How frequently do patients violate established therapeutic agreements? What might patients' deviations from discussed therapeutic boundaries signify? And what if the therapist themselves departs from these boundaries? What does this indicate?
All these questions - next.
What Is the Essence of Therapeutic Agreements?
Prior to the commencement of psychotherapy, the therapist and patient establish specific agreements - the fundamental rules of treatment, such as session duration, frequency of visits, vacation policies, conditions regarding cancellation and rescheduling, payment terms, conditions that eliminate the patient's acting-out behavior, and other parameters.Together, these elements form the foundation of the therapeutic contract, which defines the reality of the therapeutic relationship.The treatment arrangements also represent conditions the therapist needs, to be able to offer an interpretive therapy for a patient whose pathology predisposes her to act (in self-destructive ways), rather than to think and talk.
Implicit in the treatment arrangements is the importance of the patient’s actual behavior, in and out of the session.Particularly with bright, well-educated patients who have been in therapy before, the verbal communication may be misleading: they may have learned some psychological jargon, but it may become clear over time that they have no real sense of self or others, or no consistent goals in work or relationships.
How Do Agreements Support the Therapeutic Process?
The arrangements create a frame in which the patient’s acting out can be addressed in terms of what it implies about the patient’s attitude toward therapy, the therapist, and herself: the various manifestations of her chaotic internal world of relationship dyads. The problem behaviors become subjects for transference exploration and interpretation, that is, discussions of assumptions about relationships.
The treatment arrangements also help to protect the therapist from guilty countertransference when the patient accuses her of being controlling and unreasonable: Asking a patient to pay on time, or come to sessions, or carry out her promises to care for herself, is not the same as being a cruel, demanding therapist, at least according to many conventionally useful views of reality, even if the patient insists on this.
Do All Patients Adhere to Established Agreements?
In practice, therapeutic agreements are easily broken, which is the reason for the often-lengthy early discussions of the patient’s past therapies, and the joint setting up of contingencies for the patient’s failure to maintain the treatment arrangements. It might also be argued that the patient’s reaction to being reminded of the agreement is an iatrogenic development due to the “harshness” of the therapist in requiring a particular frame for the therapy, and this is why she reacts with anger.
Given borderline patients’ tendency to split and deny, acting out that is not sufficiently addressed can easily become the locus of hidden, never- to-be analyzed transference feelings and enactments. For example,
a patient may be happily feeling cared for by the wonderful idealized therapist, while outside the therapy she continues her chaotic relationships and self-destructive acts.
The agreement in some ways acts as a bridge between reality—in this case, the reality of the patient’s self-defeating acts—and her internal world. In the past this link has been attacked by the patient’s denial. As the treatment arrangement is, or should be, a joint project of the patient and therapist, even though the therapist may have taken the lead role, it also represents something outside that the pair can talk about together, potentially a bit removed from the intensity of their relationship. In this way it not only protects but enhances the therapy by providing an chance for joint reflection on the patient’s problems—practice in mentalization.
Can Therapists Also Violate Established Agreements?
Yes, such violations may occur, either consciously or unconsciously.
What Are the Implications for the Therapeutic Process?
If the therapist consistently fails to maintain the formal agreement, she may become predominantly the giver of advice or support or the manager of crises and self-destructive behaviors. This pulls the therapist farther and farther away from the ability to interpret transference, with the patient taking less and less responsibility.
The more worried or preoccupied the therapist becomes, the less mental space she has to contain and understand the meaning behind the acting out.
A therapist’s reluctance to identify, contain and understand certain material is sometimes the reason for the therapist’s failure to maintain the frame and to offer reassurance. At this point the therapeutic contract protects the therapist’s functioning because she knows to be suspicious of her wish to change it so quickly.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy