An intense affective storm in a patient represents one of the most challenging moments in psychotherapeutic work. In such states, the therapist is confronted with a sharp shift in the patient’s perception, thinking, and emotional regulation. At these moments, almost any intervention may be immediately experienced by the patient as an attack. Affect escalates rapidly, thinking narrows into black-and-white evaluations, and the image of the therapist is transformed into a cold, aggressive, critical, or completely indifferent object.

All of this means that the therapist’s actual intentions become inaccessible to the patient’s perception, while the interaction is governed by the dominance of affect and primitive defense mechanisms.

In Transference-Focused Psychotherapy (TFP), a central clinical task in such situations is the therapist’s capacity to contain the affect—to recognize and hold in mind all poles of the internal conflict that are being externalized, and to remain present with the affect without attempting to avoid or suppress it. This involves the therapist’s describing in detail the patient’s apparent perception of the therapist without either accepting that perception or rejecting it 

Example:

 “I see how it can be frustrating coming back again and again to someone who seems totally lacking in empathy”; “So right now I’m being harshly critical of you?”).

Carefully articulating how the patient is currently experiencing the therapist—without implying that this experience is merely an element of the patient’s inner world—allows the patient to gradually increase tolerance for what is being projected, to reflect on it, and to accept it as something that is “happening in the room.” This process makes it possible to clarify the nature of the projection and, over time, to link it back to the patient and interpret the underlying reasons for its emergence.

During the patient’s intense affective arousal and outburst, the therapist’s

affective state—not only the content of his or her statements—is an important

part of interventions. 

The patient in this state is particularly sensitive to the therapist’s nonverbal cues and emotional tone. Interventions made with a wooden, flat, unresponsive tone usually inflame an ongoing affect storm. Such an affective demeanor on the

therapist’s part could convey that he or she does not understand the patient, is

detached and contemptuous of the patient’s loss of affective control, or is

terrified and paralyzed by the patient’s feelings and behavior. 

The therapist must engage the patient at an affective level that

communicates affective involvement in the situation with the patient yet

manages to contain the affect of the patient.

With an appropriate affective response, the therapist can gradually interpret

the dominant object relations from surface to depth, starting with the patient’s

conscious experience and proceeding to the unconscious, dissociated, repressed, or projected aspects of the patient’s experience and the motivations for defending against it. This process of affective engagement and gradual

interpretation transforms the affect storm, characterized by a flood of affective

intensity, into a reflective experience in which the patient’s affect and cognition

become connected by the clarification of the object relations dyad that underlay

the storm.

Thus, work with intense affect in TFP proceeds from containment and careful description of the lived experience toward the gradual interpretation of object dyads. This process makes it possible to reconnect affect with reflective thinking.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy