What we’ve said about Treatment frame

“rules are important because there is actually a freedom to operating within a system of rules. And it's actually anxiety provoking to be operating within a system that doesn't have rules”

“There are some boundaries that are absolutely essential to every practitioner. Things like protecting confidentiality, things like, you know, listening and doing like, yeah, there are things that absolutely cannot be changed”

“a kind environment is a predictable environment. This is where the rules are very clear. There is reliable feedback from the system and patterns are predictable and repeat”

“a shared understanding of what the problem is the clinical problem or problems and what to do with it the goal okay and then part three is a shared understanding of how to get that problem fixed or how to get to that goal okay so the treatment target basically and also the treatment modality”

“we operate within the medical model. And in short, it means that we look for pathology. We look for a problem that might be defined medically or has been defined medically. that has specific treatment recommendations, okay”

“This stuff that we're talking about, about the frame and timing, you know, it's been tried and true for psychotherapy. If you've had any training, this is old news to you”

“I don't know if people are gonna appreciate the term train but yes it's your responsibility as the clinician To set the frame and to keep the frame”

“you should have a uniform way of introducing yourself in the purpose of the meeting. to every patient, even if they're an experienced patient, because there's a lot of variation between different doctors, right”

“I think a lot of that comes from misunderstandings about what your role is. So another important thing is to make your role clear from day one and to remind people about your role and the limits of your powers as needed”

“We're there to try to get as accurate as possible of a picture diagnostically and formulation wise of the patient in order to recommend them certain treatments, medications or other”

“keeping appointments, keeping a plan, and letting people know in advance how long you're going to be seeing them for, when you're not going to be seeing them, and when you're available is a huge part of establishing a treatment frame and making sure people feel safe in the treatment”

“There's an argument that you should do a full disclosure about your limits of confidentiality at the first visit”

“if, you know, you find that you're constantly going over, set early expectations with your patients and the intake say, you know, my intake is an hour, my follow-ups are 20 minutes”

“I know there's a 30 minute block of appointment. I consider that 30 minute block the full time I have to finish the encounter. and what is the encounter the encounter is talking with the patient giving all my recommendations writing my notes and finalizing”

“if the time into the session has elapsed enough, let's say over 50%, so that you cannot have a meaningful visit, I'm not going to attempt to give the full visit. I'm going to tell the patient, we missed the time today”

“But for patients that, you know, are going to go long, at the 15-minute mark, I give, if they're in the middle of something really heated, no matter what they're in the middle, I'll pop in and say, hey, just a reminder, we got five minutes left”

“So just set the expectation with patients that whenever we're going to do some work together, whenever something needs to get filled out, whenever we're talking about side effects or whatever, we're going to do it in that 20 minute chunk”

“Even if there is something urgent, don't try to set out, put out that fire unless it's a true emergency. Say, let's get you into the schedule as soon as we can, if that's appropriate”

“A clinic is not an emergency room. A clinic is not urgent care. A clinic is a place where you have to and you get to learn to wait and to sit with yourself”

“it matters a little bit less whether or not you correspond to my style. What matters is that your Boundaries and frame match all the patients that you're seeing in that setting. That's way more important”

“The less you have hard and fast rules about boundaries and frame, the more dangerous things are. Even if nothing bad ever happens, all you're doing is that you're making it harder on yourself”

“the courts and society love to hold clinicians accountable OK, even for things that are outside their control. So because of that, my recommendation, my personal recommendation is that you follow some pretty strict rules and boundaries”

“I do think that escalating or allowing more and more physical contact is just, you know, uh road to hell paved with good intentions in many cases maybe you're fine with it maybe you can get away with it i think it just depends”

“The reason why we don't do self-disclosure is because it interferes with the treatment. That's why. It's not anything else, really. It interferes with the treatment both from taking time away and also removing the focus, shifting the focus, fuzzing the focus”

“the technique is to notice when you or the patient are stepping out of the frame or to notice when there are ruptures in the alliance and how you would repair that”

“if you detect any kind of a problem, a divergence or mismatch in the therapeutic alliance, a rupture in the therapeutic relationship, or some kind of a boundary crossing or a frame violation, I recommend that's addressed explicitly and relatively quickly, if not right away”

“you have to keep strict boundaries in frame. then you have to refer back to that frame and the therapeutic alliance when you notice anything that is amiss”

“I say, how do you feel about how things are going, your treatment progress? How do you feel about how I'm doing? OK. Now, I want to know just overall, what do you see as the main problem that we're trying to get better, that we're trying to work on”

“in any situation like this in the doorknob common you're going to be thrown off kilter as a clinician So you better try your best. You're going to fail sometimes to keep your composure and try to keep it warm, interested, and connected to the next session”

“You don't have to intervene every time. If it's important, it's going to come back in a future session”

“you may notice times where you are actually acting outside of the treatment frame, that you're just doing something because you were personally curious or that you were afraid of a bad outcome”

“I try to be extremely clear about two things. Why we're meeting, basically the modality of the treatment, and also diagnosis. Okay, and treatment recommendations”

“a lot of anxiety for anyone is just being untethered, not knowing what to expect. Right. So if you can set and keep expectations, that is how you show that you and the treatment are trustworthy”

“People do come in and they think how this works is I'm going to tell my doctor all my traumas. I'm going to trauma dump on the doctor or I'm going to tell my doctor about my crisis of the day or I'm going to tell my doctor about my past and my story”

“You can say, actually, what you're talking about doesn't sound like it should come from a psychiatrist. I think you can get that best from social worker, therapist, a friend. social organization, whatever it might be. Make sure that you're actually able to do what the patient wants you to do”

“if you try to make this shift way too fast or without explaining yourself, people will rightfully get angry at you. They're going to leave treatment with you. They're going to say, what are you doing to me? OK, I'm used to this”

“I don't want to talk about exactly how upsetting it was or agree that it was upsetting or tell me which specific event made you unhappy. No, I want to know how's this come into your life and how's it impact your ability to do the rest of your life”

“And if the patient's sending intrusive emails, I've gotten more and more comfortable with saying like, you know, talking about it. This is not how I really work. Why do we think we're having this? Talk about patients who are sending me emails. Talk about the content of the emails”

“If it's important enough to be your primary treatment diagnosis, if it's important enough to go on a bill somewhere, you should at least explain it”

“Have it so that they know that if they do this, this is going to occur. And those expectations are very comforting. They're protective”

“trust is sort of the fundamental thing that you need to establish first, really for any treatment, but especially in the treatment of trauma”

“You can't just say these things. You have to just make them true. You have to be available to the extent that is realistic. You have to actually be interested, investigate, and help in some fashion. And you have to keep your promises”

“reframing things that like the frame and the limitations and the difficulties that you experience in treatment are the treatment itself. They're not disruptions to the real treatment”

“borderline patients require more structured treatments. Right. So even Kernberg and the transference focus people, they talk about the need for a therapy contract at the outset of treatment for for for very careful attention to the frame and the boundaries and the rules, the ground rules of psychotherapy”

“building structure and stability, it helps every aspect of mental health. It's a big focus for my patients with personality disorders, with trauma”

“It is not normal to sit in a room or over Zoom with somebody and talk about all these extremely intimate, embarrassing and painful details about one's life. Right. So don't be afraid to do things that are a little bit socially unusual if they're serving a very important treatment function”