Every type of psychiatric treatment requires some form of patient participation if the treatment is to be effective. However, patients often approach treatment expecting to passively receive treatment as the therapist works on them.
A therapeutic contract helps dispel this misconception by defining the key elements of the upcoming therapy.
What is the value of a therapeutic contract?
A therapeutic contract is the cornerstone of successful therapy, outlining clear and mutually understood terms for treatment.Through the therapeutic contract, therapists:
- Establish a mutual understanding of the issues with the patient
- Define the reality of the therapeutic relationship
- Set the central focus on treatment goals
- Specify the responsibilities of both the patient and the therapist
- Protect the patient, the therapist, and the therapy itself
- Safeguard the therapist's ability to think clearly
- Create a safe space for the unfolding of the patient's dynamics and affects
- Lay the foundation for interventions regarding deviations from the contract (which provide a direct path to understanding the patient's unconscious material)
- Establish the basis for forming the therapeutic alliance
Treatment contracting is carried out by the negotiation of a verbal treatment contract or understanding between the therapist and patient.
The primary function of the contract is to bring conflicting object relations into the therapeutic process—in other words, to transform chronic acting-out behaviors into identifiable and examinable component object relations.
What changes does the therapeutic contract introduce into the treatment of patients?
The idea of having responsibilities in treatment may be foreign to some borderline patients who feel that they have no control over their actions and that the therapist’s role is to take care of them. These patients may feel that lack of control is the essence of their illness. This attitude may be supported by family members and therapists who view borderline patients as incapable of controlling their actions and who feel it is the therapist’s role to “take over” for the patient.
These patients are generally capable of both a higher level of control and a higher level of activity than is often assumed and that approaching them with this understanding is beneficial for progress in therapy and appeals to the patient’s potential.
Patients with severe chronic acting-out behaviors—such as addictions, eating disorders, self-harming behavior (in a broad sense), and suicidal tendencies—pose a challenge for the therapist. Through the carefully discussed contract conditions with the patient, we limit such acting-out behaviors, which in turn allows us access to the aspects of the patient's psyche that they have been protecting themselves from through these acting-out behaviors.
With narcissistic patients, we often find ourselves in situations where devaluation, seeping in like carbon monoxide, leaves us questioning who actually needs the therapy—the patient or us. In such moments, relying on the reality of a well-negotiated contract allows us to "untangle" the situation by integrating into the therapeutic context the processing of rigid defenses that the patient is not aware of.
What should be discussed with the patient when establishing a therapeutic contract?
The areas of patient responsibility that should be routinely discussed with every patient include:
– Therapy Attendance - this phase is designed to determine whether treatment can begin.
- Participation in the form of reporting thoughts and feelings without censoring
- Responsibility Regarding Fees - establishing the ground rules regarding the fee at the outset establishes an anchoring point to which the therapist can return if the situation warrants.
- Reflection
- Managing acting out behavior
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy