At the outset of clinical work with patients within the borderline spectrum, fluctuations in their affective tone, unpredictable shifts in interpersonal distance, and contradictory impulses appear to test the therapist’s capacity to remain containing, attuned, composed, and stable within a highly charged relational field. These phenomena, though subtle, serve as significant indicators of whether the therapist will be able to jointly withstand the requisite level of affective tension with the patient, sustain the therapeutic process, and move it toward genuine psychological transformation.

In Transference-Focused Psychotherapy (TFP), there are stable reference points that help illuminate the moments in which the true configuration of the therapeutic relationship becomes visible: moments that reveal whether the relationship can support psychological change or, conversely, obstruct it. These reference points form the foundation of the therapeutic alliance, which in each individual case unfolds through seven key parameters:

1. The nature of the patient’s and the therapist’s understanding of the patient’s difficulties. 

The assessment phase leads to a discussion of the therapist’s impression of the nature of the patient’s difficulties. Taking into consideration that BPD is a complex phenomenon and often comes with other comorbid conditions, the therapist and patient need to agree that the patient would benefit from psychological exploration as the focus. What is needed is a minimum joint agreement on the reason for and objectives of the treatment.

2. The achievement of a relative consensus as to the conditions of treatment. The contracting process is evidence of the therapist’s attention to and interest in the patient. The process is a bid to engage the patient in joint reflection on how to address problem areas. Achieving an adequate degree of consensus is a step in building the alliance.

3. The nature of both the patient’s and the therapist’s expectations of the

treatment. These include both the expectation regarding the outcome from

treatment and the expectation of what the process of the treatment will be. Questions to consider include these:

- Does the patient expect the focus of the treatment to be on getting advice and guidance or medication, or do patient and therapist agree that the focus will be on the patient’s learning about himself or herself in conjunction with the therapist? 

- Can the therapist visualize this particular patient advancing to a better experience of self and others and a better level of functioning and satisfaction in life?

4. The affective investment of the therapist in the patient.

‍The ability of the therapist to engage affectively with the patient may depend on the therapist’s ability to imagine that the patient’s initially small healthy part can join in the effort to change from internal conflict and chaos to successful integration. The affective investment is largely in what the patient might develop into, in the therapist’s realistic hopefulness.

5. The tolerance of intense affects by both therapist and patient.

‍Aggressive affects are often more prominent in the initial phase of therapy. The therapeutic relationship must be such that the duo can accept and work with

these affects, being open to the expression and experience of intense affects without subtly or overtly backing away from them or acting them out.

6. The ability of both patient and therapist to meaningfully participate in the dialogue.

This is manifested in the ability of the patient to consider and build on the therapist’s interventions. Early in therapy, participation by the patient might be a matter of considering the therapist’s way of describing the current interaction and the affect linked to it. In later stages, it involves considering the therapist’s interpretations. In a symmetric way, the therapist manifests the ability to listen effectively to the patient, to immerse himself or herself in the affect of the session, and then to coherently elaborate these experiences.

7. The early approach to diagnosing and resolving manifest negative transference.

‍Clarifying and tolerating negative affective reactions in the transference may be a dominant way to permit the emergence of whatever potential the patient has for a more trusting relationship.

‍

(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

‍