Have you ever found yourself sitting across from a patient, faced with a chaos of fragmented stories, conflicting emotions, and elusive hints?
How do you find what truly matters in the midst of this confusion?
How do you stay focused amid a sea of information and grasp what is really driving your patient right now? And most importantly, how do you make sure your intervention doesn’t dissolve into emptiness, but instead lands exactly where it is needed?
In Transference-Focused Psychotherapy, we rely on the dominant affect, which must be identified. But how do we determine what it is? And how do we then build interventions based on it?
Transference-Focused Psychotherapy (TFP) provides clear answers to these questions. TFP embodies a synthesis of effective strategies, techniques, and tactics that enable therapists to work systematically with the material that arises in a session. These tools help you reach the core — the hidden conflicts, affect states, and object-relational dyads that shape the patient’s inner world and determine their behaviour in the here and now.
In TFP choosing the priority theme involves:
1) monitoring the three channels of communication:
- the verbal content of the patient’s discourse;
- the patient’s nonverbal communication, including how the patient says what he or she says (tone of voice, speech volume, etc.)
- the therapist’s countertransference.
Awareness of all three channels is especially important because when a therapist who has been trained to listen carefully to the patient’s associations is not attuned to subtle observation of the patient’s interaction with the therapist and of the countertransference, the patient can go on for long periods without making any progress in therapy.
2) following the economic, dynamic, and structural principles of intervention
The economic, dynamic, and structural principles are based on psychoanalytic concepts involving the dynamic forces at work within the mind: the interaction of drives, affects, internal prohibitions, and external reality.
The economic principle refers to the dominant investment of the patient’s affect in any given material and is the principal guide in helping the therapist decide what material to focus on. The rationale for this principle is that intense affects serve as flags pointing to the dominant object relation in the transference. An issue may be considered affectively dominant either if significant affect accompanies the content or if there is a striking absence of affect appropriate to the content, which indicates that affect is being suppressed, repressed, displaced, or split off.
The dynamic principle - manifests itself after the therapist has determined which material is most invested with affect.This principle has to do with the forces in conflict in the psyche and assumes that the presence of heightened affect signals an unconscious conflict involving a defended-against impulse. Both the impulse and the defense against it are represented in the psyche by respective object relationship dyads. Because the patient’s internalized relationship dyads are observed most clearly in the transference, the dynamic principle is intimately linked with a focus on the transference. The dynamic principle instructs the therapist to work from the defense, which is observable on the surface, to the impulse, which is out of awareness at a deeper level.
The structural principle is also helpful in guiding the therapist’s interventions. This principle involves the therapist’s developing understanding of the structure of the particular patient’s conflicts and comes from the therapist’s stepping back and getting an overview of how the specific dyads that have been activated in the transference fit together in a larger pattern.
With neurotic patients, the structural analysis involves conflicts between the id, superego, ego, and external reality, or with an inconsistent element in an otherwise consolidated identity.
In borderline patients, in whom the ego and superego have not become integrated, conflicts are structured around the most prominent internal relationship dyads and their relations to each other. Although the number of possible relationship dyads is immense, in clinical practice we find that each individual patient presents with a limited number of highly invested dyads that are frequently repeated in the transference.
Thus, each therapy comprises a limited number of transference themes. Establishing which transference themes are prominent in a specific patient, and their relation to each other, helps the therapist guide his or her interventions.
In summary, these principles of TFP remind the therapist to:
- follow the patient’s affect as an indicator of what the predominant object relations dyad is at a given moment,
- look for and address first the material that seems to be serving a defensive purpose,
- look for the overall organization of dyads in terms of which surface dyad is defending against which underlying dyad.
3) adhering to the hierarchy of priorities regarding the types of material the patient brings up assumes that in each session, the therapist first must establish whether any emergency priorities are present or whether the session will involve the ordinary priorities of therapy. The therapist must give highest priority to any behaviors that threaten the safety of the patient, of the therapist, or of the treatment. The hierarchy of priorities helps the therapist determine what constitutes emergencies or threats to the treatment versus business as usual.
Emergency themes (e.g., threats of suicide or selfinjury, threats to discontinue treatment, withholding of information) tend to recede over the first 6 months of treatment if dealt with effectively.This allows the therapist to focus more on the issues that truly form the essence of psychotherapy — understanding the internal world of the patient.
Thus, through the clear adherence to a hierarchy of priorities, the identification of the dominant affect, and a deep understanding of the economic, dynamic, and structural principles, TFP enables the therapist to remain grounded amidst the clinical chaos and to guide the patient step by step toward recognising the unconscious conflicts that drive their behaviour in the here and now.
It is this structure and depth that make TFP an effective model for working with personality disorders.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy