Academic journal article American Journal of Psychotherapy

The Shifting Landscape of Psychotherapy in Residency: Stable Framework of Change

Academic journal article American Journal of Psychotherapy

The Shifting Landscape of Psychotherapy in Residency: Stable Framework of Change

Article excerpt

Stable Framework of Change*

This paper explores the impact of change on a psychiatry trainee's development through a case presentation. During training, psychiatry residents are exposed to constant transitions with frequent shifts in training sites and supervisors. Change is perhaps the most consistent characteristic of residency training. And yet, the maintenance of a changeless, stable frame is considered the gold standard for psychotherapy. The effect of a constantly shifting framework on the training therapist, the patient, and the therapy itself is considered. Reflecting on the multiple and varied themes elucidated by the case, it is evident that there are rich opportunities for growth for both the patient and the trainee who embark on a course of therapy together. Contrary to widely held beliefs, rather than diluting the psychotherapy and diminishing the learning experience, change can be a stimulating and enriching force.


The vantage point from which I (C.G.) begin this paper is that of a trainee in the final months of a psychiatry residency. My training program has been rich in diverse, and at times challenging, psychotherapeutic encounters and supervisory relationships. The period of passage from neophyte therapist to fully credentialed psychiatrist is not a gentle transition. The experience might best be characterized by a term borrowed from the field of evolutionary biology-punctuated equilibrium. Between relatively short stable periods are chaotic bursts of change. Physical and conceptual shifts must occur regularly with each change in setting, modality, and supervisor-all demanding rapid acclimatization. The most consistent factor of residency is, in fact, extreme change. And yet, the maintenance of a changeless, stable frame is presented as the psychotherapeutic gold standard. What impact, then, would a constantly shifting framework have on a training therapist, the patient, and the therapy itself?

Sharing his clinical wisdom in "Recommendations to Physicians Practising Psycho-analysis," Freud advised adherence to certain rules of technique as a means of averting unfortunate outcomes in therapy (1). In a follow-up paper, these rules were presented as helpful instructions to guide the opening gambits of therapy (2).

Acknowledging the utility of Freud's advice, later authors have reinforced this theme of structure (3, 4). For psychotherapy to unfold smoothly, certain fundamental factors must be established as constants from the outset. These include: the fee, the timing of the appointment, both with regards to length and frequency, guaranteed confidentiality, and setting, all of which must remain firmly fixed if a stable therapeutic framework is to be created and maintained (3-6). Failure to do so could result in boundary transgression (5).

The concept of stability appears also in Bion's writings, where the therapy becomes a holding environment, and the therapist a container (7). As well, there are parallels between the concept of the stable frame of therapy and Winnicott's emphasis on the necessity for experiential and environmental reliability during development. He writes, "The baby's development cannot take place except in relation to the human reliability of the holding and the handling" (8).

In an ambience of safety and security, with a trustworthy, consistent therapist, the patient is enabled to struggle with conflict and achieve its resolution, develop insight, and become an autonomous, healthy individual (3). A stable frame will degenerate into chaos if one or more of these rules are ignored, setting up a deviant frame. If there is gratification it will be of a pathological sort; the patient will experience relief only superficially. More likely, confused by hazy interpersonal boundaries, the patient will be thrown into turmoil. The manner in which the therapist lays out the ground rules and boundaries of the therapeutic relationship is "perhaps the single most important determinant of the therapeutic experience" (3). …

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