What is the therapist's primary task following the completion of the diagnostic assessment of the patient?

At this stage, the primary therapeutic task is:

- establishes the treatment frame

- delineates the responsibility of each participant

- prepares the foundation for observing, studying, and modifying the patient's psychic dynamics within the therapeutic space.

All these tasks are encompassed

within the therapeutic contract.

The therapeutic contract is a tactic that ensures the effectiveness of the entire treatment.This is the first step toward consistent and successful psychotherapy, which cannot begin without establishing clear treatment parameters.

Why is the therapeutic contract important?

Individuals with borderline and other personality disorders tend to enact their conflicts in potentially dangerous ways that can create serious difficulties in psychotherapy, where the therapist may feel that their primary role is to "rescue" the patient from self-destructive behavior rather than conduct psychotherapy.

The more severe the patient's disorder and the more distorted their interpersonal interactions in the therapeutic relationship, the more powerful the primitive object relations in the transference. These evoke an intense countertransference. The therapeutic position is vulnerable to the threat of potential acting out of transference feelings by the patient and, at times, to the therapist's temptation to act out their own countertransference. Without a well-thought-out and mutually discussed therapeutic frame and contract, the mutual enactment of transference and countertransference obscures the therapist's clear understanding of the psychodynamics of what is taking place.

With higher-functioning patients, different challenges emerge. The dynamics of higher-functioning patients are more difficult to track because their reactions in therapy appear almost normal. It is not easy to notice subtle deviations, and this is where the therapeutic frame and contract also helps - minor deviations from the agreed frame open the way to exploring deeper dynamics.

With a therapeutic contract, psychotherapists across different modalities can:

– 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

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.

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.

A simple example is the therapist who begins to feel (countertransference) that he is selfish and withholding because he is not available to the patient by phone when the patient is upset at night. Checking his reaction against the part of the contract about communication outside of sessions can remind him that he is not in fact negligent but rather is following the treatment agreement. This reminder can help the therapist understand that his countertransference corresponds to an element in the patient’s internal world that should be discussed

A guiding principle in setting up the conditions of treatment is that the therapist must feel comfortable and safe enough to think clearly. This is no small matter in the treatment of patients who often create a level of anxiety that can lead the therapist either to abandon psychodynamic techniques in favor of whatever measures seem to meet the need of the moment or, much worse, to abandon the case. In so doing, therapists are usually participating in acting out the primitive dynamics of the patient rather than helping the patient understand and resolve them.

Another guiding principle in setting the frame of treatment is to limit the patient’s secondary gain of illness (use of symptoms to obtain extra benefits, such as more access to the therapist or medical disability)

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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