Does the therapeutic contract guarantee that a patient will strictly follow the agreed framework of therapy? And what should the therapist do when, in the course of treatment, these agreements are nevertheless violated?
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.
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.
Moreover, simply using the contract as a tool to enforce “correct” patient behaviour is fundamentally misguided. The contract, and the therapeutic frame it establishes, functions instead as a litmus test: it makes visible the patient’s enactments (through deviations from the contract), brings into awareness countertransference and transference reactions, helps identify the dominant affect, and supports the formulation of an understanding of the activated dyad. From there, the therapist can explore the process together with the patient and use this material for subsequent interventions aimed at integrating splits and working through identity diffusion.
Thus, the therapeutic contract is not merely a formal agreement. It serves as a tool for exploring the relational dynamics within the therapeutic process.
Violations of the therapeutic contract (though not always appreciated at the beginning of TFP training) in fact signify the activation of enactments. With growing clinical experience, therapists come to perceive such violations with a sense of interest, even inspiration.
In such situations, the clinician’s primary task is not to avoid these challenges, but to use them as opportunities to advance the therapeutic process and to gain deeper understanding of the unfolding psychodynamic dynamics.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy