past trauma, or feed the soul. The rare psychoanalytic supervisor seemed to have a deeper grasp on the exigencies of being human. But what is so special about the psychoanalytically oriented psychotherapeutic relationship? why psychotherapy; why psychoanalytic training; what distinguishes therapy from a good friend or a loving family member?

In addition to an analytic attitude (Jan 3, 2011), psychoanalysis (and psychoanalytically oriented psychotherapy) allows the patient a freedom of self unlike any other relationship. It allows for the safe exploration of automatic ways of being with another. Together therapist and patient negotiate the frame, or rules, on which the two will come to rely, such as punctuality, alertness, and a readiness to be interested and self-reflective. When we as therapists fail to be punctual or alert or ready, we must open our failings to the patient for exploration. The frame includes the psychoanalytic attitude with its asymmetrical focus on what is in the best interest of the patient and with the safety of the patient’s psyche foremost. Safety is fostered when we do not judge or incredulously question in a way that humiliates; when we are attentive to changes in the patient’s (and our) self states, tone or prosody of speech, autonomic responses, or other indications that we may need to ‘slow down’.

Likewise our reliability, punctuality, earnestness in the experience, our listening, processing, and considering what we have seen, heard, felt, and experienced also facilitate safety. Maintaining the frame will, at times, help communicate safety. Sometimes the patient seeks to break the frame, not as resistance but as an attempt to reach us, particularly if we hide behind a role. At other times, the frame must be flexible enough to allow for negotiation, and for reenactments. Because psychoanalytic psychotherapy is a dialogue within a frame-- with a reciprocity of sorts-- and because it includes the multiple unconsciouses of both participants, both patient and therapist will emerge changed in some way.