In psychotherapy, much of the healing happens within the therapeutic relationship itself; not just what is said, but how it’s held. One of the foundational elements of this relationship is the therapeutic frame. While often invisible to the patient, the frame provides the structure that allows the work to unfold safely, consistently, and meaningfully.

For PMHNPs and other clinicians stepping into the therapy space, especially those trained in settings more focused on medical or diagnostic frameworks, holding the frame can feel unfamiliar or even unnecessary. But neglecting the frame often leads to confusion, boundary issues, or a loss of direction in therapy. Let’s break down what the frame is, why it matters, and five tips for holding it with confidence and care.

What Is the Therapeutic Frame?

The therapeutic frame refers to the consistent boundaries and expectations that create the container for therapy to occur. It includes the logistics of therapy; start and end times, fees, cancellation policies; as well as the emotional and relational boundaries, such as neutrality, confidentiality, and how communication occurs outside of session.

The frame is what makes therapy feel like therapy rather than a casual conversation. It’s what allows patients to project, test, regress, and feel held, even when things get messy.

Why Holding the Frame Matters

• It promotes safety and trust. A clear, consistent frame helps patients feel secure, especially when working with vulnerable material.

• It allows for depth. Without structure, therapy can become diluted or diffuse. The frame creates space for insight and emotional movement.

• It supports clinical curiosity. When the frame is intact, we can notice what happens within it, such as resistance, enactments, transference, or unconscious communication.

• It protects the clinician and the patient. Maintaining boundaries minimizes the risk of burnout, re-enactment, or ethical missteps.

5 Tips for Holding the Frame in Your Practice

1. Define the Frame Explicitly from the Start

Be clear and consistent when introducing the structure of therapy. Review fees, session length, cancellation policies, and communication boundaries during your intake. Putting it in writing, and revisiting it as needed, models containment and professionalism.

Example language:
“In this space, our work happens in the room during our weekly 50-minute sessions. If anything urgent comes up between sessions, we can discuss how to handle that during your next appointment.”

2. Start and End on Time; Even When It Feels Awkward

It can be tempting to give a few extra minutes, especially when a patient is tearful or “just getting to something.” But consistently starting and ending on time communicates reliability, predictability, and care. Overextending erodes the boundary and may unintentionally reinforce urgency over process.

Tip: Offer a gentle time reminder 5 minutes before the session ends:
“We have about five minutes left, so let’s begin wrapping up for today.”

3. Notice (and Reflect On) Boundary Testing Without Punishment

When patients test the frame; showing up late, texting between sessions, asking for exceptions, it’s often a clinical communication, not just logistics. Rather than reprimanding, use it as a moment of curiosity.

Example:
“I noticed you’ve been arriving late the last few weeks. I wonder what’s been coming up for you as we start our sessions?”

4. Hold the Emotional Frame, Not Just the Logistics

The therapeutic frame isn’t just about time and boundaries, it’s about how you show up. That includes managing your own countertransference, regulating emotional reactivity, and staying grounded when sessions become emotionally charged.

Holding the emotional frame might mean staying steady when a patient is angry at you, or allowing space for silence instead of rushing in to soothe.

5. Use the Frame as a Clinical Tool

Once the frame is well established, you can begin to use it to deepen the work. Is the patient testing your reliability? Are they trying to move outside the frame because something in the relationship feels threatening? Is a missed session unconsciously timed after a particularly vulnerable disclosure?

The more intact the frame, the more it reveals.

Final Thoughts

Holding the therapeutic frame isn’t about rigidity; it’s about creating a consistent space where vulnerability, reflection, and transformation can occur. For PMHNPs navigating the dual role of prescriber and therapist, the frame becomes even more essential to differentiate therapy from a medication check.

It’s okay if this feels uncomfortable at first. Like many therapy skills, holding the frame is something we grow into; with intention, supervision, and a dose of self-compassion.

5 Tips for Working with Resistance in Therapy

Resistance. It is one of those words that can send a ripple of self-doubt through even the most seasoned clinician. A patient skips sessions, dodges questions, or shifts topics every time you get close to something meaningful. It is tempting to push through, problem solve, or reframe. But what if resistance is not the enemy of therapy, but a doorway into something deeper?

Here are five ways to approach resistance in therapy with curiosity and clinical wisdom.

1. Assume resistance makes sense

Start with the belief that resistance is protective, not pathological. It is a signal that something feels too vulnerable, too fast, or too unknown. Instead of trying to get rid of it, try to understand what it is trying to protect. Ask yourself, "What would it mean if this patient let down this defense right now?"

2. Slow down the pace

When resistance shows up, it often means the pace of therapy is mismatched with the patient's capacity. This is an invitation to slow down. Reflect on the process itself. Wonder with your patient, “What feels hard to talk about right now?” This opens space for a meta-conversation about the therapy relationship without demanding change.

3. Track your own responses

Resistance does not just show up in the patient. It stirs something in us, too. Do you feel annoyed, confused, bored, defeated? Your countertransference can be a clue. Instead of reacting, reflect. These feelings may mirror how others have responded to the patient before. Staying curious about your own reactions can help you stay present rather than pushy.

4. Frame resistance as part of the work

Normalize it. Let your patient know resistance is expected and often a sign that therapy is getting closer to something important. You might say, “Sometimes when we’re near something meaningful, part of us wants to shut it down. That makes sense. We can take our time here.”

5. Remember the relationship is the intervention

When resistance surfaces, the way you respond becomes the therapy. Will you retreat, interpret, confront, or connect? When you can hold steady with empathy and respect, you offer a new relational experience. One that does not demand change but invites safety.

Final thought: Working with resistance can feel uncertain, even uncomfortable. But it is also where therapy begins to deepen.

From Diagnosis to Depth: Learning Case Formulation as a PMHNP

I was recently reading The Personality Syndromes by Jonathan Shedler, and one line stopped me in my tracks:

“Without a coherent case formulation, treatment can devolve into a haphazard ‘spaghetti-on-the-wall’ process, with the clinician trying one intervention after another, hoping something will ‘stick’. It can also devolve into aimless, directionless ‘supportive therapy’ in which the therapist has essentially given up on meaningful change.”

THIS! This right here is exactly how I felt when I first began offering psychotherapy as a PMHNP.

In school, we were taught how to diagnose. We might’ve been introduced to various therapy theories, watched tapes, and observed some sessions. But what I never truly learned, and what I now realize is a cornerstone of meaningful psychotherapy, was how to develop a case formulation.

Sure, we wrote up plenty of case studies using a biopsychosocial or medical model. We practiced writing SMART goals. But the deeper process of crafting a therapy case formulation? The kind that links symptoms to inner conflicts, defenses, attachment patterns, and early relational templates? I’ve either fully dissociated that from my program… or it just wasn’t there.

So now, this is the work I’m actively doing, learning how to conceptualize cases not just through a diagnostic lens, but through a psychotherapy lens.

What about you?
How were you taught case formulation (if at all)?
And how has your understanding of it evolved in your therapy work?

Let’s talk about it, because if you’ve ever felt like you were just tossing interventions at the wall, you’re not alone.

Stop Collecting Tools—Start Building Roots

In the early days of adding psychotherapy to my PMHNP practice, I felt like I was in a constant sprint—chasing certifications, flipping through workbooks, listening to podcasts at 1.5x speed. I thought if I just consumed enough knowledge, I’d suddenly feel like I belonged in the therapy room.

But the truth is, no course could teach me what it feels like to sit in a session when a patient goes silent… or angry… or weepy… or disconnected. No worksheet told me what to do when transference showed up, or when my own countertransference surprised me.

I didn’t need more checklists. I needed more roots.

The Temptation of Tools

We’re trained to act. To treat. To fix. So it makes sense that when we step into the therapy space, we reach for tools—we want a clear modality, a workbook, a map. Something known.

But therapy isn’t only a set of steps. It’s a relationship. A process. An unfolding.

That’s why learning the framework of therapy—not just the interventions—is the real game-changer.

What It Means to Be Rooted

Being rooted doesn’t mean having all the answers. It means having a strong enough foundation that you’re not swayed by every wave of doubt. You can sit with the unknown. You can pause instead of rush. You can notice what's happening—in the room, in the relationship, in yourself.

And you can begin to trust that you are part of the work—not separate from it.

Growth Doesn’t Happen in Isolation

I’ve seen how powerful it is to grow with others. Not in a massive forum where you’re lost in the scroll or one of 30 thumbnails in a zoom. But in small, honest spaces—where people know your name, your style, your stuck spots.

That’s where confidence grows. Not from having the “right” intervention, but from knowing how to hold a moment in therapy—and yourself in it.

If You’re Craving That Groundedness

If you’ve been running on therapy fumes—piecing together skills from courses but still feeling shaky in sessions—you’re not alone.

Join us in The Consultation Room. Let’s dig in together. Build those roots.
Because the deeper they go, the more we can hold.

The Consultation Room is a mentorship and consultation space for PMHNPs ready to grow their therapy voice and deepen their clinical work. Doors to our small peer group open soon.

Rooted in the Work: A Note from the Founder

When I first decided to offer therapy as part of my PMHNP practice, one of the biggest questions I had—and one I hear often from other nurse practitioners—was:

“What trainings should I do?”

CBT? DBT? EMDR? ACT?

These are amazing modalities, no doubt. But what they all have in common—and what I’ve found to be the most transformative in my own work—hasn’t been just collecting more tools. It’s been deeply understanding the framework of therapy itself.

Think of it like this: the therapeutic alliance is the trunk of the tree. Every training, technique, and modality? They’re the branches. Without a strong trunk, it doesn’t matter how many branches you add—they won’t hold.

Through formal classes, peer consultation, and way too many books to count, I’ve come to believe that learning how therapy works—how to build trust, work with transference, attune to the process—is what truly helps us grow as psychotherapists.