Everyone therapist has experienced situations where, under the influence of projections and projective identification from the patient, it became difficult to distinguish between reality and what was being projected by the patient.

 How can a therapist stay grounded in their professional position? How can you timely recognize that your reactions are driven by countertransference rather than therapeutic judgment?

A well-structured therapeutic contract helps to resolve these doubts.

A therapeutic contract is not only about setting rules — it is also about supporting the therapist in difficult therapeutic relations with the patient. Contracting is not just a formality or a standard procedure. It is an essential tool that defines the boundaries of responsibility and the roles of both participants in the process — the therapist and the patient.

The contract creates a space for safe and clear interaction, where the established framework can be relied upon even during difficult, emotionally charged moments in therapy.

Setting the contract defines the limits of responsibility for each participant; it defines the reality of the therapeutic relationship. As the therapy develops, the therapist will repeatedly experience moments in which he or she is not clear whether his or her experience of the moment corresponds to an accurate objective appreciation of the interaction or whether it is being determined by projected elements from within the patient’s internal world. The therapist caught up in possible countertransference reactions can use the contract to monitor whether his or her reactions are appropriate to the treatment method and goals or

are motivated by the power of the patient’s influence on his or her internal responses. For example,

if in the course of treatment the patient addresses the therapist with accusations of coldness and insensitivity, arousing countertransference fears in the therapist that the patient’s condemnations are accurate, the clinician may have a hard time assessing whether not answering the patient’s nonemergency phone calls is proof of the validity of the accusation.

However, if this is a patient whose prior history included excessive calling to previous therapists and if the issue had been discussed as a potential threat to the current treatment, the therapist, at the moment of doubt as to his or her motivation, can reflect on the contract and recognize that the thought that he or she may be harming the patient by refusing to answer the phone calls runs counter to the agreement and therefore signals a countertransference issue.

This reflection helps the therapist avoid acting out by getting involved in phone conversations rather than exploring the dyad that is active.

Setting the contract gives the therapist bearings for the exploratory therapy that is to follow. Should the patient begin to deviate from the agreement, the therapist can refer to that agreement and search for an understanding of what in the current situation might be responsible for the patient’s deviation. This is a way of approaching important dynamic material before it “erupts” into more major acting out. 

The potential for threats to the treatment also calls on the clinician’s efforts to include both an adequate articulation of the nature of the problem and sensitive and judicious responsiveness to the patient’s reactions.

Contract setting does not eradicate the problem; it does alert both patient and therapist to the nature of the threat as well as to the need to construct a plan to contain the danger. It provides the clinician with a reference point to return to should the threat emerge in the ensuing treatment.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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