What is Transference-Focused Psychotherapy, how does it work, and which tactics does it employ?
Transference Focused Psychotherapy (TFP) is a specialized, evidence-based psychoanalytic psychotherapy designed for individuals with DSM borderline (BPD) and other personality disorders (this also includes individuals with borderline personality organization (BPO) who do not meet DSM criteria but have significant, chronic personality problems.
How does TFP work?
TFP has its well-defined strategies, tactics, and techniques that ensure clarity in the therapeutic process.This distinguishes TFP from a number of other psychodynamic and humanistic models, which may develop certain conceptual approaches to understanding the mind and its disorders but do not provide a clearly formulated technical framework for the therapist’s work.
The tactics of TFP are the maneuvers the therapist uses to set the stage for and to guide the proper use of techniques within the individual session.
The treatment tactics are essential for creating and protecting the necessary conditions for treatment, guide decision making with regard to intervention.
The tactics involve therapist activities that range from creating the framework for the therapy (contracting and limit setting) to guiding the therapist’s choice of what material to address (determining the hierarchy of priorities) to maintaining appropriate attitudes with regard to the patient and the material.
TFP tactics include:
1. Carrying out a comprehensive assessment
2. Sharing the diagnostic impression
3. Establishing treatment goals
4. Discussing the treatment contract to set up the frame of treatment
5. Maintaining the frame and boundaries of treatment
6. Identifying the focus and intervention in each session
– Following the affect
– Following the priorities of intervention
Each of these tactics plays a key role in ensuring the structure and consistency of the therapeutic process. They enable the therapist to maintain focus on transference dynamics, promptly recognize interpersonal distortions, and respond to them effectively within the session.
Carrying out a comprehensive assessment means that in TFP, we do not begin therapy without conducting an initial patient evaluation (diagnosis).
Why do we emphasize the importance of clinical assessment?
Clinical assessment of the patient is a mandatory step before starting therapy, which captures current symptoms and mental status, level of personality organization, and current functioning in key areas of adjustment (work, social and intimate life, and creativity) that are crucial to the psychological investments that constitute identity. Without it, the therapist is guided more by assumptions than working with the patient’s actual problem.
How is clinical evaluation conducted in TFP?
In the TFP the clinical assessment of the patient is conducted with research:
1) subjective experience (e.g., symptoms such as anxiety, depression)
2) observable behaviors (e.g., investments in relationships and work, deficit areas in functioning)
3) psychological structures (e.g., identity and identity diffusion, defenses, reality testing)
This method of evaluation is not purely descriptive, as is sometimes the case in psychiatry, which often focuses primarily on symptoms. Nor is this method of assessment a traditional psychoanalytic one with a focus on history and underlying dynamics related to the past. Rather, in TFP we maintain that the nature of the treatment experience will be shaped by the level of personality organization (neurotic personality organization [NPO], high-or low-level borderline personality organization [BPO]), the symptoms the patient experiences, and the areas of functioning that are compromised.
In TFP, the clinical assessment is typically conducted over 1-3 sessions prior to treatment contracting (which we will discuss in our upcoming publications).
The goal of clinical assessment is to ascertain the diagnosis and, if a personality disorder is present, the severity of the disorder and its organization as NPO or high- or low-level BPO. In addition to providing the therapist with information on the symptoms, critical areas of dysfunction, and level of personality organization, the assessment also has the potential for providing the patient with a careful view of his or her difficulties and a beginning experience of the interaction with a helping other.
What clinical assessment methods are used in TFP?
1. The structural interview (Kernberg 1984) is a method of clinical assessment that focuses on the patient’s symptomatology, present and past; the patient’s personality organization, including conception of self and others; and the quality of here-and-now interaction between patient and interviewer. The interviewer focuses on the patient’s main difficulties with tactful assessment of the variables central to structural diagnosis:
1) identity integration versus diffusion
2) characteristic defenses
3) level of reality testing.
The interviewer also assesses any awareness of internal conflict—in contrast to externalization— within the patient. It is assumed this exploration creates enough tension so that the patient’s predominant defensive or “structural” organization of mental functioning will emerge.
2. The Structured Interview for Personality Organization—Revised (STIPO-R) – used by clinicians trained in conducting this interview. The STIPO-R provides the clinician with a guide to the assessment of key areas needed for a psychodynamic diagnosis distinguishing patients with BPO from patients with NPD.
Although the STIPO-R lacks the clinical intuitiveness and subtlety of the structural interview, it provides a standardized way to gather information and score it objectively, which is very helpful for research purposes.
The goal of the STIPO-R is to arrive at a structural diagnosis (of NPO or high- or low-level BPO) through the thorough assessment of seven essential constructs: identity, coping and rigidity, primitive defenses, reality testing, quality of object relations, aggression, and moral values.
TFP requires the mandatory clinical assessment of the patient and analysis of its results. As a result, the therapist gains an evaluation of the patient’s areas of functioning and is able to tailor treatment based on the problematic aspects in the patient's life.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy