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This paper is an attempt to explore how maintenance of a secure frame, or provision of secure-frame moments within the deviant frame of the general practice surgery, may have a positive effect on patients in therapy. This assumption is supported by data from my own practice where attempts to secure the frame in several ways contributed to changes in number of failed appointments, premature termination and number of sessions attended.
While the therapist's maintenance of the basic ground rules in relation to the therapy is shown to create a background of safety, a hold or container, and a defined therapeutic space within which communication between patient and therapist can lead to resolution of conflicts and personal growth, it is also suggested that there can be positive effects on the wider setting of the surgery and its staff.
The psychotherapist or counsellor in general practice is in a pioneering role, and may get caught up in her own ambivalence in terms of needing to be seen as acceptable and useful to the medical hierarchy in which she works and, at the same time, needing to provide for patients the setting necessary for psychotherapeutic work to take place. Flexibility of the therapist in managing this situation must be balanced by a willingness to acknowledge the positive potential contained within the basic ground rules, and an ability to examine carefully the effects of deviations from these ground rules.
It is hoped that the material presented here will stimulate other therapists working in general practice surgeries to examine the frame, work to secure it, and acknowledge the effects on the patient of deviation from it. There is also certainly a need for further research on the effects on the wider setting and its staff of having a therapist working as part of the primary health care team.