Last Sunday, TFP-Group Ukraine and Ukrainian Institute for Personality Disorders Studies conducted a thematic webinar entitled “The Therapeutic Contract: How treatment arrangements determine the effectiveness of therapy”. participants acquired fundamental theoretical and practical preparation regarding the establishment of therapeutic contracts and the development of  an effective alliance between therapist and patient.

With an understanding of the contracting process the therapist must decide when he or she and the patient have achieved a good enough agreement to end the discussion of the conditions of treatment and move on to therapy. 

But how can this transition be made?

After a joint discussion, clarification of the terms, and acknowledgment of consent under the therapeutic contract, the therapist may offer the patient something along the lines of:

“It seems we have a good enough understanding about working together to begin the work. At this stage, if you do not have any more questions, let’s start, as we discussed, with your reporting what is on your mind.”

As careful as the contracting process may have been, the therapist may have to return to contracting issues during the course of the therapy. This necessity could originate because either:

1) a new problem arises that was not present at the beginning of treatment (e.g., first onset of self-cutting or of substance abuse) 

2) the patient does not adhere to the conditions discussed in the initial contract. 

In the first case, the therapist should feel free to take time to address the need for new parameters: 

“Since we have this new problem in front of us, we should discuss how it affects our therapy and what conditions of therapy would make the most sense in dealing with it.”

The second problem, nonadherence, is a common form of resistance. In this case, the therapist works with a combination of reestablishing the parameter of treatment and interpreting the meaning of the patient’s breaking of the contract. It is advisable for the therapist to give the patient a second chance and to consider the possibility that the patient is provoking the enactment of a harsh punitive object representation.

In a situation like this, the therapist alerts the patient that the latter has created a situation in which the treatment is at immediate risk. By returning to the parameters, the patient can reestablish the treatment and move on, but a repeat of breaking the contract could well signal the patient’s unwillingness or inability to work in this form of treatment and could lead to referral elsewhere.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy