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On The Preservation of the Therapeutic Container
27th Nov 2011Posted in: Blog 0
On The Preservation of the Therapeutic Container
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In any form of psychotherapy whether it be humanistic, cognitive behavioural, psychodynamic there is some high degree of importance placed on the establishment and maintenance of a therapeutic container or frame. The notion of a therapeutic container is taken in part from Winnicott who stressed the importance of the initial holding environment in the development of personality. Donald Winnicott rightly noted the importance of that initial bond between infant and caretaker (usually mother) in the development of an individual's basic psychological makeup. Kohlberg, Maslow, Erikson and Freud were a few other notable humanists with a similar emphasis on the initial holding environment. It has been held, to this day, with much scientific support that the early environment has a profound effect on later development and that relatively minor events occurring in that environment could have relatively pronounced and rather long lasting effects on later life. I guess this is why mother's tend towards over protection.

Art therapy, which draws simultaneously from cognitive behavioural, humanistic and psychodynamic types of therapy, has placed enormous importance on the value of the therapeutic container or frame. In accordance with Winnicott's definition of the initial holding environment, a primary  focus of art therapy is to create and foster a secure container within which the proper conditions for therapy can be provided. The container consists of a specific time and a specific place. You can draw a parallel to the 9 months spent in the womb here. Gestation happens over a course of somewhat specific time and an extremely specific space. It happens in the womb over a period of approximately 9 months. Therapy ideally happens in the same place at the same time over a period of time just as gestation does and if you want to walk further down this analogy, both gestation and therapy lead to some form of birth (in the case of gestation) or rebirth (in the case of therapy).

In therapy just as in life, the developing individual benefits from some form of consistency. Somewhat regular feeding hours, somewhat regular rest, somewhat regular stimulation and somewhat predictable environments. Change is o.k, so long as it is carefully gauged and properly timed. Any change too great, or any change introduced with awkward timing is likely to throw the entire system out of whack. I remember the doctor just last week telling me not to take the blanket of my soon to be newborn son too quickly because this could overwhelm him with anxiety as he comes to realize he has limbs! This is why we say that loud noises should be avoided with newborns and precocious challenges should be avoided in therapy.  If a challenge is ill timed in therapy, you can experience a set back which can be devastating for a client. In my training as an art therapist at the one of only two master's programs in Canada, a fair but heavy consideration was placed upon the therapeutic container. I say fair because it is true that the therapeutic frame is one of the only things which the therapist can guarantee. I can guarantee that we will meet at a regular time and a regular place but i can hardly guarantee anything else because the client is necessarily responsible for everything else that happens in the container. As a therapist, my job is to preserve and protect that container by ensuring not only time and place but also confidentiality. There are the important physical elements of time and place but also psychological elements of confidentiality. If confidentiality is broken, the container is broken. If it is preserved than the container can survive even if therapy moves to a different time or a different place.  You could say that time and place are necessary conditions of therapy but that confidentiality is sufficient for most. This also means that time and place, although necessary, are not sufficient on their own. Still, overall, you want those three elements present in a solid and consistent fashion if you are going to undertake helping someone in a psychotherapeutic relationship. This notion of therapeutic frame is consistent across all modalities and all types of therapy. This being said there are exceptions and it does not serve any kind of therapy well to employ a dogmatic stance on this issue.

Like most of the theory related to psychotherapy, i believe that dogma must be avoided. We know through science and through con-science that certain rules serve us well but I have always believed that what does not bend must break. So there may be times when the therapeutic container becomes flexible or semi-permeable.  One obvious example i can think of is in the case of family interventions for drug addicts and people engaged in other destructive behaviour. Clearly, a therapist must by law break the container any time he feels that a client is at risk of harm to self or others. If a client is at risk to self or others, no lawyer, no doctor, no priest and no therapist should consider maintaining confidentiality. The therapeutic container instantly dissolves any time that happens.  I do realize that the idea behind family interventions is contentious and that there are many therapists who support the process while there seem to be just as many if not more who have determined that interventions do not work and are never an appropriate application of therapeutic principles. The concept of interventions does remain a topic of popular interest among pscyhotherapists and lay people based on the abundance of reality t.v. shows dealing with the subject. I remain divided on this issue but i think i believe that an intervention can be deeply therapeutic in some cases while exacerbating a problem in others. A number of therapists have suggested to me that experimental methods reveal that interventions do not work, but i have yet to see these studies and for now, i can not even comprehend how a valid scientific study could be conducted in this area because so much of the result of the intervention is determined by individual characteristics of those upon whom the intervention is being practiced. Not to mention the fact that there is little in the way of standards or protocols regarding how an intervention should be conducted. Anyway, i want to come back to the idea of interventions in a later post, for now, let's stick to the concept of the therapeutic container.

Another example of a situation where the therapeutic frame could become flexible is the following: A client whom you have been seeing for several years has gained autonomy and self confidence. That client has evolved over the course of therapy to be able to tolerate modifications in the frame such as changing time, place and context. Of course, the aspect of confidentiality remains unchanged because it is a essential condition of therapy but the framing of time and place might become flexible at some point. A therapeutic relationship could transition into life coaching. A situation where the therapist goes on the road with a client at specific times and places, just as a reported gets embedded in a context for greater clarity. I am not advocating that this is a situation which a therapist should strive for but only that it is possible to transition into that type of relationship and to produce positive results while doing no harm. Of course, playing around with the container is risky business. Many clients naturally tend to try and warp the container for their own reasons. Borderline clients are known to everything in their power to modify the frame. The same could be  true of clients facing addictions, anger management or gambling issues. It is natural for any client to want to modify the frame for any number of reasons and a seasoned therapist has to be ready for that when it happens. If a therapist allows the frame to be modified at some time when it is inappropriate because of unconscious transference or counter transference motivations on the part of the client or the therapist, then  the clinician will surely find himself in very hot water indeed. By hot water, i mean a highly uncomfortable situation which places the client at risk, places the therapist in a highly compromised position with possible legal and professional ramifications. It is for this reason that most therapists prefer to not even consider a flexible frame. After all, a solid frame is safer for everyone. Yet, if there is no posibility of modifying the frame ever than that is tantamount to a therapeutic protocol which knows no exceptions. My position is that such a protocol is bound to break in some cases or at least be limited by its own laws. This would be like having a medication which could help someone but not giving it to them because they might have side effects.

Ultimately, the container is there for a reason as i have just mentioned. It keeps us all safe. Let me give you another example of when the container was modified. In my internship at a children's hospital, i was once asked by the attending psychiatrist to leave the door open an inch or two while i was seeing a 6 year old female patient. I asked why and she responded that the mother was prone to getting the "wrong idea". I surmised that because i am a male therapist and because over 90% of pedophiles are male, i should avoid even the suspicion which can be sparked in people who perceive a male stranger in a room with a 6 year old girl. I obliged the psychiatrist but never fully got over the strange feeling that this left for me. Surely, i was facing a gender issue here as i thought to myself "would she have asked the same of a 20 year old female intern?" Whatever the case, in this instance, the container was semi transparent because of the open door and this supposedly served to protect not only the young patient but me as well. This is one instance in which transparency of the frame can be mutually beneficial. In another case, the same psychiatrist suggested that i might take a young male, 13 year old day patient out for a walk to the store so he could buy his favourite candy. At first, this went against all my understanding of what therapy is. Then, i learned that this 10 minute walk advanced our therapeutic alliance by several hours and launched us into what turned out to be some good work. In a later post, i want to talk about the clinical aspects of family interventions and their relevance to the notion of therapeutic containment.

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