Teaching Tip Sheet: Flexible Therapeutic Frames
Important Issues or Topic in Psychology
Flexible therapeutic frames address the need to move along a continuum of roles and therapeutic styles in accordance with a client's changing circumstances. This approach to therapy is also known as "bending the frame" (Winiarski, 1993a). The setting of limits or therapeutic boundaries is a central issue in clinical and counseling psychology. Limit setting occurs primarily around the formal aspects of the patient-therapist interaction (Singer, 1970). The importance of boundaries can be traced to Freud's (1915) belief that cure and emotional well-being are the outcome of judiciously applied deprivations and frustrations. The lack of boundaries is believed to engender in patients terrifying feelings of omnipotence and paradoxically a disturbing sense of nothingness and nonexistence. Limiting the patient-therapist relationship strictly to the therapeutic setting is believed to promote purer transferences. Thus, therapists are admonished to avoid allowing patients see them in other settings and to reveal as little as possible about themselves to their patients. HIV/AIDS has forced psychologists not to limit themselves to traditional roles but, as necessity demands, to go beyond the ordinary limits and established boundaries. Psychologists have responded to the needs of their patients in roles that take them outside of the traditional setting with no harm done to the patient and often with extremely therapeutic results. In this way, HIV/AIDS has broadened counseling and clinical psychology's understanding of the practice of psychotherapy.
Lessons Learned from HIV/AIDS
The term "bending the frame" first appeared in Winiarski's (1993a) description of an integrated system of medical and mental health care for people living with HIV. The term was then appropriated by the American Psychological Association's AIDS training curriculum. In practice, bending the frame may include making home visits, counseling patients on spiritual issues, providing basic medical information such as the common side effects of HIV-drugs, and case management. Eversole (1997) writes that this requires:
Development of a large repertoire of skills and resources with which to serve clients. Provider roles now encompass a field of skills as diverse as advocacy, case management, and existential psychotherapy.
Deliberate, ethical, and theoretically sound selection of therapeutic responses to client needs. Bending the frame brings with it responsibilities. In practice, professionals must re-examine the legal and ethical aspects of their work, their real and therapeutic relationships, and the sources of personal authority from which they practice.
HIV/AIDS also has challenged the established construct of the therapeutic frame by requiring psychologists to examine the nature of multiple therapeutic relationships. The role of a psychologist providing care to someone living with HIV may often come in conflict with a narrowly defined notion of limited client-counselor interaction. In his discussion of multiple relationships in working with people living with HIV, Kain (1997) writes that because the HIV/AIDS community is a small one, a psychologist involved in any active way in AIDS education, advocacy or fundraising, will almost assuredly meet patients in "social" situations. Psychologists must take care to consider what impact this may have on patients and confidentiality must be a priority.
It is inevitable that psychologists working with HIV positive patients will bend the frame. Kain (1997) maintains that what is of ultimate importance is how psychologists bend the frame or enter into multiple roles. Is bending the frame acknowledged to patients or down-played? Are patients encouraged to talk with their therapists about the effects on them (both positive and negative) of multiple roles or are such discussions avoided? Is consultation sought out when psychologists become confused (or anticipate becoming confused) about multiple roles or is talking with colleagues avoided for fear of being judged unprofessional or unethical? Are psychologists aware of their own limits when new roles are taken on particularly in terms of their education, experience, and training. Are they equally aware of their personal limits, of their comfort in taking on new HIV-related roles, and of their emotional capacity to engage in such activities? Kain (1997) maintains that the clearer psychologists can be about bending the frame with themselves, their clients, and those they turn to for professional and personal guidance, the more they can rest assured that bending the frame is in the service of their patients.
Eversole (1997) provides a table comparing traditional mental health services and bending the frame (see below) which provides the foundation for an excellent classroom exercise. Give students a copy of the table with only the first column completed. Ask students to fill in the remaining columns. Use students' responses to generate class discussion. You might add a forth column entitled "what I would be willing to do" and have students delineate their own comfort zone for each topic, or how far they would be willing to bend the therapeutic frame.
Comparison of Traditional Mental Health Services and "Bending the Frame" (Eversole, 1997)
|Topic||Traditional||Bending the frame||What I would be willing to do|
|Home visit request||Decline visit||Consider visiting|
|Case management||Refer to case manager||May do varying degrees of case management, making contacts for client, etc.|
|Spiritual/Religious issues||Refer to clergy||Sharing, disclosure, discussion|
|Self-disclosure||Usually very limited||Often more disclosive, mentoring, modeling|
|Medical information||Usually refer to medical worker|
|Advance directives||Explore meaning of directives in context of therapy||Often educate and facilitate client's decision process|
|Contact with family, partner, friends||Minimal or none||At client's request: joint sessions, other meetings, grief work|
Eversole, T. (1997). Psychotherapy and counseling: Bending the frame. In M. G. Winiarski (Ed.), HIV mental health for the 21st century (pp. 23-38). New York, NY: New York University Press.
Freud, S,. (1915). Observations on transference love. In E. Jones (Ed.), Collected papers of Sigmund Freud, Vol. 2. New York, NY: Basic Books.
Kain, C. D. (1997). Coloring outside of the lines: Multiple relationships in working with people living with HIV. In B. Herilhy & G. Corey (Eds.), Boundary issues in counseling: Multiple roles and responsibilities. Alexandria, VA: American Counseling Association.
Singer, E. (1970). Key concepts in psychotherapy. New York: Basic Books.
Craig Kain, PhD