How to Contract for Therapy and Attend to Client Therapist Power-struggles

1. Demetrios Peratsakis, LPC, ACS
Natalia Boyanirova, LPC
April 05, 2017

3. Goals of Contracting
 To establish the role of the therapist
 To establish the rules and format of session
 To establish, by agreement, the work to be done
 To establish the therapeutic alliance
Initial Goal-setting
 Exploring the Presenting Problem (PP) and Identified Patient (IP)
 Why this particular problem or symptom?
 Why now?
 Why this particular symptom bearer or Identified Patient (IP)
 Who else is affected by the problem and how? Who participates in the behavioral loop and how?
 If this/she was NOT the problem what/who would be?
On-going Goal Refinement
 Reduces the “carousel effect”
 Reduces “blind-spots”

4. Human Nature
 People prefer to remain the same and have others or circumstances change; change is thrust upon us
 Change is fraught with pitfalls and uncertainties, including the need to surrender ideologies and abandon biases
 We desire freedom from pain, so long as it doesn’t take work
 We like to pick and choose the parts of things we like and don’t like
 Therapy can be an admission of failure and inadequacy
The Nature of Therapy
1. Client desires relief from pain but may be fearful and ambivalent about change
2. As the therapist “pushes” for work, one of three things occurs
1. Legitimate confusion over the task or its instructions
2. Agreement/Compliance with the task
3. Defiance over the task (power-struggle)

5. 1. Not talking
2. Not following advice or suggestions
3. Non-disclosure [Selective disclosure] or not answering questions
4. Taking notes or recording sessions
5. Coming late or leaving sessions early
6. Non-payment/Non-compliance with Required releases and Paperwork
7. Stalking, Threatening, or Intimidating
8. Change seating or other office arrangements
9. Provocative or threatening clothing
10. Provocative or threatening language
11. Use of language
12. Belligerence and Rage
13. Dominating the conversation
14. Inappropriate touching, hugging, etc
15. Inappropriate gifts
16. Inappropriate or offering incentives
17. Acting seductively, coy or unduly vulnerable

6. 1. Shot-gunning/Carpet-bombing: too many Presenting Problems and Identified Patients
2. Fugue over selecting Presenting Problem
3. Sets appointment, cancels/no-shows; sets appointment, cancels/no-shows
4. Spouse/Partner sets appointment, partner refuses to attend
5. One sets appointment, then sabotages their partner’s participation
6. Both attend, one sees a problem, one does not
7. Both attend, both agree that one partner is the problem (identified patient/I.P.)
8. Both attend, agenda moves to Individual Counseling (I/C) or child focus (F/C)
9. Both attend, one begins to No-show (leaving therapist with partner/spouse)
10. Both attend, one drops a “bomb” (ie. sexual affair, drug abuse, major illness)
11. Both attend, one discloses their desire to separate or divorce
12. Both attend, one or both unclear on commitment (separate or remaining together)
13. Both attend, one or both continually triangulate the therapist
14. Both attend, the agenda and goal of therapy continually changes or vacillates
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7.  Do they need to control everybody or simply “slay the therapist”?
 Is the client angry or upset with the therapist?
 Is the client second-guessing the utility or effectiveness of treatment?
 Has the therapist behaved in a manner that is suspect or that has damaged the trust?
 Does the therapist misuse their power and belittle, shame, or induce guilt in the client, especially by
moralizing, lecturing or assuming a haughty or “parental” attitude?
 Is the client frightened?
 Is the client reacting to anger or counter-transference material from the therapist?
 Is the emotional pain associated with unresolved feelings of Loss, Trauma or Chronic Discord?