On the ‘frame’ of psychoanalytic treatment
Date : May, 2025
Both in psychoanalytically-oriented psychotherapy and in psychoanalysis as such (there are profound qualitative differences in both procedure and process), it is the responsibility of the practitioner to develop with the patient a ‘working alliance’ that will withstand the vicissitudes of their ongoing relationship (i.e., the rockiness of ‘transferential’ relationship). That is, to act in ways that ensure what Adam Limentani described as the fundamental sense of intimacy, freedom and safety that should pervade each session. If we remember how Pythagoras defined a friend as one who accompanies you on a journey, facilitating your perseverance on the road to a life that is more joyful and free, then it might be said that, in a very specialized way, the practitioner befriends the patient.
Of course, the patient contributes to the security of the session by having resistances to its procedures and processes ― which is why resistances must always be addressed appreciatively because, in the context of the patient’s psychic reality, they are the means by which the patient protects her/his functioning and sense of self.
The practitioner’s role is to secure the session for the patient, not only by being fully present (physically, emotionally and cognitively) for its duration, but also by establishing and maintaining the ‘frame’ of the treatment. This ‘frame’ has seven essential aspects:
(1) The practitioner’s schedule of availability is known to the patient in advance, and the practitioner is reliable in her/his attendance. The patient should know dates that the practitioner is going to be unavailable (on vacation, and so forth) and, if the practitioner has to miss sessions unpredictably (emergences, and so forth), the patient should not be left guessing as to why sessions were missed. In terms of regular scheduling, there should never be more than two or three days between sessions.
(2) The practitioner must always begin the 50-minute session punctually, and also end it punctually. Open-ended sessions (and any sessions that are unpredictable in other ways) endanger the free-associating patient. Patients cannot allow themselves to ‘regress’ into free-association (which, if undertaken as fully as possible, is an altered condition of consciousness) unless they know that, at the end of the session, they are going to have to leave the consulting room and proceed with their quotidian lives. Even if the practitioner interrupts the patient mid-sentence, the session must end on time.
(3) The practitioner’s consulting room must be as quiet as possible, and protected from interferences such as a ringing phone, knocking on the door, excessive external noise, etc. Given that the treatment depends on special modes of listening, such quiet is necessary.
(4) The practitioner must insist that the patient pay ― promptly, on a weekly or monthly basis ― a professional fee that ensures the practitioner’s reasonable standard of living. This transactional dimension of the relationship is essential, not just because the practitioner needs to be well, but also because the patient needs to know that s/he is taking care of the practitioner. Patients need to take responsibility for looking after their practitioner in this way ― and only in this way ― and they need to know they are doing so. Treatment is wholly undermined if patients feel they are being given to without their reciprocating properly. In this regard, the amount a patient pays each month should be proportional ― in relation to the practitioner’s total income ― to the amount of time the patient has taken from the practitioner’s professional schedule. Moderations in the customary fee (i.e., reductions honouring the patient’s financial challenges) should only be undertaken very carefully, with diligent attention paid to their repercussions in the relationship. Unrealistically low fees sabotage the potential of the treatment. This dimension of transactional reciprocity is necessary for a viable treatment relationship.
(5) The practitioner must ensure that all third-parties are kept out of the treatment relationship. Ideally, this includes consultants, supervisors, presentations at seminars, and so forth. Note-taking during the session should be strictly avoided ― even if only intended for the practitioner’s private use ― because it implies a sort of ‘third-person’ in the consulting room, in the form of the practitioner at some future point.
(6) The practitioner resists the patient’s longings for physical closeness, including especially sexual enactments. This prohibition is essential if ‘transferences’ are to be fully experienced and properly explored. Once a patient has contacted a practitioner in her/his professional capacity, the prohibition of sexual enactments ― which is a protection against the performance of unconsciously incestuous fantasies that can never be resolved ― is never lifted. That is, it is lifelong. Other prohibitions and boundaries that are maintained during the course of treatment (for example, the practitioner’s dining or dancing with the patient) may judiciously be lifted upon termination of the treatment.
(7) The practitioner is not only continuously and candidly compassionate toward the patient, but also consistently non-judgmental or ‘neutral.’ Although coaches and counsellors may know how the patient should live her/his life, the psychoanalytically-oriented therapist and the psychoanalyst stand fast in the awareness both that they do not, and that their task is to facilitate the patient’s self-understanding and personal growth toward insight and awareness.
Patients benefit greatly just from the performance of the ‘frame’ of treatment. They necessarily benefit less ― or not at all ― if any of these seven aspects is disregarded by the practitioner.