What type of transference are we dealing with at each stage of treatment?

This question is crucial for understanding the course of therapy, since it is precisely the dynamics of transference that allow us to assess the patient’s level of structural organization and the direction of possible change.

The majority of our patients with BPO begin treatment with a predominantly paranoid transference, with the expectation that the patient will be rejected or hurt by the therapist. In this phase, the therapeutic space is structured by mistrust and the expectation of danger: the object is experienced as potentially destructive, while one’s own aggression is located outside the self. For this reason, early work often focuses on containing projections and gradually helping the patient to reflect upon them.

Paranoid organization is not an accidental obstacle to treatment. It is a necessary stage that preserves the patient’s psychic equilibrium under conditions of internal splitting. This integration helps the patient move from the paranoid-schizoid position (projecting aggression) to the depressive position within which the patient is able to recognize the internal origin of the aggressive impulses that previously were projected, to tolerate ambivalent reactions toward objects, and to experience guilt feelings, concerns, and impulses to repair previously damaged relationships.

This transition represents a significant shift in the organization of internal experience: aggression is no longer perceived exclusively as an external threat, but becomes part of the self, opening the possibility for responsibility and care.

Depressive transferences are characterized by intense guilt over the aggressive impulses that are no longer projected and include the possibility of a negative therapeutic reaction based on guilt and feelings that one is too demanding and not worthy of being helped.

In clinical practice, this may manifest as self-devaluation, fear of “overburdening” the therapist, or the unconscious sabotage of positive changes as a form of self-punishment.

The evolution from paranoid to depressive transference is the major change in TFP. It is accompanied by resolution of the structural characteristics of BPO—that is, identity diffusion and predominant use of primitive defenses. 

It is at this point that the gradual weakening of splitting becomes evident, along with the growing capacity to integrate contradictory affects and representations.

This evolution involves two overall steps. 

The first step in the transformation, which occurs as the reversals within dyads are observed and discussed, is the gradual acceptance by the patient of his or her identification with the persecutory as well as the persecuted objects within him or her, along with the corresponding hateful and yearning impulses. 

In other words, the patient begins to recognize that both positions — aggressor and victim — belong to their internal world, rather than existing solely in external reality.

The second step is the gradual change from split internal representations of persecutory and ideal experiences to integration into a more complex whole as the alternation between opposing dyads is worked through.

At this level, the capacity develops to tolerate ambivalence without destructive splitting — which constitutes the essence of structural change within TFP.

(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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