Shirah Vollmer MD

The Musings of Dr. Vollmer

The Therapeutic Contract

Posted by Dr. Vollmer on November 27, 2012

Annie, fifty-one, begins psychotherapy because she feels it will make her a more compassionate primary care physician. She denies any pressing pain, and to the “why now” question, she says, “well, my kids are done with college. ” “You mean that you don’t feel guilty spending money on yourself now that you have educated your kids,” I respond, trying to tie the notion of starting therapy with her new financial phase of life. “Well, yes, you could say that,” Annie reluctantly agrees that she has put her financial life on hold in order to get her kids through school. I think to myself that she probably has also put her personal life on hold and so perhaps she enters into psychotherapy, partially to be a better physician, but more importantly to sort out her new life, now that her kids are carving out their own lives. Annie begins treatment talking about her patients, but after a few months, it becomes clear that she has deeper issues which concern her. “Coming here to talk about your patients gave you permission to enter into my office, but now that you have settled in, you are allowing yourself to explore deeper parts of your emotional interior.” I say, highlighting that, like a dream, the initial reason for psychotherapy is often a way in which the patient “fools himself” into a therapeutic relationship. This is like a dream, since when one discusses a dream, the implication is that logic does not have to be at play. “It’s only a dream,” means that I know this does not make sense, but I want to talk about it. Likewise, Annie’s stated purpose to help her patients, is a way of saying that she needs help with her emotional pain, but she has to enter with a different initial contract, in order for her judgmental side, her superego, to allow her to begin treatment. This phenomena, labeled “reversible perspective” by Bion, is what I call the “back door into treatment”. The therapeutic contract changes slowly, as the patient feels more trusting of herself and of me. The relationship becomes solid,  so the work of the “mid-phase” begins. As I conclude my class on the “mid-phase” I will miss discussing the theoretical underpinnings of this process. Ending a class, in this case my  “midphase class” is like ending a good book. I find it sad to finish.


4 Responses to “The Therapeutic Contract”

  1. Jon said

    This can be viewed as a post of beginnings and endings – the multifaceted reasons for beginnings and the bittersweet aspects of endings.

    Annie, like most of us, has many a layered reason for beginning something new – psychotherapy. One can always as “Why?” and, most of the time, come up with reasonable answers. One must be subtler about addressing the question of “Why really?” for the answers may not be reasonable or even knowable at the time of asking.

    As for the sad part of endings, consider the irony of what is ending – the “midphase class.” By its very name there is the implication of phases to follow. Indeed there is a sadness in finishing, but there is also an excitement about a potential new beginning.


  2. Shelly said

    I was following this piece perfectly until you brought up the “midphase class.” How does the solidification of your relationship bring on the work of the midphase? What is the definition of the midphase? Thanks, in advance, for the clarification.

    • Yes, Shelly, I was not clear about how my class relates to this post of the “therapeutic contract”. To clarify, psychotherapy or psychoanalysis often works like an arc. In the beginning there is a “dating” phase where the two parties are determining if they can trust one another. Then, after trust is established, there is a “midphase” or “going steady” phase where the work of understanding unconscious processes happens intensively. Then, there is the “termination phase” where the patient begins to pull away so that they can now use their “new ego” to manage the stressors in their life with greater abilities for adaptation and coping. The obstacles in the “midphase” is what my class focuses on. One obstacle is helping someone, such as Annie in this case, transition from her stated reason for beginning psychotherapy to a deeper understanding of her neurotic issues. Thanks, as always, for helping me add clarity to my posts.

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