At different stages of therapy, not only does the patient’s condition change, but the very nature of clinical work evolves: what is central at the beginning of treatment gradually recedes, making space for other processes.
In the course of effective therapy, the patient’s life outside the sessions gradually stabilizes. This is reflected in the fact that severe acting out outside the treatment sessions should be better controlled even during the early stages of treatment (3–6 months into treatment), and by the advanced phase the patient’s life outside the sessions may have already normalized to a significant extent.
The model of Transference-Focused Psychotherapy (TFP) understands this as the gradual integration of split representations of the self and others, along with a reduced need for external acting out as a means of affect regulation.
At the same time, the sessions themselves often become increasingly emotionally intense: transference developments are reflected in emotional intensity and possibly affect storms in the sessions.
In TFP, this is conceptualized as the activation of dominant self–other dyads in the transference, making internal conflicts directly accessible for therapeutic work.
In the advanced stages of the treatment, the patient has become aware of the difference between the therapist’s tolerance of his or her regressive behavior in sessions, with the goal of understanding it, and the need to control his or her behavior outside and bring strong reactions to external events into the therapy for exploration rather than act out outside the treatment sessions.
Therefore, the threats that were the highest priorities of intervention in the earlier stages—namely,
1) threat to the patient’s or others’ well-being,
2) threat to the continuity of the treatment,
3) threat of severe destructive or self-destructive acting out outside the sessions—
should have decreased enough to permit the therapist to focus increasingly on transference itself. In TFP, this is understood as a shift from structure-maintaining interventions to more intensive interpretive work with the transference.
Many patients tend to split their external reality from the sessions in the early part of treatment, but in the advanced phase the therapist should be able to rely on the patient’s communication of his or her experiences outside the session without having to continue to actively inquire about the patient’s outside life.This reflects an increased capacity to integrate experience and a reduction in primitive defenses, which is one of the markers of change in TFP.
Sometimes turmoil in the sessions may make it difficult for the therapist to be aware of the patient’s improvement outside the sessions. A development in a successful therapy is that the patient comes to trust the therapist enough to remain open about negative reactions that he or she realizes are best hidden from people outside sessions. In TFP terms, this can be understood as a strengthening of the therapeutic alliance and an increased capacity to tolerate ambivalence within relationships.
This is particularly true when the paranoid transference is not fully resolved and the patient is uncertain whether to stay with his or her old instinct of mistrust or anxiously be open to the possibility that his or her wish for a relationship may be reciprocated.This oscillating dynamic reflects a conflict between persecutory and libidinal object representations, which are gradually integrated in the course of TFP.
In some cases, when the transference is negative, the improvement outside the sessions may be so dissociated from the material in the sessions that the therapist may not be aware of and thus may not be able to take into account the patient’s changes in significant areas of his or her relationships. In the TFP model, this may indicate insufficient integration of positive changes into the structure of the self and object relations, and calls for their incorporation into the work with the transference.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy