Australasian Journal Of Psychoanalytic Psychotherapy
NO.1&2 - 2022
Australasian Journal Of
Psychoanalytic Psychotherapy
NO.1&2 - 2022

The Psychotherapeutic Frame and Its Relation to Patient Abuse

Lyndsey Fletcher

This paper was presented at the NSW Institute of Psychotherapy. The editors thought it would be of interest to readers in other States as well.

One of the neglected areas for open, honest discourse amongst psychotherapists would seem to be the concept of the psychotherapeutic frame, particularly the actual details of the therapeutic setting that we provide for patients in our clinical practices. Why is it such a difficult area to know and to discuss and why is the subject so taboo? We can all comfortably, excitedly discuss theoretical issues and clinical material but what is seldom mentioned is the frame – the boundaries of the psychotherapeutic setting. Maybe such practical details seem too prosaic, too mundane. There is a blind assumption that we all share, know and respect the same basic frame. Yet through experience and observation we are all aware of the enormous variations which exist in the actual frames we provide for our patients and the manner in which we maintain boundaries. It would seem that the more we consciously know, the less we are able, openly and honestly, to discuss the frame. Perhaps it is our attempt to maintain our illusion – our illusion of a shared frame. Do we, through denial, protect ourselves from having to disturb or question our own practices?

Maybe we turn a blind eye to the obvious variations in the frame because of our narcissistic need to preserve our self-idealisation, grandiosity and omnipotence. Any shame or guilt we feel about breaks in our frame are readily split off and projected onto others. In our efforts to defend ourselves from having to analyse our own behaviour, we can be hostile and devaluing of perceived errant colleagues, other schools of thought.

Such narcissistic defences are not responsive to cognitive reasoning. Hearing different ideas can be stimulating only if they confirm our own position, but if they do not fit and are dystonic to ourselves and our practice, we tend to criticise, denigrate and reject them. At the very least they make no impact at all. We turn our blind eye, our deaf ear and maybe even our tied tongue to them, in our desperate attempt to maintain our illusion about ourselves, and in this case, about our frame.

Another complicating factor in openly discussing our frames is the fact that boundaries and ethics are so interlinked. Ethical issues can arouse such intense feelings in us that we may have to contain them by resorting to the Christian ethic ‘Let he who is without sin cast the first stone’. Our guilt inhibits us; fear of self-righteous condemnation from ourselves and from others inhibits us and so blocks communication.

Whatever the underlying issues may be we cannot deny that the question of boundaries and the actual individual frame in which we practise is a very controversial and evocative topic.

My initial response to the task of discussing the frame was to take refuge in the literature and I was reassured to find that many writers had sought a similar protection. Many have sought refuge in extremely erudite terminology which then protects the reader from direct confrontation and keeps information esoteric and distant rather than directly applicable to everyday practice. Many papers are not ‘reader friendly’. Because it is such a potentially exposing topic, it is difficult to discuss the issues surrounding the frame in even a ‘listener friendly’ fashion.

The Psychotherapeutic Frame: The Theory
It would appear from the literature that despite the vast theoretical differences dividing psychotherapy, which places practitioners in sharply uncongenial schools and factions, the actual analytic setting – the frame – has scarcely been altered. The ground rules of the frame continue to be defined in much the same way as Freud suggested. It seems to me that what has changed is the way in which we conceptualise the frame and the deeper appreciation we have of its essential, integral role in the therapeutic process. This change can perhaps be illustrated graphically The frame has evolved from a linear concept of ground rules, providing a firm foundation, to a two-dimensional concept of a picture frame delineating boundaries, to a more three-dimensional concept of a vessel with holding and containing connotations. To this graphic we could perhaps add a shadow area to represent a fourth dimension – the illusory, unknown, unconscious aspect of the frame.

The basic ground rules are no longer just seen as a set of tenets to safeguard the transference and to preserve the integrity of the therapeutic relationship. The frame in itself is seen to embody important therapeutic experiences.

If this aspect of the frame with its multi-dimensional qualities can be more fully appreciated, then it is easier to understand and accept why it is so important to respect all aspects of the boundaries in maintaining the frame.

As Freud (1912, 1915) laid the foundation stones on which our present frame is based, it is important to refresh our memories as to his definition. In summary, he enumerated several essential elements of the analytic setting:

  1. Set fee and time and frequency of sessions.
  2. The analyst should be reliable, on time, breathing and alive.
  3. The analyst should keep awake and become preoccupied with the patient, with evenly suspended attention; no note-taking.
  4. The analyst should work in a quiet, well-lit, undisturbed room.
  5. The patient should be comfortable, on a couch with a rug and with water available.
  6. The method is of objective observation with physician-like concern, mirroring with surgeon-like detachment.
  7. The analyst:
    – is neutral and abstemious
    – is free from moral judgements
    – does not intrude details of personal life or ideas or external
    – reality (naturally if there is a war or earthquake, or if the king
    – dies, the analyst is not unaware [Winnicott, 1958, p. 285])
    – is free from temper tantrums, and does not retaliate
    – is free from compulsive falling in love
    – maintains confidentiality
  8. Analysts are responsible for their own countertransference – Freud recommended personal analysis with regular ‘top ups’.
  9. He advocated the fundamental rule of free association.
  10. He warned against using a case for scientific purposes while the patient was still in treatment.
  11. The analyst survives.

As Winnicott (1955, p. 286) in his reflections on these issues observed – ‘The whole thing adds up to the fact that analysts behave themselves.’ Ferenczi (1929) was among the first to question the analytic scientific techniques, seeing them as hypocritical, cruel, insincere and insensitive. He felt some patients needed to be ‘adopted and thus to partake of the advantages of the nursery’ (Malcolm, 1981, p. 133). Leo Stone (1961) and others further developed this theme, thoughtfully advocating flexibility for the sake of humaneness.

Eissler (1953, p. 536) attempted to contain such flexibility by delineating the concept of ‘parameters’. He uses the term ‘parameter’ for a carefully considered deviation from analytic passivity to active intervention, which is usually to do with direct management issues, advice and directives. Parameters are only admissible if the basic rules of the frame can subsequently be re-established – for example in stalemates, or phobic, suicidal or homicidal episodes.

In 1952 Marion Milner gave us the more graphic image of the frame to help conceptualise the setting and the ground rules, by likening them to the frame surrounding a work of art.

She defines the frame as an area within which what is perceived has to be taken symbolically, while that which is outside can be taken more literally. It is formed by the distinctive set of conditions which form the boundaries between the interactional field between the therapist and patient and the outside reality.

Winnicott (1955) developed a further understanding of the analytic setting by introducing a more three-dimensional quality to the frame – its holding qualities. Bion’s (1977) concept of the container has added further clarity to this dimension of a holding space. Winnicott specifically recognised that the frame itself embodies important therapeutic experiences. He felt that for certain patients who had experienced a failure of good enough mothering (a basic fault, as Balint described it) or unempathic mothering (as Kohut described it) the management of the frame, the analytic setting, is the whole therapeutic process.

Yet another dimension was identified by Jose Bleger (1967, p. 511), who further developed Winnicott’s concept of the essential aspect of the mother/ child symbiosis which is embodied in the frame. He talks of the psychoanalytic situation as involving two fundamental aspects:

1. The Process, which is the therapeutic relationship that is analysed and interpreted – the variable.
2. The Non-process, which is the frame within whose boundaries this process takes place – the constants.

Bleger further suggests that this non-process, the frame, the constant, has two meanings, a conscious and an unconscious function. This unconscious function could be visualised as the shadow area to represent the fourth dimension.

Indeed, as I was writing I found myself delineating the difference between the conscious and unconscious function, as we do with fantasy, with an F or a Ph (Isaacs, 1958). It helped me to conceptualise these two aspects of the frame: frame with an F and frame with a Ph.

  1. The F frame refers to the explicit ground rules that are established and maintained by the therapist and consciously accepted by the patient, including the therapeutic alliance. With good enough holding by the frame, the patient is involved in ‘as if’ experiences ‘as if’ being fed, being held, etc.
  2. The Ph frame refers to the implicit aspects. Bleger suggests that we need to acknowledge that the frame also has unconscious meanings beyond the known. He talks of the ghost world, the metaframe (Bleger, p. 512) – lying beyond that which is immediate and obvious; the holding aspects where the frame is the mother’s body, the chair is the mother’s arms. The Ph frame ‘is’; it is not ‘symbolic of’. As Winnicott suggests (1955, p. 283), it is re-experiencing that stage of ‘primary narcissism where the environment is holding the individual and at the same time the individual knows of no environment and is at one with it’. We only become aware of it when it is missing or changes. We have all had glimpses of this Ph frame if we have ever had to change the time of a session, or been a minute or so late. Even a slight change within the room can elicit such responses as “I got such a shock”, “I never knew how important it was”, “I felt this sudden panic, I don’t know why”!

For Robert Langs (1981, p. 469), arch doyen of the defenders of the faith, the frame, is one of the most prolific writers regarding the role and the maintenance of the frame. He asserts that the humanistic maintenance of the frame is one of the essential components of psychotherapy. He suggests that most, if not all, deviations and breaks in the frame contain important countertransference inputs, stressing that any deviation in the ground rules has wide and deeply significant consequences for the patient, for whom only a certain portion are modifiable through subsequent interpretative work. He feels some effects are impossible to alter through any means at all.

Langs (1973) is one of the only writers who itemises elements of the frame, rule by rule, deviation by deviation. By contrast most other authors make only passing reference to the practical details which institute the frame and even then they put them in brackets – for example ‘The frame (fees, set times, frequency, etc.)’. The ‘etc.’ seems to assume that we all know. But do we?

The Frame: From Theory to Practice
The theory suggests that there is a common frame. The reality is that there are many and varied frames in practice.

I feel we should all stop and think for a moment as to how we learnt about the frame and as to whether our intellectual understanding is in fact translated into our practice.

We need to be aware of the various factors that have contributed t our learning. Apart from didactic input there is also the significant impact of our experiential learning. Mostly I think we learn about the frame from our own personal therapy experience, but then there is the inevitable struggle within us between the introjects of our therapist/ analysts, our supervisors, our colleagues and our own parents. We need to question and be responsible for any inclination either to comply rigidly with or rebel against these models no matter how pure or how variant. We must be prepared to honestly question how we establish and maintain the details of the frame in our individual clinical practices and not simply hide in theory or in our illusions – particularly the illusion that we share a common frame. From observation and experience we must all be aware of very marked differences that exist amongst us in the actual practice and maintenance of even the most fundamental ground rules of the frame.

For example
Times of sessions vary from forty-five minutes to one hour and more. (As a colleague once remarked, at forty-five minutes the item number changes from 138 to 140 precisely!) Some end sessions with precision – others have flexible endings.
Set fees vary from $20 to $160 or more per session.
Some increase fees regularly- others rarely.
Some charge full fee for missed sessions – others charge half-fee or no fee.
Some psychotherapists use a couch five times a week – others a chair, once to twice a week.
Some tell personal anecdotes – others maintain anonymity.
Some have contact with patient outside of sessions – others avoid any contact.
Some gossip, tell anecdotes about patients – others respect confidentiality.
Some loan books, articles, etc. – others, no concrete giving.
Some shake hands.
Some touch and cuddle patients – others feel any physical contact is contaminating.
Some make friends with patients.
Some have sex with patients.
Some live with former patients.
Some feel once a patient, always a patient – others feel that the professional relationship ends on termination.
Some use patients for scientific purposes while the patient is still in therapy – others consider this a violation of confidentiality.
Some use first names – others, formal address.
Some handle payments as part of therapy – others handle payment outside therapy, involving a third party (secretary).
Some feel it is an abuse to see too many patients a day – some see ten or more
Some see supervision as an integral part of their frame – others feel it is an infringement of frame.
Some see patients’ relatives and friends – others see this as contamination. Some accept referrals from patients.
Some use videotapes and tape-recorders with and without patient consent.
Some don’t charge above the refundable fee – others feel it is important for patients to pay a significant amount.

So when we honestly look at specific elements of the particular frame we each provide we are forced to acknowledge that very fundamental differences do exist, and yet we continue to talk and authors continue to write as if there is an established common code of practice, a common frame.

From some quarters of the literature there would seem to be a pluralistic view that metapsychology, self psychology and object relations are all equal and alternate views, all metaphors for the same observable data. Some view the curative element in therapy as reconstructive; others see it as interactional. Despite the diversity of theory there seems to be some consensus that there is broadly one clinical method, one basic frame. This leads one to postulate, is it the medium and not the message?

If the medium, the frame, is such a significant element in psychotherapy how do we reconcile the lack of consensus regarding the ground rules of this clinical method? If there is such a credibility gap between our theory and practice, then surely it deserves a great deal of our attention – not denial and not divergence into our theoretical differences.

The Frame as a Concept
The frame has been variously conceptualised as:

– the means to safeguard the integrity of both the patient and the therapist;
– the means to contain the transference and countertransference reactions;
– as a holding environment which provides a silent, trustworthy, confidential background of safety to support the development of knowledge through insight;
– as providing a transitional space, analagous to the mother supplying the non-impinging supportive background;
– as creating a nurturing, caretaking, safe environment – a play space with a listening, empathic presence.

I find it useful to conceptualise this play space as a transitional area (Winnicott, 1958), perhaps even with Teddy Bear connotations. It requires an empathic mother to know about the importance of the Teddy Bear transitional object to her child. It requires her as caretaker to provide, maintain and safeguard the Teddy, not knowing specifically how its sameness and presence are so important.

Similarly we as therapists need to be empathically aware of the transitional aspects of the frame we provide, both the F and Ph aspects of it. We need to be constantly aware of the very special, unique, highly precious, fragile aspects of it, so that we can know the vital importance of accepting our responsibility in providing, monitoring and caretaking the boundaries of the frame we establish with each patient.

A Faulty Frame
Too often we minimise our responsibility in safeguarding the frame and almost glibly rationalise any deviation or break with the cliche that it’s all ‘grist for the therapeutic mill’!

If we truly appreciate the four-dimensional aspect of the frame, we will realise that this is a far too superficial and simplistic approach, As Howard Bacal said, ‘It’s like believing in the Rumpelstiltskin Myth, that just by naming a reaction or a problem, it will disappear’. If we as therapists have broken the frame, then we as the therapeutic mill are malfunctioning and so we are no longer as able to grind the grist as effectively. We may deny the full impact of the break for the patient because of our countertransference blindness and so be simply unaware of or unresponsive to painful reactions hidden in the patient’s material. We may be so uncomfortable with the material that arises from a deviation that we will avoid it, deny it or interpret it intraphysically or historically, thus absolving ourselves. Alternatively it is a naive assumption that the grist will automatically be available to grind. Once the frame has been broken, once ambiguities and changes have been introduced, it is no longer safe to provide the grist, because the firm, basic hold has been undermined.

As the Ph of the frame will have been threatened, the patient will desperately, often unconsciously, attempt to adapt to protect their inner self, so the real grist may not appear. It is like a catch-22; the frame can only be analysed within a safe frame. A flight into health or a flight from therapy may result from a broken frame prefaced by “I don’t know why, but I feel better”, or “I don’t know why, but I’ve got to leave”, But perhaps more commonly, the conscious, observing self of the patient will adapt to breaks in the frame by colluding with the therapist, by compliance, by fitting in, to ensure the ongoing support and help from the therapist.

The break may in fact fit in with the patient’s frame, his pattern of relationship, It will be experienced as a familiar repetition – for example a patient who has suffered exploitation may readily accept a large raise in fee, or a break of confidentiality; it’s so ego-syntonic that It does not arouse deep grist. Patients readily identify with the aggressor; they introject the blame and the anger to maintain the relationship, A loosely maintained frame may even produce an adaptive ‘iatrogenic false self’ in the patient.

The patient may accept whatever the therapist does to protect both of them from knowing the real significance of the broken rules. The patient can become so supersensitive to the therapist’s needs that a role reversal occurs, with the patient carefully attuned to meet the therapist’s needs, no matter how devious, subtle, no matter what the cost to themselves emotionally and financially.

The frame that we provide is crucial not only for its reality aspects of holding and containing but also for what it unconsciously represents for the patient. These are the Ph illusory aspects which are to do with the actual experience of the safe creative space within the frame: the holding, nurturing, containing experience; the play area with a listening interactive presence which when safe enough allows patients to experience and know the intimacy of themselves. I’ve heard of a patient who described this phenomenon in terms of her need to find a white room within a house. She felt that only when the house was solid, unchanging and secure was she able to go exploring to find the white room within the house, without having to be on the alert against dangers and intruders, She felt this white room would be bare of all clutter, save a chair to hold her. There would be no windows, so she would not be distracted by outside realities. Only within this room did she feel she would be free to get to know herself – “where I can just play with my own thoughts”.

So obviously this white room, this inner space, is very private, very fragile. The patient can only risk experiencing this space in therapy when the F frame is safe enough. The risk is a threat to the Very existence of their inner self, the risk of annihilation. It is only under extraordinarily safe and trustworthy conditions that the patient can risk unlocking the white door. This trust develops through the manner in which we maintain the boundaries of the F frame. It must be fully safeguarded and taken seriously. There are ‘life and death’ issues at stake regarding the inner life of our patients.

Is there a vague analogy between psychotherapy and a roller’ coaster ride or a plane journey? We only risk such potentially life- threatening experiences if we trust that the design is scientifically well based and tested and that full recognition is given to the risk involved by continued checks and maintenance of equipment. We feel safer by knowing that the responsibility is not just left to the individual operator, but safety regulations are formalised and implemented. But what of the patient who contracts to partake of a psychotherapy journey? A faulty frame involves very many risk factors to a patient’s inner life which can have painful and destructive consequences. Is there a process to safeguard the welfare of patients? What are our safety regulations? What are the rights of patients?

Patient Abuse and Child Abuse
Over the years society has slowly and resistantly become aware of the extent of child abuse in the community and is gradually recognising the rights of children and their need for help and for safety regulations to protect them from exploitation and abuse.

Are we similarly resistant to becoming aware of the extent of patient abuse within the psychotherapy community and the rights of patients to protection from exploitation?

As I was reading the literature on the psychotherapeutic frame, I was struck by some similarities between child abuse and patient abuse. If in fact there is a second chance in the therapeutic experience based on providing a good enough frame which reverberates with early childhood experiences, then could there not also be a second chance for child abuse?

Patients are at risk of abuse when they become caught up in a system where they are exploited and used for the fulfilment of their therapist’s needs.

As with the abused child, the patient can then feel the helpless victim with no rights, no one to turn to, trapped by the collusion and denial of the broader psychotherapy community.

Some patients leave therapy but like the abused child they carry the feeling and the projection that it was all their fault. It is hard to complain; who would believe them? Just as children’s perceptions are often dismissed on the grounds of their immaturity, patients’ perceptions of their therapy experiences are often invalidated on the grounds of transference or psychopathology.

Often abused patients will comply with their therapist, desperately denying their own needs as if their very survival depends on sticking with the abusive therapist. They internalise the blame and see their therapist as all good and omnipotent. They will collude with any violation of the frame so the therapist can feel validated. Patients can become sensitively attuned to meeting their therapist’s needs at all costs. An abused child I once saw put it so succinctly when she said, “I just want to be held but I know I have to look after Mum ‘cause I think she just wants to be held, too, and she is all I’ve got”.

Sometimes a role reversal occurs as patients struggle to help their therapists become more holding by alerting them to deviant behaviour. Patients often make valiant efforts to teach their therapist to become better therapists.

Briefly, I would like to follow the possible analogy between child abuse and patient abuse a little further in the hope that it could alert us to possible risk factors developing in our own practice. A rather simplistic conceptualisation of some of the factors involved in placing a child at risk of abuse from its caretaker involves four very broad areas (Pollock and Steele, 1972):

Early, severe maternal deprivation of the caretakers Themselves
High, unrealistic expectations of the child where the child is seen as a need gratifying object for the caretaker
Isolation – where the caretakers are alone, feeling alienated, not part of any support system
A crisis, which may be personal or environmental.

The first three areas can be seen as the predisposing risk factors. It then only takes a crisis to precipitate an actual act of abuse or intensification of abusive behaviour.

Can these very general areas offer anything towards our understanding of possible factors that may be involved in therapists at risk of abusing their patient? More importantly can they alert us to the possibility of some constructive preventive suggestions? Maybe we as therapists need more support from a holding, valuing network if we or to be able to adequately hold our patient.

Now to look more specifically at these predisposing factors for abuse in relation to psychotherapy practice. In so doing it gives us an opportunity not only to run our own checklist within ourselves, but also offers the hope that we as a professional group may become more aware of possible risk factors and so fine-tune some areas of functioning to more responsively meet the professional needs of our members.

1. Deprivation
For psychotherapists, this could cover three broad areas:

(a) Our own early childhood experience.
(b) Our own personal psychotherapy or analytic experience. I am sure all of us are becoming more questioning of the self-righteous assumption that a personal psychotherapy or analysis is a magical absolution of problems, be it 300 hours or 10 years. We still do have some over-idealised ‘blind faith’ in analysis, despite all the evidence to the contrary we see around us and experience within ourselves. Having more than one such experience tends to introduce reality and humble one to the ongoing responsibility of being aware of and caring for ourselves.
(c) Didactic deprivation. We all recognise the need for a good enough didactic background, but are we aware enough of our ongoing need for didactic nurturance? Even our ‘blind spots’ and controversial areas need to be known, questioned and explored – for example the frame.

2. Unrealistic Expectations
Unrealistic expectations can occur when our patients become a need gratifying object for us. This is a very ‘at risk’ area, one which all of us can identify as having at times affected our frame.

(a) We need our patient to confirm our omnipotence, our skill, our theories, our adequacy to ourselves and to our colleagues.
(b) We need our patient, beyond what is reasonable, to fill our hours and pay high fees, for a viable practice. Does our practice have a more entrepreneurial orientation than a therapeutic one?
(c) We need our patient to fill our personal emptiness, our need to be loved, valued and appreciated, sometimes to the extent of becoming a friend or a lover.
(d) We need our patients for grandiosity, using them for scientific papers to exhibit as proof of our competence.
(e) We need our patients for factional wars, for gossip, to use what they say as ammunition for our professional battles and splits, and for personal needs to impress others.

3. Isolation
The sense of isolation and sometimes alienation which is so characteristic of abusive caretakers is often very real for psychotherapists. Isolation is a reality for those of us in private practice, often tucked away in suburbia in lonely rooms. Our work is so intense yet confidential that we are left carrying heavy loads often with no support and no outlet.

When we meet with colleagues, open, honest communication is often inhibited by loyalty factors, hierarchical fantasies, perceived alliances, factionalism and splits. A lack of trust can develop between colleagues because there are so many unmentionable issues like frame and boundary differences, the tension between medical and nonmedical, the referral network These all block open communication, which exacerbates our sense of isolation and alienation.

We may develop a professional false self, appearing contained and competent to our colleagues, so we unwittingly turn to our patients for an outlet. We may spill over to them using them for gratification for our support.

The above areas cover some of the issues that may predispose us, as therapists, to abuse our patients. A crisis may actually precipitate more blatant abuse.

4. Crisis
To the ‘at risk’ psychotherapist the crisis may be:

(a) A ‘special’ particular patient who may arouse strong countertransference and cause a deviation in the frame and so suffer abuse.
(b) A personal crisis for the therapist may be the straw which breaks the holding frame, that precipitates the abuse of a patient. The loss of a personal relationship for the therapist would seem to be such a precipitant in some cases.
(c) The crisis may be a culmination of private stress or overwork.

I offer this confronting analogy between child abuse and patient abuse as food for thought and to stimulate discussion. Somewhere we need more safeguards and more holding provisions. We all need to be more prepared to offer support, to reach out to troubled colleagues for their sake and for the sake of their patients, not just turn a ‘blind eye’ or accept their reassurance that all is well. This is an extremely difficult and delicate area. From my experience in working with child abuse I have been impressed with the abusive, forceful, plausible, rationalisation for actions; by denial and resistance to offers of support. Reaching out often requires a team approach and group support.

Concluding Thoughts
We all need to think about our frame and how we actually practise. Is there a difference between what we think we do and what we actually do?

We all need our illusions and faith in our illusions in order to live end to practise. We tend to protect our illusions by splitting and projection. We must be very careful of a we/they defence developing: we are kosher; they are not!

The whole concept of the frame has to be brought out of the unmentionable category, or the too-hard basket or the ‘blind faith’ illusory space. We can no longer collude with the myth that we share a common frame. Surely the time has come to confront this evocative topic and work towards developing some consensus regarding our boundaries and what are acceptable standards of practice for psychotherapists. It requires much thought and open and honest discussion if there are to be any constructive formulations and hope rather than destructive persecution, pessimism, despair and withdrawal. It is painful process, because as Hanna Segal said, ‘Thinking robs us of the luxury of blind faith’ – blind faith in ourselves, in our frames, in our theoretical position, in our analysts, in our supervisors, in our professional group.

We are all responsible for ourselves and the roles we fulfil. We must be wary of abusing others to expiate our own doubts, our own guilt. We must be wary of protecting ourselves from questioning and thinking about our own functioning by becoming exclusive, isolated, omnipotent and elitist, and hiding behind big words and complicated terminology, or by withdrawal and burying our head in the sand about what is happening in our profession.

We all need to be more aware of the multi-dimensional aspects of the frame so that we can more fully appreciate the necessity of defining the essential elements of a shared frame and not just accept idiosyncratic modifications. We need to be alert to the ‘at risk’ factors which exist within our profession which can seriously affect our ability to maintain the frame and so lead to patient abuse. I also feel we need more supportive safeguards which are firm and holding enough to protect the welfare of ourselves and our colleagues, with the ultimate responsibility being that they ensure and safeguard the welfare of our patients.

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