In clinical practice, we often observe a discrepancy between the content of a patient’s statements and their affective expression. A patient may speak almost without emotion about significant losses, crisis experiences, or even suicidal thoughts, while expressing marked affective tension when describing everyday events that seem insignificant at first glance. In other cases, the patient limits themselves to a brief phrase or a dry factual statement, without elaboration, while closely monitoring the therapist’s reaction.
In such situations, the verbal content alone is not always the primary carrier of clinically meaningful information. Equally important are the manner of expression, the affective tone, and the relational context in which these words are addressed to the therapist. This is precisely the starting point of Transference-Focused Psychotherapy (TFP), which views the patient’s initial statements not only as descriptions of external events, but as expressions of activated internal object relations unfolding within the therapeutic interaction itself.
TFP is a principle-driven treatment, based on the concept that the patient’s dominant internal object relations will unfold in an appropriately defined treatment setting. In contrast to treatments that describe the therapist’s agenda for each session, in TFP the therapist is silent at the beginning of the session and waits for the patient to start with what is on his or her mind. The initial treatment contract includes the instruction for the patient to talk about current problems and preoccupations and, if none are pressing, to say whatever comes to mind.
Once this instruction, which defines the reality of the treatment relationship, has been given, the therapist assesses the extent to which the patient carries it out. Patients will follow the instruction to varying degrees; any deviation from this basic rule of therapy can be explored in terms of transference analysis— understanding the patient’s experience of himself or herself in relation to the therapist that is motivating the deviation (e.g., expecting that the therapist will be sharply critical of anything the patient says or waiting for the therapist to dispense magic).
In a certain sense, then, the patient sets the agenda. However, although the initiation of the session and the content of the session are introduced by the patient, the therapist then begins to address resistance, if present, and to focus on the most central theme(s) that have emerged as affectively dominant. The therapist’s chosen theme(s) may or may not be what the patient is directly discussing because often the most important information is communicated through nonverbal channels, especially at the beginning of treatment.
For example, a patient may be talking at length about a problem at work, but rather than comment on the content of the patient’s discourse, the therapist might say, “I hear what you are saying, but you seem to be talking about the work issue in a monotonous way without a great deal of affect. On the other hand, there seems to be a lot of feeling in the intense way you are looking at me, as though you are scrutinizing me for any hint of how I may be reacting to what you are saying. It might be helpful to think about that.”
Although the general rule is that the therapist should not initiate the first topic, he or she may have an idea of things that must be discussed in the course of the session according to affective dominance and urgent priorities.
For example, if a patient left a message between sessions suggesting that she was unable to control herself and needed to go to the ER, or if the patient ended the prior session with a statement about something that, if left unexamined, would threaten the continuation of the therapy.
Even under these circumstances the therapist waits to see what material the patient will introduce at the beginning of the session.
If a patient begins the session with no mention of the important material she had previously introduced and left unresolved, the therapist should seek clarification and confront the patient about the meaning of her behavior: “Last time, just as you were leaving, you mentioned that you had lost your job and didn’t know how you were going to be able to continue to pay for therapy. Today, you’ve begun the session with no reference to that. This affects whether we can continue to work together, so I’d like to hear more about it. I’m also curious about the fact that you introduced this and yet are continuing as if nothing happened, and about what that means.”
Another reason to let the patient speak first even when the therapist intends to bring up material is because the patient may have a more urgent issue to present. Even though we follow the customary practice in psychodynamic therapy of letting the patient speak first, many psychodynamic therapists are surprised to see both 1) how quickly the TFP therapist may begin to intervene in the session and 2) how much the TFP therapist contributes to the dialogue.
The reason for participating more actively than is usual for psychodynamic therapists treating nonborderline patients is that in the early phase of treatment of borderline patients, the most important material is not as much what the patient says as the discrepancies between the channels of communication; splitting keeps the various aspects of the patient’s personality apart. The therapist’s effort is to link what is being communicated verbally with parts of the personality that are being communicated through the other channels.
In addition, patients often tend to discuss relatively trivial material because the more important material can be very disturbing. A principal task of the therapist in the early and middle phases of treatment is to refocus discussion on the most important issues.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy