David E. Ness, MA, MD

"What  should I say now?” is something that we all weigh as we talk with our patients.  Often, the advice about what to say reflects a particular theoretical outlook  (eg, “Address dysfunctional emotions, behaviors, and cognitions,” or “Adapt the  degree of emphasis on transference interpretation to the specific type and 

More  simply, the advice is to empathize with and to elicit feelings (“Go where the  affect is”). Whatever theoretical view we might take, the challenge is to  relate what we say to a concept of what is going on in the conversation at the  time, and where we think the conversation might go after we say it. Key  guidance with this can be provided by the concept of  “frame.”

We  are familiar with the idea of the “framework of 

,” which refers to the  arrangements and understanding that are “contracted” between therapist and  patient at the initiation of psychotherapy.

 However, the concept of  frame discussed here comes from sociology and linguistics.  It is “built up” from such elements as roles, tasks, culture, and the  interpersonal setting, as well as from individual perspective.

In linguistics, the concept of frame initially derived from  efforts to explain the cognitive mechanisms by which we interpret ambiguous language: it is defined as a  “schema” or as a “structure of expectation.”

 A simple example is  the question, “How are you?” In a psychiatric interview the frame of this query  would be one of clinical examination that establishes the expectation of a  non-casual reply. A very different interpretation and response is expected if  you encounter an acquaintance.

How  might the concept of frame help us with psychiatric communication? The task of  identifying a frame requires us to identify the multiple social and subjective  elements that comprise “What is it that’s going on here?” This helps us to  dissect the elements of a discourse, therapeutic or otherwise, by identifying  the multiple frames that may exist concurrently, concordantly, or in conflict  with each other. This applies particularly to our  work as psychiatrists because our therapeutic frame necessarily conflicts with the  patient’s maladaptive frame.

The  usefulness of the frame concept to us, then, lies in how it helps us to arrive  at an integrated view of the 

, and how it can suggest  ways to negotiate frame conflict. Multiple frames exist concurrently, and they  may be concordant or they may be in conflict. In any conversation, we may  observe the presence of multiple frames, the cueing of frames by language,  frames in conflict, and successful or unsuccessful efforts to negotiate frames.

Let  us consider a clinical example to illustrate a conflict in frames and  negotiation through reframing. Frank, a 22-year-old man, has been treated for  substance abuse, oppositional behavior, and abusive behavior toward women. He  is being discharged in two days.

I’m afraid I’ll sabotage myself, go right back to using drugs and screwing up.

Well, the good news is that you are insightful about this. As long as you are  aware of it, you won’t.

 I’m worried about going back to old patterns of behavior . . . messing up . . .  I really know only the old me.

 I don’t think it’s fair to say you’re messing up. That’s not all of you . . .  You are insightful about it. You know you will get caught. Maybe you are  sticking it to your family, maybe to react.

 Yeah but . . . if I do something bad, I don’t feel bad about it . . . I’ll feel  it sucks but it won’t keep me from doing things.

 It sounds like you are trying to get the reactions.

This dialogue appears to end in a  standoff, with the patient insistently repeating his worries and the  psychiatrist repeatedly appealing to his insight: the speakers are “not on the  same wavelength.” The patient’s insistent repetition  of his worries, in his frame, indicates that the standoff will not yield solely  to more suggestions about utilizing insight. Frame analysis can suggest an  integrative response to the apparent standoff-a way to negotiate with the  patient about how to address his concerns. The first step would be to  identify the conflicting frames. The second would be to reframe in a manner  that integrates both of these frames, so that psychiatrist and patient have  something to work with. The psychiatrist’s frame might be “the preventive value  of insight,” while the patient’s frame might be “the potency of old patterns of  bad behavior.”

“What  is it that’s going on here?” reaches beyond what is referenced within the  dialogue itself. Much is implied. It includes the patient’s treatment while in  the hospital (insight-oriented); the imminence of discharge from the hospital  and his anxiety about this; and probably his tendency to “stick it to”  authority figures. Indeed, he is more or less “sticking it to” the staff here,  by projecting helplessness that, in effect, throws the problem into their court  in the final hours of treatment.

What  is needed is an integrative reframing: one that incorporates insight, Frank’s  anxiety about discharge to the “real” world, his recognition of the tendency to  self-sabotage, and-perhaps most importantly-his  externalization of agency onto the staff for achieving enough behavioral  change. All of these are  components of “what is going on here,” of the essential frame. One such  reframing might be, “

 to apply new  knowledge to preventing bad behavior.” There are many ways to present this. Here  is one possibility:

“What sucks? What have you  learned? How do you think you can go from ‘sucks’ to helping yourself to do what is best for you?”

In this example of reframing, insight is clearly requested; the  setting of imminent discharge is referenced in “What have you learned?”; the  problem of self-sabotage is acknowledged in “sucks”; and the work of taking agency-“helping yourself”-is encouraged in a collaborative way with “How  do you think…?” This integrative reframing is both specific enough and  open-ended enough to invite the patient to reply, in any of several ways.  Inviting his collaboration is a key step in negotiating how to address the  patient’s concerns.

Another  possible way to present this reframing to the patient is:

“You are about to leave, but you sound  afraid that the pull to sabotage yourself will  overwhelm anything that you’ve gained here.”

In contrast to the previous  example, nothing is requested. This example incorporates the elements of an  integrative frame: these include references to imminent discharge and the  attendant anxiety about it, to the problem of self-sabotage, and to the  patient’s having developed insight (“anything that you’ve gained here”). By  virtue of being a statement rather than a question, this comment also  challenges the patient’s resistance to taking agency: its phrasing obligates a  reply, but leaves it to the patient to decide how and with what to respond. The  linguistic frame of the intervention (“reflection back to him of his fears”)  leaves his options for reply even more open-ended than in the previous example.  Which intervention to chose depends on, for example, characteristics of the  patient and his treatment and the stage of the discussion.

There  are different comments that present an integrative reframing, but would do so in  a more indirect, implicit, and open-ended way. Sometimes these carry more  emotional impact. Reflecting back the patient’s own words, for example, can  underline the patient’s own emotional concerns in his own voice and obligate a  reply very forcefully:

“Sabotage  yourself?”
   “I  can hear that you’re worried.”
   “Only  the old you, is it?”

The  echoing technique and the severe brevity of these reflected phrases might seem  to violate the idea of integrative reframing, or even of framing per se. But  each one, so to speak, crystallizes the several facets of what is going on  here. In addition, each one is given force and validity by the psychiatrist’s  special regard for the patient’s words.


 We  have seen how frames in conflict may be an underlying feature of standoffs in  treatment between the patient and the inpatient team. Frame analysis can not  only help us to discern the roots of such standoffs but also to conceptualize  specific ways of addressing the conflicts in therapeutic language with the  patient, with the goal of forging an integrated approach to treatment.  Integrative reframing is one way a person may be moved by words. As with art,  music, and literature, the emotional impact of an experience derives from its  richness of associations. That belief underlies much of our hope in working as  therapists.

 Stewart RL. Psychoanalysis  and psychoanalytic psychotherapy. In Kaplan HI, Freedman AM, Sadock BJ, Eds. 

,  Vol 2. Baltimore: Williams & Wilkins; 1980: 2113-2143.
  

 Kernberg OF, Selzer MA,  Koenigsberg HW, et al. 

Psychodynamic  Psychotherapy of Borderline Patients

 Goffman E. Frame Analysis:  An Essay on the Organization of Experience. New York: Harper & Row; 1974.
  

 Tannen D. What’s in a frame?  Surface evidence for underlying expectations. In: Tannen D, Ed. 

 New York: Oxford University Press; 1993.

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Frame analysis can not only help us to discern the roots of such standoffs but also to conceptualize specific ways of addressing the conflicts in therapeutic language with the patient, with the goal of forging an integrated approach to treatment.

David E. Ness, MA, MD

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