In the long-term treatment of patients, there is a specific clinical risk:
the gradual narrowing of the therapist’s perception of the full range of the patient’s conflicts, life situation, and potential.
For the therapist, it is critically important not to become drawn into a passive acceptance of the patient’s current condition. When the therapist adapts to a limited level of the patient’s functioning, a subtle narrowing of therapeutic goals begins to occur. In effect, this deprives the patient of the possibility of realizing their potential for a fuller life. Instead, the clinician must continue actively exploring both the patient’s current functioning and their potential future development.
Often, this process unfolds almost imperceptibly for the therapist themselves. Gradually, therapeutic progress begins to be evaluated not from the perspective of the patient’s potential for personality integration, but rather in terms of the absence of acute crises, self-destructive behavior, or destructive enactments. As a result, the mere absence of catastrophe may begin to feel like sufficient therapeutic success.
Within Transference-Focused Psychotherapy (TFP), the working process is sustained through a unique combination of two seemingly contradictory attitudes:
1. Impatience (rather than passive satisfaction) within each session
This refers to an active therapeutic stance that protects against the therapist’s natural tendency to “relax” once things appear relatively stable. Such impatience maintains the momentum of the work and counterbalances the patient’s gradual ability to maintain psychic equilibrium during sessions.
2. Considerable patience in the long-term perspective
This is necessary for the prolonged working-through of dominant conflicts. The therapist recognizes that structural personality change is not immediate and requires sustained endurance.
At the same time, the effectiveness of therapy depends directly on the therapist’s capacity to track the connection between what develops within sessions and the patient’s use of this experience outside the consulting room. When this connection is lost, therapy risks becoming an isolated process that no longer meaningfully affects the patient’s overall life situation.
External stabilization does not always indicate structural personality change. At times, behind improved adaptation, the same split object relations, identity diffusion, and primitive defenses may remain in place, merely taking less obvious forms.
For this reason, continuous analysis of the therapist’s countertransference assumes particular importance in TFP. Fatigue, a reduction in internal tension, a sense that the patient is functioning “well enough,” or an unconscious wish to avoid renewed destabilization may gradually weaken the therapist’s investigative stance. Under such conditions, the therapeutic field risks losing its orientation toward deeper structural change.
The transference itself often becomes the place where the therapist unconsciously begins to accept the patient’s limitations as an unchangeable reality. In response to the patient’s chronic hopelessness, passivity, or fear of disintegration, the therapeutic process may gradually lose its orientation toward development and personality integration.
TFP regards ongoing self-reflection as an essential condition of treatment. As psychotherapists, we must continually ask ourselves:
“Has my view of this patient become too narrow? Have I replaced the goals of structural work with the mere maintenance of the current stasis?”
Supporting the patient is an essential part of therapy; however, in TFP, support must not replace structural work itself. Otherwise, therapy risks shifting from the exploration of internal conflicts toward the maintenance of adaptation without deeper personality change.
Only by maintaining a balance between acute attention to the conflicts emerging in the here-and-now of the session and long-term patience regarding strategic personality change can we sustain a genuine process of identity integration.
At times, the greatest risk in working with severe pathology lies not in an overt therapeutic failure, but in the gradual loss of the belief that a fuller and more meaningful life may still be possible for this patient.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy