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.

There are contract conditions that we discuss with each patient, as well as individual conditions formulated by the therapist based on an understanding of the aspects of the patient’s personality and lifestyle that may act as resistance to therapy.

Setting up the contract represents a microcosm of the dynamics that will unfold in the treatment. The therapist must appreciate the complexities that can develop around establishing the contract and avoid moving prematurely from the contract phase to the therapy. 

So, what difficulties do therapists face when establishing a therapeutic contract?

1. Failure to Pursue Patient’s Response. A deficiency in setting up the contract may result if a therapist did an adequate job of presenting the conditions of treatment in each area but then failed to adequately explore the patient’s response. This type of error is common because patients often reply with a superficial compliance, saying little or nothing about their deeper thoughts.

Another reason this type of error is common is that therapists may prefer to avoid the difficulties and resistance that may emerge if a thorough pursuit of the patient’s response is carried out. This constitutes a naïve “looking the other way” regarding issues that are sure to emerge eventually in the treatment. 

A therapist might be reluctant to pursue the patient’s understanding, fearing that exploration would elicit underlying objection or anger from the patient. The fear that the patient might object to the terms of treatment is often based on the therapist’s concern that the patient might, in fact, not accept the therapy being offered. This concern is most typical of beginning therapists, who often judge their success or failure by whether they can keep the patient in treatment.

In addition to having concern that the patient might not accept the treatment, the therapist might fear that uncovering strong patient objections to the conditions of the contract would provoke negative transference. 

The therapist who fears encountering major objections to the conditions of the contract may sense the potential for an angry and devaluing response from the patient and may shy away from any exploration or confrontation for fear of unleashing that response. This reaction would be an error on two scores. First, the therapist would be working under the illusion of being able to control what comes out of the patient. This would be an illusion not only because the therapist cannot exert this type of control but also because it would be the patient in this case who is controlling the therapist’s behavior in the session. Second, the therapist is attempting to avoid the emergence of the negative transference. Transference and countertransference emerge very early in the therapy of borderline patients. Working with the negative transference is essential with this population. 

From the experience of our colleagues: the sooner the negative transference emerges in the treatment and the sooner the therapist indicates that it can be contained in the treatment, the more likely the treatment is to continue and to approach the central issues. 

2. Aggressive Pursuit of Patient’s Response - instead of avoiding exploration of the patient’s response, the therapist might address the patient with a tenacity and assiduousness that take on an aggressive quality. Any material that comes up in therapy, whatever its manifest content, can be used in a defensive manner by either the therapist or the patient.In this case, one possibility is that the therapist may already be caught up in a projective identification and may be acting out through bearing down on the patient when aggression originates within the patient.

Another possibility is that the therapist could be enacting aggression of his or her own, whether it is primary or in reaction to anxiety evoked by the prospect of working with a potentially difficult patient. Therapists are not immune to blindness regarding their own resistance around accepting a case and subsequent actions that may contribute to the patient’s leaving treatment. 

In this case, attention to the treatment contract, meant to strengthen and advance the treatment, could turn into overbearingness and become the arena in which a therapist’s ambivalence gets played out. 

3. Therapist Ambivalence About the Contract. A more complicated form of difficulty with the contract arises when the therapist has adequately studied the contract setting procedure and is able to carry it out but inwardly harbors objections to it as a technique of therapy. 

This problem is most typical of clinicians who feel that therapy should not include expectations of the patient but should follow the patient’s lead within the context of a loosely established treatment frame. 

Of course, the establishment of the treatment contract is a challenging task. It requires skill on the part of the therapist and effort by the patient to agree to responsibilities that he or she may never have accepted before. The therapist who feels that the demands of the contract are unrealistic for the patient might wonder about his or her anxiety with regard to setting up an expectation or a limit with patients characterized by impulsive and sometimes rageful reactions.

However, the difficulties that typically surface during contract setting are illustrative of how even the most cognitive and rational element of the treatment can become a field in which intrapsychic dynamics are played out.

An awareness of these issues is important to guide the interventions of the therapist during this phase of treatment.

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(c) Yuliia Holopiorova,

Ukrainian association for Transference-Focused Psychotherapy

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