Chapter 5.Establishing the Treatment Frame

the initial treatment task after assessment is setting the frame of treatment, the first of a series of tactics of transference-focused psychotherapy (TFP; other tactics are described in Chapter 7, “Tactics of Treatment and Clinical Challenges”). Both the assessment and contract setting precede the initiation of therapy because therapy cannot proceed until clear conditions of treatment are in place (Yeomans et al. 1992). 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. A treatment contract establishes the frame of the treatment, defines the responsibilities of each participant, and sets the stage for observing the patient’s dynamics in a defined “space.” 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.