The Therapeutic Frame and Covid 19

In both my work as a therapist and in my personal therapy, covid 19 has presented some profound and complex challenges to the therapeutic frame.

As has been widely discussed, moving to work online has had benefits for some, and involved significant difficulties for others, including issues around privacy, grounding, internet access, technology, loss of therapeutic touch and adapting to this very different way of working, and all the while, both therapist and client are managing multiple external disruptions, difficulties and often, grief. It has, and continues to profoundly impact on therapeutic work globally.

I have written many times about the importance of a safe and predictable therapeutic frame, most crucially when working with trauma, but actually this is a fundamental part of what all therapists must offer their clients, and what sets the therapeutic relationship apart from other relationships in our lives.

I am someone for whom the boundaries of time and space have always had particular significance for me in therapy. I have always had therapy at the same time, on the same day, in the same place. This (along with a therapist I can rely on to be fairly predictable in his behaviour and what I can expect from him) has always been a key part of why I have been able to engage so fully with the process of therapy, and why I am able to be so vulnerable in the room. This didn’t happen by magic – it was a matter of my therapist proving himself reliable and trustworthy, again, and again, and again over a number of years.

Covid 19 is disruptive to the therapeutic frame in a number of ways. Decisions about face to face or online working have not been straightforward, and often made at short notice as scientific guidance is updated and tier-changes are announced. The truth is, along with everyone else, it has been difficult for clients and therapists to know what is the right or best thing to do, and making important decisions like these in the context of such a high degree of uncertainty is inevitably unsettling for both therapist and client. Often decisions have necessarily had to be made unilaterally by therapists, creating a potential trigger for rupture in a relationship that has previously been experienced as collaborative by the client. The therapist, while managing their own uncertainty, also must pay careful attention to how power and disempowerment impacts on their therapeutic relationships, whilst also, very likely not feeling particularly powerful themselves.

While unexpected illness and emergency always present a potential for disruption in therapy, the threat of sudden cancelled sessions is greater with covid; one of my concerns for my practice is that if were to be asked to self-isolate due to symptoms, or contact with somebody who has tested positive, I would not be able to see clients for the period I am isolating, because I work online from my office, and do not have a sufficiently private space at home from which to see clients.

Therapists still seeing clients face to face will have had to recontract with their clients around confidentiality in case of needing to disclose the names of those with whom they have been in contact for the track and trace system. Clients will have to agree to this change to the therapeutic contract, yet a change to the contract it is. In my view, every change to the frame is significant and worth paying attention to.

Some therapists have begun offering walk and talk sessions; this seems to have been a helpful addition to therapy for many, and also, it is a significant change to the therapeutic frame. Again, these considerations are so important. What meanings come with that change of space? What influence on the therapeutic process does the absence of the physical boundaries of bricks and mortar have? This might be good, bad, neutral or all three, but one thing is for certain – it has meaning.

I think the biggest uncertainty for me, both as a therapist and as a client comes when I look at the long picture. When will I be welcoming clients back into my room again? What impact might the not-knowing have on them? When will I again sit with my therapist, in the safe little room which had become so familiar to me? For me, in both chairs, the key must necessarily be ongoing discussion about how the client is experiencing the relationship and the changes to the frame of therapy.

The therapeutic frame cannot be underestimated. It is the container which allows the chaos and uncertainty of life to emerge safely in the room. It is the boat which the sailors must have confidence in its integrity before they set sail, or they will be too busy worrying about it sinking to explore new lands.

The uncertainty of covid is not insurmountable, it is not the case that good work can’t happen in its midst, but we mustn’t underestimate it either, nor minimise the experiences of those who are navigating these choppy waters.

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