The Therapeutic Frame
The therapeutic frame refers to the fundamental guidelines within which psychotherapy is conducted. Psychodynamic therapists are especially concerned with formulating the therapeutic frame to create a predictable and safe psychological and physical space for conducting therapy (Howard, 2009). It is imperative to have this space in counselling as it has been proven to optimise the conditions for the client to come to touch with his/her internal world, thus, enabling emergence of the transference relationship (Corsini, Wedding & Dumont, 2008).
By establishing the frame with clients, psychotherapists essentially set out a therapeutic contract so that when they or their clients deviate from the so formed contract, they can remain open in thinking out and understanding the deviation. To construct the therapeutic frame, psychodynamic therapists utilise conventions that are not only very discipliners but also entirely incompatible with social relationships. This makes the rame act as a demarcation to set the scene for therapy by delineating the therapeutic relationship from all other associations in the life of the client (Mathison, 2009).
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As such, the client is able to express their thoughts, fantasies and feelings, some of which would not be acceptable in many other types of relationships, and are actually discouraged and shunned in some therapeutic models. In the end, the client is facilitated to access unconscious materials through a framework comprised of clinical techniques that include transference and counter-transference exploration (Zunker, 2011). The analytic frame in psychotherapy is made up of two components: the analytic attitude and the analytic setting.
The analytic attitude refers to the stance adopted by the therapist towards the client, and this has four core features that have been established through many years of consistency in clinical practice – neutrality, reliability, abstinence and anonymity (Lemma cited in Howard, 2009). On the other hand, the analytic setting is the physical aspect of the therapy such as the management of place and time. Should the client feel safe enough within the established therapeutic frame, they are more able to utilise the presence of the therapist in facing their deprivations, hurts and anxieties that have made them seek the therapy.
They also feel safe in working with the therapist in a transference relationship. The ability to deploy the five features proposed by Lemma depends largely on the work completed in each therapy session and is further supported by supervision, reading and observation. Ethics and Ethical Dilemmas in Counselling In the course of their practice, psychotherapists are often faced by challenging circumstances in which it is virtually impossible to reconcile all the relevant principles of psychology and choose between the available options all of which have their benefits and shortcomings.
Nevertheless, ethical decisions in psychotherapy have to be strongly supported by valid ethical principles as provided by the Psychotherapy and Counselling Foundation of Australia (PACFA) and be free from any contradiction from others. However, it is imperative to note that a decision or course of action cannot be necessarily regarded as unethical just because it is contentious or because other practitioners would have arrived at different conclusions and decisions in the same situations (Akhtar, 2009).
The Psychotherapy and Counselling Federation of Australia (PACFA) states fidelity, autonomy, beneficence, non-maleficence, justice and self-respect as the ethical principles that direct the attention of psychotherapists to concentrate on their practice with appropriate responsibility and accountability for their actions (PACFA, 2011). Fidelity entails the trust bestowed in the practitioner by regarding confidentiality as an obligation that arises from the trust of the client (Corsini, Wedding & Dumont, 2008).
Autonomy concerns respect for the right of the clients to govern themselves and protects them from being manipulated by therapists against their personal wills, not even for favorable social ends (Nelson, 2002). Furthermore, the principle of beneficence requires practitioners to act in the best interests of their clients because of professional assessment while non-maleficence depicts the practitioners’ commitment to avoiding inflicting any harm on the client (Corey, 2009). Moving on, justice as a principle emphasises the impartial and fair treatment of all clients through provision f adequate services without any discrimination (PACFA, 2011). Finally, the principle of self-respect means that the psychotherapists apply all the aforementioned principles appropriately as entitlements for themselves by seeking therapy or counselling and other opportunities that lead to personal and professional development as necessary (Chandra, 2004). Setting the Parameters for the Counselling Process In setting the parameters for the counselling session the points to consider are namely discussing counselling goals, conducting an intake interview, use of assessment, and execution of the counselling process (Zunker, 2011).
The entire counselling process commences with an intake interview, moves to client assessment, on to diagnosing the client’s condition, then a counselling session to maintain the collaboration of the client, followed by intervention strategies, and finally evaluation of the therapy outcomes and future planning but individual needs may alter the parameters for some people (Mathison, 2009). On the first encounter with a client, the therapist should explain the frequency and length of the sessions, what is likely to happen during the sessions as well as the assurance of their confidentiality.
This means that the parameters begin with the counselling goals in order to enhance a framework in which the client-therapist relationships are important so that they can collaborate in formulating the fundamental reasons and objectives for getting involved in the counselling session (Coombs, 2004). In this case, the counsellor can simultaneously work as a mentor, a teacher, an overseer, and more often than not, a collaborator who establishes a relationship characterised by a working consensus.
The intake interview involves making the foundation to establish the client-therapist relationship and fulfills a noble role in assessing the client’s problems. In accordance with Ivey and Ivey (cited in Zunker, 2011), there exists a distinction between interviewing and counselling as interviewing may be regarded as the most basic method of gathering information, communicating and giving advice while counselling is a more personal and intensive process. As for diagnosis, identification of the client’s problem is crucial in providing a starting point from where objectives can be set to sort his/her issues.
The diagnostic and statistical manual of mental disorders (American Psychiatric Association, 2000) is utilised in identification of the mental health problem/s of the client that need further evaluation and management. However, diagnosis on dysfunctional or irrational thinking is determined by systems of appraisal that involve objective or subjective evaluation, and both in most cases (Zunker, 2011). Finally, the counselling process requires the counsellor to be ready for every encounter that is likely to involve a unique person who requires some special attention.
The client and the therapist need to form a strong bond that will remain intact throughout the counselling process. The relationship should be very inclusive in the sense that the counsellor should function as a facilitative collaborator involving the client in the continuous psychotherapy process (Howard, 2009). It is also good for the therapist to be knowledgeable in varied standardised and non-standardised assessment instruments because identifying the problems of the client is a major psychotherapy function.
The effective use of intervention skills such as occupational information is a crucial component of the counselling process for all aspects of dynamic psychotherapy (Weiner & Bornstein, 2009). Throughout the counselling process, the counsellor must maintain the established collaborative relationship in helping the client recover from their mental disturbances. Involving the Unconscious in the Counselling Process Freud introduced the concept of people being unaware of most of their mental processes, which has turned out to be recognised by psychologists as one of the most important ideas to be discovered in psychology (Singh, 2007).
This is the unconscious mental activity that whose motivation emanates from instinct that has been socialised and modified through interactions with significant others, especially the parents in the formative years of life. Should ineffective parenting or unfavorable interactions with others for older persons block the satisfaction of instinctual impulses such that the acceptable strategy of expressing oneself is not applicable, the unconscious motivators promptly propel the individual to meet those needs by any other available and convenient means (Clark, 2008).
The important concept is that, more often than not, individuals do not understand why they behave the way they do because the motivation is always unconscious. This is true even the client seeking counselling seems to give plausible explanations for some behaviors, and the explanation may be a defense covering that is socially acceptable that covers a motive that the individual is not aware of (Clark & Clark, 2004). Thus, all behaviors are understood to have a particular purpose although the person may not be aware of their intended purposes.
Discovering the motives behind unusual behaviors and formulating effective strategies of meeting the related needs of clients with unconscious abnormal behaviors is one of the most noble tasks of dynamic psychotherapists. Further inquiry into the unconscious mind in counselling is elaborated by Sigmund Freud’s emphasis on the significance of the unconscious mind as a data repository that has never come into the conscious part of the human mind or that had been briefly brought to the conscious mind but was suppressed (Corey, 2009).
Furthermore, Alfred Adler (cited in Clark, 2008) contends that it is only the parts of the human mind consciousness that are not fully comprehended that should be considered as unconscious. However, an important aspect of the unconscious process of the human mind is associated with the core convictions that an individual maintains in relating with the self, their life and the entire world (Singh, 2007). It is at this core level that an individual lacks the awareness of the influential convictions required for their normal functioning. The fundamental Rules of Counselling
The process of counselling requires that the therapist observe all the fundamental rules of neutrality abstinence as identified by Lemma (cited in Howard, 2009). As far as neutrality is concerned, psychotherapists are required to be non-judgmental in their entire practice, meaning that they should never criticise their clients but instead help them address their distress and anxieties (Clark & Clark, 2004). In this case, the practitioners need to apply significant efforts in managing their emotions even when under pressure. It is actually important to hold back from retaliating by holding onto and developing powerful, although uncomfortable mpulses and not acting on them (Corsini, Wedding & Dumont, 2008). The second fundamental rule of abstinence emphasises refrain from social conversations when making initial contacts with clients in order to establish and maintain a professional and therapeutic relationship from the start. Therapeutic abstinence facilitates the emergence of the negative transference that is usually accompanied by feelings of hostility, anger and disappointment towards the therapist and is therefore difficult for clients to maintain the abstinence (Howard, 2009).
Helping the clients express their hurting and disappointment feelings while maintaining abstinence is a highly developed skill required by all practitioners especially when the issue at hand is of high personal valence for the psychotherapist in that situation (Nelson, 2002). The Matter of Case Management Due to the large numbers of people being discharged from hospitals, most people with mental illnesses that require counselling no longer reside in hospitals. Thus, they have to fend for themselves in seeking the much needed psychotherapy services.
Kring, Johnson, Davison and Neale (2009) observe that lack of a centralised health facility at the locality where most health services were delivered in the 1960s and 70s made acquiring mental health services even more difficult. This prompted the National Institute of Mental Health to establish a program that gave grants to states to facilitate psychological management of the cases of people with mental illnesses such as schizophrenia that still required attention after discharge from the mental care facility (Kring et al, 2009). It is from this phenomenon that the mental program of case management emerged.
Initially, case management was ran by brokers of mental health services because they were more familiar with the case management system and could easily get patients and link them to psychotherapists (Clark, 2008). With advancement in time, other models of case management have developed with the major innovation being the acknowledgement that case managers are often required to administer direct clinical services and that those services are better when delivered by a team of specialists rather than be brokered out to individual practitioners (Mathison, 2009).
Thus, case managers are responsible for ensuring that the discharged patients are referred to affiliate psychotherapists and should then continue to monitor the progress of the client throughout the course of treatment. With increased need for comprehensive management of individuals discharged from mental healthcare institutions, case management is especially useful for counselling and treating clients recovering from such conditions as schizophrenia and substance-induced psychosis.
In fact, a multidisciplinary approach should provide psychotherapy by case management through provision of specialised services in the community setting such as psychotherapy, prescribing medication, vocational training, and assisting the homeless patients with acquiring employment and good housing (Kring et al. , 2009). In short, case management involves coordinating the range of psychological and medical services required by people with mental conditions to be functional and productive outside healthcare institutions.
Other important considerations: Fees for Psychotherapy services As far as the payment of fees for psychotherapeutic services is concerned, there are divided opinions on whether it is necessary to charge for services with a view to making progress in psychotherapy. On one hand, some psychotherapists hold to the conviction of their working experiences that it is essential for the clients to make a financial sacrifice for the accrued benefits while practitioners on the other hand believe that fee is essentially incidental to the outcome of the therapy (Weiner & Bornstein, 2009).
It is supported that the fees, more often than not, have a modest relationship to the outcome of the therapy rendered unto the client although making patients pay for the services can positively influence their attitudes towards the therapy (Corey, 2009). Regardless of the impact of paying fees, it is acceptable that most psychotherapy clients are expected to pay for the service therefore; there must be some careful discussions to make decisions on fee arrangements in the finalisation of the treatment contract.
Most people will often find it difficult to deliberate much on the money, and the psychotherapists are at times tempted to talk around instead of talking about the money (Mathison, 2009). This avoidance of discussing money is readily justified by such reasons as the therapist wants the patient to see that they actually value them and their psychological well-being regardless of the amount of money they are paying.
In as much as therapists set their own fees or have them set by other parties, it is imperative that they do not fail to inform their patients of the fees and be allowed to raise any questions they might be having about the charges. Although setting the charges is not supposed to be a prolonged bartering affair, therapists need to be prepared to discuss any variation of fees with individual clients with realistic considerations, just as they are always ready to schedule sessions on unplanned odd days for patients with difficulty in keeping convenient appointments (Weiner & Bornstein, 2009).
By explicitly discussing the fees, patients receive the information they are entitled to and also facilitate communication of all the aspects of their lives as important elements of discussion during the session. In fact, money matters have some role in everyone’s life, and therapists who avoid discussing such obvious matters inadvertently give an implication that financial concerns and other unsaid subjects are not important and should not be brought up during the dynamic psychotherapy session.
Finally, it is worth noting that psychotherapists do have in mind the specific kind of patients with a right to expecting or not expecting any refund of their money. Patients attending psychotherapy sessions pay for the professional services of the therapist, not some piece of merchandise that has a money-back guarantee in case they are not satisfied, nor do they take a free trial offer when attending counselling (Kring et al. 2009). This means that patients should pay their treatment fees regularly right from the beginning of the contract of treatment. Concisely, whether the clients receive the worth of their money or not cannot be measured by the pace of their recovery progress. It is solely a function of whether the therapist is qualified and is helping the clients by exercising conscientious efforts.
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