What is Transference-Focused Psychotherapy? Which personality disorders is it designed to address, and what are the key techniques it employs? These questions are the focus of today’s overview.
Transference-Focused psychotherapy (TFP) is a highly structured, modified manualized psychodynamic treatment, typically conducted twice a week.
Authors of the TFP model – Otto Kernberg (the initial author), MD, psychiatrist, psychoanalyst, and psychotherapist, as well as a group of psychotherapists who joined him in developing and studying a treatment model for working with complex borderline cases – John Clarkin, Barry Stern, Eve Caligor, Frank Yeomans, among others.
TFP is grounded in Dr. Kernberg’s object relations theory, which emphasizes that the transference activation involves basic dyadic units of both a self and a related object representation linked by a distinctive affect. These dyadic units play important roles in determining the expression of drives and the experience of affects in an individual. These dyads are the means through which the different drives are experienced and also the means through which the inhibition to the drive is experienced. The object relations dyads therefore are the vehicle for the experience of intrapsychic conflict.
An object relations point of view enables the therapist to have a framework to understand what at first looks like a chaotic relationship and to begin to perceive the pattern in the oscillations and alternations of the relationships dyads as they are reenacted in the transference.
Clinical Application of TFP: originally developed for the treatment of borderline personality disorder and was later expanded to address the full spectrum of borderline personality organization, including pathological narcissism.
Understanding Borderline Personality Organization in TFP: TFP views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with oneself. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split-off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.
What techniques areemployed in TFP?
The techniques of TFP are the moment-to-moment interventions the therapist addresses to the patient in the therapy session.There is a constant interplay of the techniques and their relation to the treatment frame in the therapist’s mind.
There are four basic techniques used in TFP: interpretation, transference analysis, technical neutrality and countertransference.
Interpretation is one of the core techniques of TFP. It involves uncovering unconscious conflicts, whether predominantly repressed or dissociated/split off.
Interpretation is often considered the fundamental technique in psychoanalytically based therapy; it can be carried out in different ways. In work with borderline patients, we emphasize interpretation of the here-and-now transference interaction over “genetic” interpretation of historical developmental material.
In interpretation, the therapist utilizes and integrates the information stemming from clarification and confrontation to link material the patient is conscious of with inferred, hypothesized unconscious material believed to be exerting an impact on the patient’s motivation and functioning.
The therapist formulates a hypothesis about unconscious or dissociated intrapsychic conflicts that may explain what he or she is observing in the patient’s words and behaviors.
The aim of interpretation is to resolve the conflictual nature of material and, especially in the case of borderline patients, of behaviors rooted in conflicts between split-off intrapsychic parts.
The process assumes that the patient’s understanding of underlying unconscious motives and defenses will make previous apparent contradictions and maladaptive behaviors resolvable.
Making effective interpretations is central to the success of therapy, and an effective therapist must be skilled in this technique.
A therapist’s competence with regard to making interpretations in TFP involves the following elements:
1) the clarity of the interpretation
2) the speed or tempo of the interpretive intervention
3) the pertinence of the interpretation
4) the appropriate depth of interpretation.
In preparing for interpretations, the therapist must be aware of the conscious communication of the patient, of what within his or her internal world is intolerable to the patient, and of the defensive mechanism(s) by which the patient protects himself or herself from what is intolerable. The therapist gains awareness of what the patient cannot tolerate by listening to the other channels of communication—that is, the patient’s nonverbal behavior and the countertransference. In this process, the therapist must analyze his or her countertransference at deeper levels in order to have access to material beyond the patient’s awareness. When equipped with adequate data, the therapist must feel comfortable to spell out his or her interpretation in detail.
Although it is true that an interpretation is a hypothesis and the therapist should acknowledge this, the therapist is generally advised to deliver it with conviction, both because it is based on his or her careful analysis of the data and because the interpretation will often be met by strong resistance grounded in the patient’s primitive defenses.
Transference analysis - is the second core technique - is the ongoing analysis of distortions of the “normal,” “real” therapeutic relationship that is defined in the treatment contract. The сontract establishes the treatment frame, delineates the responsibility of each participant, and prepares the foundation for observing, studying, and modifying the patient's psychic dynamics within the therapeutic space. Guided by these agreements, the therapist can recognize the patient's distortions of the therapeutic relationship: any deviations from the contract by the patient become objects of exploration and understanding in therapy.
Any deviation from the relationship as initially defined provides information about the patient’s internal world. The deviations could be in the form of specific comments or actions or in the form of general attitudes in the sessions. The therapist explores these developments in the treatment relationship and eventually links them with similar distortions in the patient’s relations outside therapy.
One simple classification of transference developments divides them into positive and negative transferences. Both positive and negative transferences must be interpreted because, in the borderline organization, they correspond to the idealized and persecutory segments of the internal world. Dealing directly with the borderline patient’s primitive conflicts about aggression and intolerance of ambivalent feelings is the major vehicle for indirectly strengthening the therapeutic alliance. In other words, a meaningful therapeutic alliance is not simply a positive feeling between patient and therapist but rather the patient’s confidence that he or she is welcome to participate in the therapy no matter how intense and negative the emotions that emerge may be.
The transference as dominant affective material usually starts with the very beginning of treatment and therefore can be addressed early.
The negative transference should be experienced, explored, and interpreted as fully as possible. The analysis of the negative transference generally allows for the emergence of more positive feelings in the transference and for the development of ambivalence. If the patient senses that the therapist is avoiding the negative transference, the patient’s fear or belief that his or her affects are too destructive to be tolerated will be reinforced. The patient may then react by attempting to either suppress or displace his or her negative feelings or by “blowing the therapist away” in a triumphant and/or destructive outburst.
In the positive transference, the focus of interpretation should be on the primitive, exaggerated idealizations that reflect the splitting of all-good from all-bad object relations.
In the later stages of the treatment, after the intense negative transference has been analyzed, therapists often err by being less vigorous in their analysis of an idealized positive transference and its interference with the integration process.
An idealized transference, which may include dependent and/or eroticized features, can function as a defense against advancing to the depressive position with its acceptance of the mixture of good and bad—and limitations—that can be realistically expected from the world.
We have covered just two strategies of TFP. However, we will continue this topic in our upcoming newsletters. Stay tuned to our emails and explore the depths of psychotherapy through empirically-based approaches!
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy