Transference-Focused psychotherapy (TFP) is a highly structured, modified manualized psychodynamic treatment, typically conducted twice a week.
Оriginally developed for the treatment of borderline personality disorder and was later expanded to address the full spectrum of borderline personality organization, including pathological narcissism.
The effectiveness of the TFP model can be explained by the following key factors:
– 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 a model grounded in approaches that have been developed and empirically validated over many years by researchers and clinicians specializing in personality disorders.
– 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.
What techniques are employed 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.
The technique of interpretation and transference analysis was examined in detail in the newsletter dated May 26. Today, we will focus on the techniques of technical neutrality and countertransference.
Technical neutrality means maintaining a position that does not ally with any one of the forces involved in internal psychological conflict:
– the patient’s drives, which could be in conflict themselves;
– prohibitions to drives;
– or the constraints of external reality.
Technical neutrality is a position of equidistance from these competing forces that fosters observation and understanding of them—a process the patient is invited to join in.
From this vantage point, the therapist is free to comment on any material provided by the patient, as long as the therapist remains allied with the patient’s available or potential observing ego.
The observing ego is that part of the individual capable of perceiving and assessing both the internal forces (impulses and prohibitions) and elements of external reality that have an impact on the individual’s affects, motivations, and behaviors.
Because the therapist is clearly allied with the healthy, observing ego aspect of the patient, we can say that the position of neutrality is within a frame that promotes the patient’s well-being.
For borderline patients, the observing ego may, at times, be so overcome by stronger forces that the therapist may seem to be speaking from an outside position, unrelated to any part of the patient. In such situations, the therapist must point out to the patient that he or she is speaking for a part of the patient that is, for the moment, split off. The therapist also enters as an “excluded observing third party,” disrupting the total control of the situation by the internal dyadic relationship that keeps the patient from the capacity to enter into deep, mutual, and intimate relationships.
The therapist’s ability to diagnose, clarify, and interpret the dominant active transference paradigm at each point in the treatment is dependent on the therapist’s position as a neutral observer.
Because the dissociated internal world of borderline patients has not yet consolidated into coherent ego and superego structures, with these patients technical neutrality implies an equidistance between self and object representations in mutual conflict and equidistance between mutually split-off, all-good and all-bad object relations dyads; these representations and dyads are the elements that will come together later to form the more coherent ego, superego, and integrated identity.
It is important to stress that maintaining technical neutrality does not mean communicating in a flat and bland style. Precisely because the borderline patient’s observing ego is so weak, it is incumbent on the therapist to communicate with generally natural affect and, at those times when the healthy, observing part of the patient is being overwhelmed by intense affect, to speak firmly, although with warmth and concern.
Transference-focused psychotherapy requires a general stance of neutrality because this position allows the therapist to observe and understand all the forces at play in the patient’s conflicts, to analyze the interactions among them, and to engage the patient in observing and reflecting on the parts of his or her conflict with the goal of increasing the patient’s ability to resolve emotional conflicts and increase his or her autonomy.
The third channel of communication between patient and therapist after the patient’s verbal communication and nonverbal behavior is the countertransference.
The countertransference to be the totality of the therapist’s emotional responses to the patient at any particular point in time.
The therapist’s countertransference responses are determined by:
1) the patient’s transferences to the therapist;
2) the reality of the patient’s life (the therapist may have his or her personal reactions to the circumstances of the patient’s life);
3) the therapist’s own transference dispositions, as determined by his or her internal world
4) the reality of the therapist’s life (e.g., is the therapist frustrated in his marriage in a way that might affect his responses to the patient’s seductiveness?).
The fact that these four influences all have an impact on the therapist’s countertransference makes it essential for him or her to try to distinguish the sources of his or her internal experience in relation to the patient.
As a rule, the sicker the patient, the more prominent is the patient’s transference in generating countertransference reactions. This is because patients with more serious pathology use more primitive defense mechanisms, especially projective identification, which tends to induce elements of the patient’s internal world in the therapist as part of the patient’s effort to avoid feeling the full intensity of his or her inner conflict.
Forms of Countertransference Manifestation:
The therapist’s countertransference can also be classified into acute and chronic countertransference reactions.
Acute countertransference reactions are potentially very helpful in the treatment. They may shift, within each session, in relation to transference developments.
Chronic countertransference reactions are more problematic, usually reflecting chronic, unresolved transference and countertransference developments or a treatment stalemate. The latter reactions may start insidiously, extend over many weeks or even months, and affect the therapist’s position of technical neutrality by leading the therapist to blind spots in his or her perception of the patient’s internal world.
In clinical practice, the therapist’s clear understanding of the conditions of treatment as established in the Therapeutic contract helps him or her be aware of countertransference reactions.
Any temptation to deviate from the established treatment frame or to accept a patient’s deviation should be viewed as a sign of a countertransference reaction corresponding to some element of the patient’s inner world.
Because countertransference reactions can originate in the therapist as well as in the patient’s inner world, the therapist must be open to exploring the source of his or her reactions.
Monitoring countertransference clearly provides key access to understanding the patient’s primitive defense mechanisms of projective identification and splitting, as well as to understanding the nature of the part-object representations in the patient’s internal world.
In short, the therapist’s reaction provides clues to the dominant question of the early phase of treatment—“How is this patient relating to me?”—to which the answer is often to be found in considering the question “How am I being made to feel?”
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy