In clinical work, each of us is familiar with the moment when the external chaos of the early phase of therapy begins to subside, while emotional intensity within the sessions increases and the transference relationship becomes more charged and central to the process. In Transference-Focused Psychotherapy (TFP), this period is understood as the midphase of treatment—a phase oriented toward integration, which is often accompanied by episodes of regression.
What does this look like in clinical practice?
In clinical practice the patient enters the midphase of treatment when some equilibrium is established, characterized by increased acceptance of the treatment frame and a corresponding decrease in the chaos in the patient’s life, along with an intensification of affects in the sessions.
For example, the patient may generally adhere to the therapeutic frame, yet become markedly more sensitive to the therapist’s words, tone, and interventions. Within TFP, this often indicates that affects previously enacted outside the therapy setting are now emerging directly within the sessional interaction.
In the midphase of treatment the overt behavioral manifestations of conflict and turmoil that may characterize the beginning phase are contained for the most part. Affects, both positive and negative but usually extreme, become more intense in the sessions. The work of deepening the exploration of the transference themes can progress with a diminished threat of treatment dropout or acting-out behavior (although these may recur at times of regression). Time in the sessions alternates between reexperiencing intense conflicts in the relationship with the therapist and mutual exploration of these conflicts, with the goal of increasing the patient’s capacity to reflect on his or her internal experience and on its impact on his or her relationships with others outside the sessions. In practice, this often takes the form of the patient moving several times within a single session from sharply confrontational interaction to relatively calm discussion—and then back into conflict—enacting different poles of the transference dyad.
The intensification of affects in the session may not occur if the patient maintains an idealized and consequently superficial transference, keeping negative affects stably split off and chronically projected onto a “bad” object or objects outside the treatment setting. This issue occurs more frequently with more novice therapists who are not comfortable with the negative transference and may enact their countertransference anxiety in ways that attempt to keep peace and remain “the good guy.” In such cases, sessions may appear outwardly calm and appropriate, while negative feelings toward the therapist remain outside direct contact and do not enter the focus of transference work.
However, it is also possible that the negative transference is predominant and that the patient defends against positive affect in the transference. In sessions, this is often experienced as a persistent tension in which any therapeutic intervention can readily acquire the meaning of threat, control, or rejection within the context of negative transference.This situation, in fact, is more common because the majority of patients with borderline personality disorder (BPD) are anxious about positive, libidinal affects that do not fit with the insecure internal model of attachment that characterizes almost all patients with this diagnosis.
However, a negative transference early in the treatment does not often have the superficial quality of an idealizing transference. In addition to the latter, another stable but static scenario that may occur as treatment enters the midphase is that low-grade acting out may continue on a chronic basis, creating a situation in which the patient experiences secondary gain (i.e., a sense of gratification) from being in treatment and wishes to perpetuate it rather than work toward change.
It is precisely within this context—relative stabilization of the therapeutic frame combined with a growing intensity of transference tension—that the core therapeutic tasks of the middle phase in Transference-Focused Psychotherapy (TFP) gradually come into focus. These tasks are primarily concerned with deepening the understanding of split representations of the Self and the Other as they are activated within the transference interaction. At this stage, it is especially important for therapists to distinguish between two levels of awareness:
The first concerns the interchange of the roles of self and other within a particular dyad. The therapist helps the patient observe and reflect on elements of himself or herself that the patient has had difficulty seeing.
The second level of gaining awareness involves the fundamental split between dyads imbued with totally negative and aggressive affects and those imbued with idealized libidinal affects. The eventual integration of these two extreme segments of the patient’s internal experience helps increase affect regulation, as the extreme and discontinuous parts of the self that contribute to ongoing conflict become mutually toned down and modulated within a more complex whole.
Thus, the middle phase of treatment combines a relative stabilization of the therapeutic frame with a marked increase in affective intensity within sessions. For the therapist, this period is often emotionally more demanding than the initial phase, as chaotic manifestations give way to intense—and in some cases chronic—transference interactions. Within Transference-Focused Psychotherapy, the capacity to maintain the frame, to work with both idealized and negative transference, to address reversals of object-relational dyads, and to process the splitting between idealized and persecutory dyads, as well as to tolerate and contain regression as an integral part of the process, becomes central to enabling further movement toward integration.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy