Treating Trauma and the Therapeutic Frame

Recently someone asked me a great question via Twitter. I love reader questions! They have prompted some of my favorite blog posts! (See: How to Avoid an Abuser: Understanding Grooming, Reader Question: Treating Emotional Numbness, Can Complex PTSD Be Cured?, What Comes After Connection?)

Sushipink wanted to know about how to handle in between session contact with clients with complex post traumatic stress disorder (CPTSD), and whether such contact is therapeutic or not. Such a great question and one many (all?) new therapists grapple with, specializing in complex trauma or not. As an aside, I cannot imagine a setting where the new therapist will not be faced with trauma, but that is a subject for another day.

Thinking about how to frame (geeky therapist joke intended) a response to that question took me back to my psychodynamic training and a key concept: the therapeutic frame. Therapists operating within certain schools of thought (like psychodynamic) believe that the therapeutic relationship is made possible by the existence of this frame. The therapeutic relationship is unlike any other in that it involves processing vs talking  and the internalization of capacities missed in childhood that were disrupted due to abuse or neglect. The frame allows this unique relationship to blossom.

What is the therapeutic frame? It is the things that we do as therapists, the structure that we create for therapy, that demonstrates our beliefs about how therapy works. It includes expectations about how we, therapist and client, will interact with each other and contribute to the therapy process. Perhaps you are more familiar with a similar term, therapeutic boundaries, although the frame is more than that. Some aspects of the frame are non-negotiable, based on our clinical understanding of how therapy works, our ethical guidelines, and personal needs (yes, therapist get to have needs too!). Other aspects vary with each client, and may change over the course of therapy with a particular client.

Boundaries are critical in therapy in general. They become that much more so when working with clients who have experienced early and ongoing boundary violations in the context of intimate relationships with caretakers. With survivors of complex trauma, establishing, maintaining, and at time negotiating the boundaries is a critical part of trauma therapy. It is important that the therapist have a theoretical basis for her frame and flexibility in adapting to the specific needs of each client. CPTSD clients are often hypervigilantly attuned to any potential boundary violations, or dissociated and unconsciously attempting to reenact earlier experiences. Either way, the issues of boundaries and the therapist’s management of them will play a key role in trauma therapy.

Pearlman and Saakvine, in their excellent book Trauma and the Therapist, recommend  these five strategies for us to keep in mind as we negotiate the boundaries of trauma therapy. (While they specifically address therapy with childhood sexual abuse survivors, I feel this approach is generalizable to any complex or developmental trauma work.)

  1. Having a clear theoretical framework for the therapeutic relationship and specifically for the boundaries and frame of this relationship with sexual abuse survivors
  2. Setting a clear therapy framework with each client
  3. Knowing ourselves and our own histories, weaknesses, and vulnerabilities through personal therapy and reflection during and between sessions
  4. Receiving consultation and supervision on a regular basis
  5. Discussing frame issues with clients openly and over time, especially when the client requests a change

Back to the question! So what about in between session contact? Is it therapeutic? Not? My brief answer, in typical therapist fashion I fear, is “It depends”.  It depends on so many things: the stage of therapy, your theoretical orientation, the boundaries you have negotiated with this particular client based on your understanding of their developmental level, the reason for the contact. As trauma therapists, our decisions about this are guided by our beliefs in general about therapeutic frame and boundaries as well as how we have negotiated these with a particular client.

Some questions to ask yourself about in between session contact could include:

  • does the client need it vs. want it?
  • is it time-limited or open-ended?
  • is it specific (for example in the case of emergency, and then what is the definition of emergency)?
  • is it sustainable by the therapist ( I learned early on that I could not function well if I took calls from clients in the middle of the night)?
  • is it serving the purpose of working through the trauma and helping the client develop greater internal capacity for coping or is it reenacting some part of  the trauma triad (victim-perpetrator-rescuer) or gratifying in the moment?
  • is contact being offered by the therapist or requested by the client?
  • what is the client’s developmental level? phase of therapy? experience with boundaries and boundary violations?
  • does the client have “parts” or dissociated aspects of self? what is the meaning of extra contact to all parts of the client? is it possible to know that at this point in time?

My approach when in doubt, is to err on the side of caution, or the side of stricter boundaries. When it happens, I do believe it is important to be specific about the nature of in between session contact: the form of contact, duration of time, what the client can expect from you during the contact, and whether fees will apply. Exploring the request for (or offer of) extra contact and the meaning of this then becomes another part of the therapy process, or, as we therapist like to say, “it’s all grist for the mill”.



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5 Responses to Treating Trauma and the Therapeutic Frame

  1. Anonymous says:

    Very timely article, as I have needed to contact both my therapists today!
    Reasonably early in my therapy, both my therapists realised that I experienced from birth, complex and chronic neglect, psychological trauma, deprivation of freedom, isolation, and programming to behave in certain ways. This realisation on their part came long before my ability to understand my history. My need to have a therapeutic alliance that cares for all the developmentally delayed ”parts” of me has meant that between therapy contact is, at times, the most beneficial part of therapy. It is as if my therapists are ”growing me” through the developmental (Erikson’s) stages of trust, autonomy. initiative, industry and identity as opposed to the mistrust, shame/doubt, guilt, inferiority and identity confusion that I was experiencing prior to commencement of therapy. I had adapted to my trauma by dissociating and freezing…..the hardest part of having between therapy contact, for me, was finding the courage and learning to ask for it. I had been ”voiceless” for so long that I needed to learn to find my voice…and sometimes the voices were very young.
    I am very lucky to have found therapists who can work with all the different presentations I bring to therapy, and who can contain my emotions when I cannot. To some, this may sound like rescuing, but when between therapy contact is done properly to meet an individual’s or a certain ”part’s” needs, it is hugely therapeutic.

  2. Sarah Olson says:

    It’s very interesting to see the analysis from the therapist’s point of view! In my own trauma therapy with the same therapist over the course of 20 years, he’s always allowed extra contact. It began with me timidly asking if I could fax something to him about the previous session, which he openly encouraged. Over the years, it’s evolved into email.

    As someone who dissociates (and diagnosed with Dissociative Identity Disorder in the ’90s), it’s extremely helpful for me to read those writings later, particularly if they were written by someone other than “me”. They provide context and continuity between sessions. They bring up issues that might otherwise have gone unnoticed.

    As for boundaries, we have them. He rarely replies to my emails; we discuss them in the next session. He stated in the first session that he isn’t the one to call at 3am for emergencies. I never have, but I have written things to him at 3am that helped process what felt like an emergency at the time. It not only has a calming effect on me, but provides both of us with a written record of what the issue is which, with dissociation operating, may not be clear by the next time we talk.

    Until I met him, every previous therapist had been adamant about no extra contact, which I feel strongly is why I never felt any resolution with any of them. For such complex issues, being in a 50 minute window once a week was far too limiting.

    Sarah Olson

    • I really appreciate you sharing your experience Sarah! It sounds like the two of you developed a structure that worked very well. I also appreciate you pointing out another way writing can be valuable in terms of gaining access to dissociated material or ‘parts”.

  3. My therapist and I naturally fell into a very well-defined boundary of out-of-session contact. I refuse to call or email her, for fear of abusing both methods of communication. But I can text her during reasonable hours. She beauty is that she never, ever texts back. I know that she reads the texts in the moment, and that we can discuss them at the next session, so I feel very connected. But by not responding, she maintains a boundary and reinforces her belief that I can handle things between sessions. I am profoundly grateful that she was able to use texting as a tool and give it boundaries, rather than running from it.

  4. Interesting post. I’ve not seen you mention Complex PTSD as a diagnosis recently – it’s proposed for inclusion in the ICD-11. Draft criteria are on although a few parts I expected to see aren’t there.

    The European Journal of Psychotraumatology is currently publishing some interesting studies on Complex PTSD, including the overlap and differences in symptoms to Borderline personality disorder and PTSD.

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