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Mental Disorders

Transference Focused Psychotherapy (TFP) Continued

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

In transference-focused psychotherapy (TFP) the agent of change is the relationship that forms between the therapist and the therapy participant.  In other words, the relationship itself provides the means to identify and correct the faulty personality structure.  This is achieved by providing the participant an updated map, or corrected template of relationships.   This correction becomes possible through a process called "transference."  In its simplest form, transference means the therapy participant experiences and expresses feelings toward the therapist that actually stem from other earlier relationships. This occurs because the therapy participant draws upon their old relationship template or map, formed during childhood, in order to understand and navigate the new relationship with their therapist.  As transference occurs during therapy sessions, the therapist uses this experience as the tool to identify, to understand, and to update these internal representations (that were formed in the past).  When TFP therapists notice this transference, they assist the recovering person to understand and to modify these internal representations.

The primary goal of TFP is to assist the therapy participant to receive a corrective emotional experience via the therapeutic relationship. The therapist seeks to create an empathic and soothing relational climate that enables the participant to directly experience painful, contradictory, and ambivalent feelings toward the therapist. In this safe and comforting setting, the therapy participant learns to confront and tolerate the disturbing feelings that emerge when the chaotic and split-off, self-object representations are activated. This ability to tolerate these highly uncomfortable feelings was simply not possible as an infant or child. The purpose of this process is to assist the recovering person to integrate split-off representations of self-and-other into a cohesive whole.

Now let's use an example to illustrate how this process works. Suppose a therapist is late to a therapy session. The previously idealized "all good" therapist representation will suddenly be replaced with its polar opposite "all bad" representation. This is because the therapy participant cannot hold these two opposite representations of the therapist simultaneously without experiencing a tremendous amount of distress. Nonetheless, the therapist would guide and support the therapy participant to call forth and experience both representations of the therapist simultaneously in order to permit an opportunity for integration, even in the midst of highly distressing feelings brought about by two split-off, opposite feelings toward the same object (the therapist). Overtime, the therapy participant learns they are able to briefly tolerate these feelings as they re-assemble a new, integrated, and single cohesive object representing the therapist. The therapy participant now has a new more accurate model of relationships that can then be applied to other relationships as well.

TFP differs from the traditional psychoanalytic technique of free-association, in several important ways.  First, there is a very specific agenda.  At the beginning of treatment, there is an extensive evaluation phase.  Based on this evaluation, the therapist makes a diagnosis. The therapist and prospective participant discuss the diagnosis and agree upon a treatment contract together.  Frequently, the person requesting therapy may have had previous, failed attempts at therapy.  In this case, the reasons for earlier treatments failures are discussed.  If there were any behaviors on part of the participant that were detrimental to the effectiveness of previous therapies (e.g., missing sessions, dishonesty, or not following treatment recommendations) those behaviors are addressed in the treatment contract. The therapy contract also addresses the boundaries of the treatment, such as frequency and duration of sessions, phone calls, and emergency procedures.

Second, the therapist is not simply a passive listener.  Instead, the therapist typically takes on a very active role in the therapy, asking pointed, clarifying questions, and challenging  self-destructive or other negative behaviors.

Third, the focus is on the here-and-now, present-day relationships. Childhood fantasies and conflicts between the Id, Ego, and Super-Ego are irrelevant.  Instead, the focus is to help the recovering person make connections between their present relationship with the therapist, and the current problems they experience with other relationships in their life.

The recovering person is strongly encouraged to build a meaningful and productive life for themselves outside of therapy. This may include finding a job, going to school, or engaging in volunteer work. Typically the therapist and participant meet twice a week. Sometimes group treatment is also recommended. Furthermore, if there is an issue that requires additional attention, for instance a substance abuse problem, a referral may be made to adjunctive services such as Alcoholics Anonymous or a drug and alcohol treatment facility. This ensures the therapy remains focused and directed toward relational problems in the here-and-now. There is growing evidence that TFP is a very effective treatment for severe personality disorders (Paris, 2008).