Have you ever found yourselves in situations where the control over a session — its flow, and even the therapist’s own stance — seems to shift into the hands of the patient?
This is especially familiar to professionals working with borderline patients: their powerful projections, complex object relations, and tendencies toward manipulation can create scenarios where the therapist feels drawn into the patient’s scripts. In such moments, it’s crucial to know what helps the therapist remain active and maintain a clear professional position without losing touch with technical neutrality.
One of the models that empowers therapists to hold this active stance and work effectively with these challenges is Transference-Focused Psychotherapy (TFP) - is a highly structured, modified manualized psychodynamic treatment, typically conducted twice a week, based on Otto F. Kernberg's object relations model.
Although Transference-Focused Psychotherapy (TFP) is rooted in psychoanalytic theory and technique, the level of the therapist’s activity in TFP surprises some psychoanalytically trained therapists.
What does the therapist rely on in order to take this active position?
Clarification and confrontation:
With regard to clarification, whenever the therapist is uncertain about what the patient is saying, he or she should not hesitate to request further clarification: “What you’re saying isn’t clear to me. Could you give me an example?”
In addition to advancing the work of understanding by requesting clarification, the therapist indicates that he or she is not omniscient (thus confronting through action a frequent object representation), reestablishes the patient’s responsibility for providing data, and helps to maintain an atmosphere of exploration and inquiry.
In TFP understanding of confrontation may sometimes seem to run counter to the central instruction in most psychoanalytic psychotherapy: to follow the patient’s associations wherever they lead. This principle of free association applies to the TFP model of therapy with borderline patients but with the following considerations:
1. The patient’s associations may reflect a self or object representation that is split off from other representations.
In this case, to follow the elaboration of that split-off part may be useful to a point, but it may become necessary for the therapist to confront the patient with material representing other split-off parts that are not present in the current associations in order to advance the process and avoid having the patient perpetuate a situation in which the fragmented internal representations remain segregated from each other.
2. The patient’s free associations may serve a defensive purpose and be in the service of resistance.
Flexibility in delivering interpretations:
Because of their use of splitting, borderline patients often assume that others are as rigid as they are about seeing things in black-and-white terms.
This assumption of rigidity reflects the patients’ difficulty separating their sense of self from their sense of the therapist.
This issue can be thought of in terms of theory of mind: they assume the other’s mind functions in the same way as theirs. Therefore, flexibility serves to differentiate the therapist from the patient and to provide a model for an alternative way of perceiving and thinking.
By demonstrating the ability to hold alternative views of the same person or event, the therapist provides the patient with a model for tolerating ambiguity and appreciating complexity.
Careful phrasing is important to reinforce the patient’s responsibility as being the final validator of any hypothesis the therapist might offer.
The sequence of specific interventions:
Just as there is a priority for the focus on a theme, there is also a preferred sequence in the use of specific techniques. In general, interpretation is seen as the key technique for effecting change in TFP. Therefore, the techniques of clarification and confrontation are introduced first to prepare for the interpretations that are eventually offered. However, if the patient’s actions are jeopardizing the treatment, the therapist should deepen the level of interpretations more rapidly. If such interventions do not forestall acting out, or if there is no time for such a sequence, the therapist moves to set limits, using the least restrictive intervention sufficient to contain the behavior.
Clarification, confrontation, and interpretation are at the core of the work, but this set of techniques can be used in a relatively sterile way if they are not combined with transference analysis, technical neutrality, and countertransference utilization. Therapists may understand internal object relations and manage to discuss issues such as the fear of the persecutory or abandoning object, the longing for the ideal object with anger and disappointment when it is not found, and so on. However, interventions remain intellectualized if they do not connect at times with the patient’s affect “in the room.”
The interplay of techniques consists of the therapist’s listening to the patient’s material and reacting internally (countertransference).
The internal reaction must be experienced and appraised: Is this reaction realistic, or is it a “pull” from the patient’s internal world to enact an object from that realm? Is the therapist remaining neutral in his or her response to the patient or deviating from a neutral position? If there is such deviation, what information does it provide?
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy