The therapeutic contract - is a tactic that ensures the effectiveness of the entire treatment.It establishes the treatment frame, delineates the responsibility of each participant, and prepares the foundation for observing, studying, and modifying the patient's psychic dynamics within the therapeutic space.
Treatment contracting is carried out by the negotiation of a verbal treatment contract or understanding between the therapist and patient.
The contract details the least restrictive set of conditions necessary to ensure an environment in which the psychotherapeutic process can unfold. In essence, the contract defines what the reality of the therapeutic relationship is. It is important that the therapist keep this in mind because the patient’s inner world of object relations will be evident in pressures to distort the real relationship. Because the distortions may be subtle, the therapist must have the reality of the relations anchored in his or her mind as the reference point against which any deviations may be understood.
The therapeutic contract is established BEFORE the start of therapy, after conducting the diagnostic assessment of the patient.
Setting the treatment contract is an interactive process. Whereas many points in the contract are non-negotiable because they are the minimum conditions required for the therapy to occur, the setting of the contract is a dialogue. The therapist must inquire about the patient’s reaction to the treatment parameters. If the patient has objections to the parameters, the therapist asks the patient to explain those objections and attempts to see if the patient can come to understand why the parameters are necessary.
The contracting process is subject to the dynamics of the patient-therapist dyad. There is far more to the creation of the frame than simply reciting a checklist of mutual responsibilities. The clinician, having presented the general conditions for the treatment and listened carefully to the patient’s reaction, must decide whether to accept the patient’s response as adequate to begin the therapy or to pursue exploration of the patient’s implicit or explicit opposition to the contract.
After the clinician has presented any part of the treatment contract, he or she must then observe the patient’s response in order to evaluate the significance of these issues to the patient and to begin to observe transference patterns.
The therapist needs to be certain that the patient has listened to and heard what the clinician has said, as opposed to impatiently waiting for the clinician to finish so the patient can go ahead with getting the therapy. If the patient has heard, the clinician needs to determine what the patient’s reaction is.
The clinician also needs to consider the patient’s willingness to accept the terms of the contract. Both the willingness to hear and the willingness to accept occur along a continuum. Once the patient has clearly heard and understood the conditions of the contract, he or she may decide to reject it. Rejection of the contract is more common with narcissistic borderline patients who find the very idea of a contract offensive to their sense of importance and entitlement. The contract setting process may stir up a massive refusal to cooperate by such patients.
Another variant of rejecting the contract is that the patient may superficially agree but signal that he or she is dismissing any real acceptance of the contract by the facile nature of his or her agreement to it.
A more promising position along the continuum of accepting the treatment is represented by the patient who does not claim to agree with all aspects but presents no major objections to the basic conditions and shows that he or she has considered them.
The patient who is able to present objections in a thoughtful fashion is more likely to collaborate with the therapy than one who initially endorses every aspect without any sense of reservation.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy