Ground Rules in Psychotherapy and Counselling

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Robert Langs has long been one of the most individual and controversial psychoanalytic theorists. In this book, he concentrates on one of the most prominent areas of his thought: his insistence upon adherence to strict rules for boundaries (or "frames") in psychotherapy and psychoanalysis.Starting from the statement that "Throughout the history of the universe, frames, contexts, rules, and boundaries have been vital aspects of the development and very existence of both physical structures and living organisms," Langs goes on to examine the profile of the issues of boundaries in psychoanalytic thought. He discusses Freud's technique papers on the subject, and goes on to elucidate his own approach, rooted in his thinking on evolutionary and adaptive processes which he has discussed in his previous work. Throughout the book, Langs gives both theoretical discussions and practical groundings of his ideas.As with his previous book, Doing Supervision and Being Supervised (1994), Robert Langs here brings his unique energy and viewpoint to bear on an important but little-examined topic. Whether or not the reader agrees with him, Ground Rules in Psychotherapy and Counselling is essential reading for psychotherapists and psychoanalysts concerned about these vital issues.

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1 Nature framing nature

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Throughout the history of the universe, frames, contexts, rules, and boundaries have been vital aspects of the development and very existence of both physical structures and living organisms (deDuve, 1995; Langs, 1996).

On the material side, both large and infinitely small entities are bounded, defined contextually, and constrained by rules and regularities. The most basic set of rules take form as the laws of nature that give the universe its determinism and predictability, chaotic and otherwise. Even quantum-related events, which apply to the fundamental particles of nature and have an ultimate degree of uncertainty, are nevertheless lawful.

The consistencies and certainties defined by rules and laws are buttressed by the physical boundaries that define material conglomerates. Boundaries have also played a vital role in the evolution of the universe. It was, for example, the bounding of a chaotic mass of energy and matter that created the earth some 10 billion years ago. On all levels of physical organization, then, order is the essential grounding for disorder, development, evolution, creativity, and the emergence of new forms (Langs, Bada-lamenti, & Thomson, 1996; Prigogine & Stengers, 1984).

 

2 Frames and conscious and unconscious experience

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The results of investigations into psychotherapy depend on the conceptual framework within which they are carried out and the consequent selection of methods of study. Beginning with Freud (1912, 1913), a moderate literature on rules, frames, and boundaries has developed based essentially on observations and formulations that pertain to a patient’s overt behaviours and manifest communications, and their evident but latent implications (Langs, 1976).

The more recent literature on this subject has been motivated primarily by a heightened awareness of the detrimental consequences of therapists’ gross frame violations, such as sexual seduction of patients (Gabbard & Lester, 1995) and by the growing number of modifications of the total privacy and confidentiality of therapies that take place in settings that involve third-party payers and ancillary personnel (Bollas & Sundelson, 1996). However, because the ideas offered in such writings are based on direct communications from patients, there is debate over the extent to which these actions and conditions of therapy disturb the treatment process and harm patients. Therapists have developed many arguments that serve to deny the detrimental effects of blatant frame modifications, even though there is a growing sense that maintaining ground rules in these areas is the safest course that a therapist can take.

 

3 The basic ground rules of psychotherapy

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Although fraught with uncertainty in many quarters, the present-day ground rules of psychotherapy in use by a majority of psychotherapists and counsellors are the result of a process of cultural evolution that has taken place over the past 100 years or so. The need for rules and boundaries was evident to Freud (1912,1913), even though he was in most respects a frame-deviant psychoanalyst (Gabbard & Lester, 1995). In subsequent years, the problem of defining an optimal set of rules and conditions for psychoanalysis and psychotherapy has defied a clear solution. Therapists still cannot agree on which ground rules are essential to a secure therapy experience, nor is there a consensus as to the latitude or narrowness within which a therapist can properly manage the frame. Adding to the confusion, many therapists claim that there is no such entity as a universal frame or set of ground rules that applies to all patients and therapy situations. They propose instead that each patient requires a framework suited to his or her particular needs and in keeping with a variety of circumstances that have a bearing on the locale and general conditions under which that patient is seen (e.g. Weiss & Sampson, 1986). As we shall see, this proposition, based on conscious system thinking, is untenable by deep unconscious system standards.

 

4 Formulating and intervening with respect to frames

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In the course of every psychotherapy session, a patient will unconsciously—and at times, consciously—work over and adapt to the therapist’s prevailing frame-related interventions. Even when little attention is paid to these interventions consciously, they are at the core of the patient’s deep unconscious experiences in therapy. Thus, the patient’s encoded narratives will consistently reflect, first, the nature of the frame-related intervention with which the patient is coping (i.e. the ground rule that is at issue), and, second, the personally selected, deep unconscious meanings and impact that the therapist’s framing activities are having on the patient. The component that identifies the ground rule at issue is reflected in bridging themes (themes shared by the encoded narrative and the ground rule), while the meaning aspect of the experience is reflected in what are called power themes (those of death, illness, harm, and the like—the so-called damage package). Power themes arise in response to all frame-related interventions because even though securing the frame evokes positive imagery, both frame-securing and frame-modifying efforts by therapists are endangering for the patient—secured frames evoke existential death anxieties, and modified frames are persecutory.

 

5 Secured and modified frames

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In approaching the definition of secured and modified frames, we may recall some of the differences between the conscious and deep unconscious systems of the emotion-processing mind. The world experienced by the conscious mind is received through conscious perception, and its purview is wide and varied. Concerned with past, present, and future, the system explores and organizes the world along many different dimensions—danger, care, food, shelter, relatedness, sexuality, finances, illness and health, creativity, travel, and so on. Its adaptive resources are applied in enormously diverse ways.

Relying on subliminal perception, the deep unconscious system has its own view and experience of the world. Deep unconscious perception is concentrated intensely on a single dimension of human experience: that related to frames and framing activities—the realm of rules, laws, and boundaries. While the system also monitors the kind of listening and formulating that a therapist engages in (it distinguishes trigger decoders from those working with manifest contents and their implications) and the accuracy of a therapist’s interventional efforts, the deep unconscious system is primarily frame-centered.

 

6 Frames and the evolution of the two-system mind

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Throughout physical and biological nature, rules, frames, and boundaries have played a critical role in how entities, systems, and organisms function, interact, and survive. For organisms, frames and boundaries provide contexts and limits for behaviour and experienced meaning, while rules and laws guide adaptations and interactions.

In general, animals and other species respect these guidelines. Within the boundaries of their own territories, jackals will not attack prey; birds respect the territorial rights of other birds; and apes tend to accept social hierarchies. Secured frames are honoured and modifications of rules and boundaries are rare. Why, then, are humans so fearful of secured frames and so strongly inclined towards frame modifications?

Evolution and frames

The turning point in animal responses to rules, frames, and boundaries appears to have been the acquisition of language (Langs, 1996). This development, the most distinctive feature of our species, Homo sapiens sapiens (Bickerton, 1990; Corballis, 1991; Dennett, 1996; Lieberman, 1991), came about 150,000 years ago, after nearly 6 million years of hominid existence. Language was an essential factor in many unprecedented developments, including a firm sense of self and of personal and interpersonal boundaries. By means of language, humans developed a clear sense of their individual identities as distinguished from others, who were, in turn, experienced as similarly distinct persons. Language was also the basis for the ability to establish and manipulate internal representations of events and individuals, thereby freeing humans from a fixation on immediate life moments and enabling them to think about past and future events as they pleased.

 

7 The secured setting in private practice

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As is true in life itself, frame issues are a never-ending feature of a psychotherapy experience. At all times, ground rules are being held secured or rectified on the one hand, or sustained as deviant or actively being modified on the other. As a therapy unfolds, the frame is at all times in a particular state or being actively managed and responded to by both patient and therapist.

Many clinical issues arise in connection with dealing with the setting and the various ground rules of psychotherapy. We therefore turn now to a detailed examination of these canons in order to understand what each contributes to the secured frame and the effects of its modification. Clinical precepts are developed with regard to frame-related intervening in and solving of frame problems as they arise in both private practice and clinic settings. Both frame-management and frame-related interpreting are explored. I begin with the components of the relatively fixed frame, turning first to the setting of private psychotherapy.

 

8 Deviant settings in private practice

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The ideal private setting is a rarity. The conscious system invents countless rationalizations to justify the unconsciously driven need for deviant frames and settings— much of it stemming from the influence of the deep unconscious fear-guilt subsystem on the conscious mind. For example, economic pressures are used to justify therapists’ decisions to share waiting-rooms, have their offices where they live, or rent office space to or from others. But these conscious needs are strongly driven by deep unconscious motives in therapists that prompt them to establish deviant settings as part of their way of adapting to their own emotional issues. The common unconscious motives involved in this trend include an unrecognized dread of secured settings, unresolved existential death anxieties, and fears of the deep unconscious meanings that materialize within secured frames—many of them involving patients’ unconscious perceptions of therapists’ emotional dysfunctions as reflected in both their choice of deviant settings and other non-validated interventions.

 

9 The setting in public situations

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There are, as we know, many kinds of public sector and organizational frames for psychotherapy, such as clinics, charitable associations, group practice arrangements, health maintenance organizations, and programmes offered by insurance companies, governments, churches, and hospitals. These settings, although often socially necessary, are characterized by a series of endemic compromises of the therapeutic frame that have disruptive consequences for all concerned. Managing these frameworks and offering a deeply constructive therapy experience under these conditions are challenging and often daunting tasks for the psychotherapist and counsellor.

Perspectives on clinics and similar settings

The social necessity for clinic-types of psychotherapy has blinded most therapists to their many drawbacks and prevented a careful search for the most optimal frames possible under these conditions. It is critical in exploring this sensitive subject not to allow social need to blind us to the natural and inescapable effects of modified frames. Human systems cannot escape psychobiological rules: the power of deep unconscious experience dominates emotional life regardless of conscious reasoning and need. The dilemma we experience in these situations stems from the essential design of the emotion-processing mind and pits the harm caused by all frame modifications against the need of many patients to be seen under compromised public and semi-public conditions. Therapists have an obligation to develop strategies that will resolve these conflicting pressures with as little harm and as much cure as possible for their patients—and as little grief as possible for themselves.

 

10 The time dimension

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Regardless of the locale of a given psychotherapy, the ideal ground rules call for a definition of various time factors. Managing this seemingly simple aspect of the frame is, however, beset with potential problems. As with any ground rule, the overall goal is to secure this aspect of the frame to the greatest extent feasible, to minimize frame alterations, and to interpret and, if possible, where needed, to rectify those modifications that do exist.

The time, length, and frequency of sessions

The temporal dimensions of the ground rules of psychotherapy are an essential part of the relatively stable, fixed frame. The main components are;

1.   The duration of sessions. Sessions should last 45 or 50 minutes in standard forms of psychotherapy. This convention, which may have arisen for monetary reasons/ has psychological support in that it allows sufficient time for meaningful communications, however limited (Langs, 1993).

Once the length of sessions is established, it should be adhered to with utmost strictness—the deep unconscious system is sensitive to the slightest variation beyond a few seconds or so.

 

11 The first session and fees

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The ground rules related to the fees for psychotherapy are, in principle, stated in the first session. But before the fee is dealt with, there is an initial contact with the therapist, usually via a telephone call for an appointment to arrange the consultation session. Many aspects of these initial contacts are overlooked consciously by both therapists and their patients, even though they are processed intensely by the deep unconscious systems of their respective minds. For this reason, I offer a brief discussion of the initial contact before turning to the ever problematic area of managing the fees for psychotherapy.

The initial contact

The therapist’s handling of the first telephone call and the consultation session sets the tone for the entire psychotherapy. The rules that prevail for the call and the first hour are identical to those that apply to an on-going therapy. The only notable difference between the initial session and all other sessions is that the therapist will spell out the basic conditions and ground rules of the therapy largely without the encoded directives of the patient. In all other sessions, with the rare exception of a frame break discovered privately by the therapist, his or her frame-management efforts should be based on the patient’s encoded models and recommendations, which are always directed towards securing the frame. But because both patient and therapist must have a clear framework for the therapy from the outset, the ground rules need to be stated at some point in the first session, even in the absence of suitable encoded material from the patient,

 

12 Total privacy and total confidentiality

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Total privacy and total confidentiality

We turn now to the more fluid and less precisely definable aspects of the framework of psychotherapy. In this area, the ground rules of total privacy and total confidentiality undoubtedly are two of the most crucial and yet most often violated conditions of therapy, even though they are ardently sought, on the deep unconscious level of experience, by patients and therapists alike. Therapists who trigger decode patients’ material cannot help but be impressed by the enormous power that these two aspects of the ground rules exert on the therapeutic process and the lives of their patients—and on themselves. In this chapter, I present the position of the deep unconscious system on these two ground rules and attempt to explain why these invaluable safeguards are so often ignored and violated.

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Total privacy

While, in general, total privacy and total confidentiality go hand in hand, they tend to stress somewhat different aspects of the ground rules of psychotherapy. Total privacy calls for a treatment situation that involves only the patient and therapist, and excludes all maimer of outsiders. Ideally, it implies a referral from a professional or other neutral source; a private waiting-room and office; a separate exit from the consultation-room, or spacing sessions sufficiently apart so as to preclude contact between patients; the exclusion of family members connected with the patient or therapist; payment for all sessions by the patient alone, using his or her own, personal funds and chequing account; a one-to-one relationship and interaction, without others present or reports to others; and, on both sides, the absence of note-taking, recordings, supervision, or presentations or discussions with any other individual. Total privacy has features that are intertwined with total confidentiality. For example, the ground rules call for sessions that go unrecorded except in the minds and memories of both parties to therapy. Also required is that neither the patient nor the therapist speak to any outsider about any aspect of the therapy sessions. These tenets ask for a mixture of total privacy and total confidentiality that inherently serves to safeguard against the communication of the transactions of sessions to any third party. This canon is violated not only through the physical presence of another person in the treatment setting, but also through conversations or written contact with others about any aspect of the therapy. Even reporting back to a referral source—whether verbally or in writing, by the patient or the therapist—violates this ground rule.

 

13 Neutrality and relative anonymity

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In general, the more fluid and ill-defined a ground rule of psychotherapy, the greater the abuse of the rule. This helps to explain why, as measured by the standard of deep unconscious, encoded validation, violations of therapists’ neutrality and relative anonymity are so common as to take on epidemic proportions. The pervasiveness of modifications of these two ground rules is also the result of the fact that, more than any other aspect of the frame, violation of these tenets extensively gratifies therapists’ maladaptive needs for pathological forms of gratification at the expense of their patients. In all instances, these frame breaks introduce into a therapy the personally unresolved, unconscious pathological needs of the therapist, including his or her dread of secured frames. Such needs are, in their essence, inappropriate self-revelations of the first order. It therefore behoves us to take a careful and extended look at the nature and functions of these two ground rules and the issues raised by attempting to enforce their sound maintenance.

 

14 Issues in managing the frame

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In this final chapter, I present some over-arching precepts regarding the management of the ground rules of psychotherapy and touch on some of the more pressing unresolved issues related to this critical aspect of treatment. My themes are both practical and theoretical, and they are developed as a way of rounding out our insights into this most telling aspect of human and therapeutic experience.

The hierarchy of frame issues

Given the many and diverse components of the ground rules of psychotherapy and the central role that they play in organizing the deep unconscious experiences of both patients and therapists, sessions in which there is but a single active frame issue are exceedingly rare. Often enough, a recent frame-securing or frame-modifying intervention will dominate the picture, but in many instances there are two or more equally compelling frame issues with which a patient is dealing. This leads us to ask whether there is a general hierarchy of frame-related, adaptation-evoking triggers that assigns an order of general precedence to each type of frame issue. In addition, can we establish some basic principles of technique for handling multiple, simultaneous frame impingements?

 

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