At times, the therapeutic process may appear to be “going well”: the patient attends sessions, speaks openly, understands, agrees, and even seems to be making progress.
Yet outside the consulting room, nothing changes: the same breakdowns, conflicts, and behavioral patterns persist.
The process unfolds, but it does not extend into the patient’s actual life.
This may give rise to a troubling question: is something genuinely happening in therapy, or is it merely an illusion that unfolds within the consulting room without translating into real change?
We may look for explanations in the patient’s external circumstances. Alternatively, we may turn our attention to what is taking place within the therapeutic relationship. But what if the most significant processes emerge precisely in the tension between these two levels?
It is often in this space—between transference and external reality—that the key dynamics shaping the course of therapy become visible.
For this reason, it is essential to maintain a simultaneous focus on both the transference and the patient’s life outside the sessions.
The central transference themes often take time to develop. As this is happening, the therapist listens to the material the patient brings to sessions.
Some patients discuss their reactions to and feelings about the therapist directly and spontaneously from the beginning of therapy.
Others say little about the therapist and talk almost exclusively about other subjects. In this latter situation, the therapist may need to inquire about the patient’s experience of the relationship between them or comment on a feeling that is expressed through the patient’s nonverbal behavior.
Along with this focus on the transference, however, one of the therapist’s roles is to regularly check on the status of the patient’s life outside the sessions. This active inquiry into outside life is one of the aspects of Transference-Focused Psychotherapy (TFP), developed by Dr. Otto Kernberg, that distinguishes it from more traditional psychoanalytic psychotherapy, particularly from Kleinian psychoanalysis . This inquiry may uncover important information regarding how the patient may be enacting important dynamics in his or her life while appearing to be fully cooperative in sessions. For example,
a patient may associate freely in sessions but may not have followed up on commitments in the contract.
A therapist who does not inquire about a patient’s life outside the sessions will not be aware of the acting out. He may perceive the therapy as “good” within the consulting room, without recognizing that in the patient’s real life the same patterns of avoidance, aggression, or dependency are being repeated.
Patients who follow through on commitments regarding outside involvements can bring in important information about the repetition of pathological interactions in new settings.
The TFP approach conceptualizes these two levels—transference and real life—not as separate, but as continuously interconnected. What occurs outside the consulting room is brought back into therapy as material for analysis, while what unfolds in the transference is used to understand the patient’s behavior in everyday life.
In practice, this involves ongoing clarification and linking: the therapist helps the patient recognize how their experiences, fantasies, and expectations toward the therapist are reproduced in interactions with others. Through this process, not only awareness but also change becomes possible—as internal dynamics begin to integrate into real life rather than remaining confined to the therapeutic space.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy