We have prepared for you a brief overview of the article Judith Landway and George Brownstone “Moving to Transfer-Focused Psychotherapy from Other Psychotherapy Methods by the Same Therapist: Pitfalls and Benefits”, 2022, where in order to discuss the transition to TFP from other psychotherapy methods with the same patient, consider the Transfer-Focused Psychotherapy model and dwell on its main important aspects that distinguish TFP from other models of psychodynamic psychotherapy. It is important to clearly understand these differences when planning the transition to TFP.
This article is significant because many questions arise for therapists who have mastered the TFP model or have just begun to study it: how and with what tools to implement it in therapy, whether it is advisable to introduce it into the treatment process already started or to start it with a new patient. How to explain to the patient significant changes in therapy and how to implement the key points of TFP in the ongoing work with the client? All these questions are answered by this article, which is based on the information of surveys conducted among PTSD therapists, shows the experience of using this therapy and reveals the dyads that were activated when switching to Transfer-Focused Psychotherapy.
REVIEW OF THE TFP MODEL
Transfer-focused psychotherapy (TFP) is an evidence-based, manualized psychoanalytic therapy that is based on object relationship theory. From the beginning, TFP was developed as a therapy model for patients with borderline personality organization, including narcissistic pathologies, but later received modification for the treatment of adolescents with personality disorders (as well as for the therapy of patients with neurotic levels. Nom of the author of the review).
The authors emphasize that what all these cases have in common is the use of primitive defenses (cleavage, projective identification, denial) and diffusion of identity, and they are not psychotic, although they may have transient psychotic episodes. These characteristics distinguish these patients from patients with a neurotic or psychotic personality organization.
TFP has a toolkit that allows you to manage and step by step analyze the intense and unpleasant conditions of the patient, while analyzing their impact on the transfer. TFP involves the detailed work of the therapist with contradictory aspects, their explicit and implicit forms, which the patient may not even be aware of before the start of therapy.
TFP not only reveals the inner world of the patient, while revealing problematic feelings, thoughts and emotions, but also works with a balanced understanding and perception by the person of himself and those around him.
The TFP technique involves a sustained statement by the therapist about the importance of concluding and maintaining a contract with the patient, which certainly provides him with significant support during the treatment process.
TFP training is quite a long and sometimes complex process, as it requires the therapist to understand the deeper aspects of the personality, its defense mechanisms and the tools to work with them. It is an evidence-based technique that allows in the treatment process to form an integrated personality with a good quality of life in all its areas: work, study, friendship, relationships...
Next, the authors show in which sets TFP elements can be used:
A thorough introduction to TFP without a full course of TFP can be beneficial in general to the psychiatric and psychotherapeutic communities, providing tools to work more effectively with this very complex patient population.
Psychiatry residents may use some aspects of TFP in emergency departments, where patients with borderline personal disorder are often present due to suicidal or other crises (Hersh, 2015; Zerbo, Kohen, Bielska, & Caligor, 2013).
A fundamental understanding of the TFP method can help general medicine professionals when faced with “complex” patients who often have a personality disorder (Hersh, 2018).
Over the years, TFP elements have been used in a variety of situations (contexts), including with specific patient groups and healthcare initiatives (Hersh, 2021).
Comment by O. Lemeshchuk:
Here, the authors emphasize that in addition to the main purpose - the therapy of personality disorders, the individual elements of TFP are applied in various medical situations, both those related to the field of mental health and those related to general medicine. In all situations where the doctor is dealing with a complex patient, presumably with a personality disorder, the elements of TFP help to establish dialogue and alliance.
PATIENT EVALUATION IN TFP MODEL
Therapists who intend to carry out treatment using TFP should conduct an evaluation of the patient in advance through a structural interview. This task is mandatory even for those patients who have already been on treatment and may have a lot of information about themselves from previous therapy.
Why is the structural interview used in the TFP model, from which the entire diagnostic process begins? We pursue this goal in order to immediately assess cognitive functioning and attitude, to formulate such questions for the patient that will force him to leave his comfortable environment, to manifest the root problems of his personality and to discover (or at least reduce) his defense mechanisms.
The final, but no less important stage of the interview, is the discussion with the patient of the results of the diagnosis, including his diagnosis. This discussion must be carried out in a language understandable to the client, paying attention to points that are not sufficiently clear to him. To do this, the therapist can even use the narrative of the patients themselves regarding the specifics of their life or the difficulties that they have in it. This stage is crucial to establish a trusting relationship between the patient and the therapist, as well as for the client to understand and be aware of his personal disorders.
ESTABLISHMENT OF A CONTRACT
The last step in the transition to TFP is to establish a contract that provides for a clear definition of the therapeutic framework, the conditions in which psychotherapy will be carried out and the responsibility of each of its parties. Most of the time, the contract in other types of psychotherapy has been the same that is usually established with patients with neurotic disorders, where standard things such as schedule, payment and skips are explained. Contracting in TFP with patients with borderline personality organization is a longer and more detailed process that often requires multiple sessions.
Comment by O. Lemeshchuk:
The contract is the basis for activating the transfer, as well as the basis for understanding the reality of the therapeutic situation. In the TFP contract, so much attention is paid because:
- a clear framework with gambling restrictions activates internal object relationships to be explored in therapy
- a clear framework helps and the therapist not to be confused between the reality of the therapeutic situation and counterproductive reactions
The issue of the therapeutic contract receives a lot of attention - the contract helps prevent suicidal behavior, self-injurious behavior, avoid abrupt interruption of therapy, introduce additional parameters when we work with patients with addictions, etc.
In the winter of 2024, our readers received a review of Monica Karski's wonderful article on the therapeutic contract in psychotherapy. And participants of the TFP training program have a translation of this article among the handouts.
The contract is the dynamic basis of psychotherapy. It can adapt to new requirements in the course of treatment. In order to make changes to it, it is first necessary to discuss this aspect with the patient. These changes must be exceptional and justified. In the course of therapy, the patient will try to test the established contract and therapeutic framework, which is a direct indication of the dyads of activated object relationships that require investigation and clarification.
WORKING WITH DYADS HERE AND NOW
In the TFP model, transfer is a key aspect that requires significant activity from the therapist.
According to the theory of object relations, each person has: selfie and object representations, as well as the affect that binds them. Together, these three components constitute a dyad of object relations, the basis of which is formed through real and fantasy object relationships from the past and also includes defense mechanisms against them.
These dyads can be activated in different ways in interactions between people.
Transfer represents the reactivation of these past object relationships in the context of “here and now”.
The main task of the therapist during the session is to work on the definition, analysis, study and interpretation of these dyads and their consequences. We work in detail on the issues: Which partial object-representation is projected on the therapist, and which partial self-representation is taken by the patient?
COUNTERTRANSFER AND METACOMMUNICATION
In Transfer-Focused Psychotherapy, an important point is the use to conduct sessions of all three communication channels: verbal, non-verbal (metacommunication) and countertransference, which often provide more information about the patient than words.
TFP has been developed with systematic use of session recordings, as they reveal the particular importance of metacommunication and countertransfer when working with patients with borderline personality organization (Clarkin et al., 2005).
Why is video recording so important? Because it helps to analyze the key moments of the session after it is carried out and to identify the possible impact of the patient's projective identification on the therapist. Also, video recordings are a mandatory requirement in supervision, where the therapist reveals those aspects of therapy that were previously little noticed by him or not at all investigated.
To videotape the session, the therapist must obtain written informed consent from the patient and work to explain to him the importance of this process.
By entering into an informed consent, the therapist guarantees confidentiality to his client.
In the informed consent, we note that session videos are only available for viewing by a small group of people who also maintain the confidentiality of the information — this is a key aspect for the use of video material on supervisions.
In the process of therapy, the patient may at any time refuse to continue the video recording both at the current session and in the subsequent therapy. In TFP, this moment does not go unnoticed, it is examined and analyzed in detail by the therapist on the subject of what exactly became the catalyst for such a decision.
THE USE OF FREE ASSOCIATIONS
In TFP, it is important for the therapist to form a trusting relationship with the patient. This is done so that, in the event that the client experiences any manifestation of self-destructive behavior, whether impulses or thoughts (especially suicidal ones) that have arisen between sessions are brought to the therapist and discussed during the appointment.
The problematic aspects of using free associations during the session are described in the full version of this article.
TRANSITION TECHNIQUE
When should I go to TFP with a patient whose treatment has already begun? This is a key question for most therapists who have mastered TFP, but have doubts about when to change the instrument of therapy.
This transition should only be made when the therapist recognizes that the first therapeutic approach that has been applied to TFP does not produce visible results or the therapy seems protracted or ineffective.
Ideally, the entire process of switching to another type of therapy, be it TFP or something else, should take place under supervision. This is due to the fact that a change in any method of therapy is tangible for the patient himself, since the therapist takes new tools into work, and in connection with this, the approach to the client also changes.
It is more convenient for the therapist and patient to work when TFP is applied from the very beginning of therapy, when a structural interview is immediately conducted, a contract is established and there is a clearly established therapeutic framework.
But experience shows that even those therapists who start supervision while undergoing a theoretical course translate current cases, rather than waiting for new ones.
The first step that should be taken when switching to TPD in therapy that has already been started is to talk in detail with your patient about the importance of changes and their impact on the entire therapy process. It is important not to immerse the patient immediately in the full range of changes, without paying attention to his new condition and experiences. It is worth asking and discussing with him his reactions and feelings that have arisen as a result of these changes.
Sometimes therapists “over-explain” the transition, perhaps as a defense against feelings of guilt and shame because they started out wrong. This is reckless and can cause a loss of confidence in the therapist or the feeling that this new way of working is somehow dangerous or too complicated and therefore needs to be implemented and applied very carefully.
Another important aspect in the transition is the therapeutic alliance, which is especially important for patients returning to therapy.
The difference between TFP and other psychotherapies is that the patient will undergo therapy with a therapist who behaves completely differently from the person he is used to. This “new” therapist will be less supportive and may initially be perceived by the patient as unhelpful or intrusive. Problematic aspects of the patient's pathology that have been given insufficient attention or avoided altogether will begin to manifest themselves, and the patient will feel uncomfortable, feel threatened and abandoned: “What happened to my friendly therapist that I was so comfortable with? I don't like it at all!” As a result, the therapeutic alliance is often tense. However, it is the study and interpretation of these shifts and the associated protections that are very useful.
The other side of the same coin is the therapist, who was often taught to make the patient comfortable without interrupting, analyzing resistance, not discussing uncomfortable material, and not addressing negative transfer directly. We often hear, “Can I say this - or not too straightforwardly?” Getting rid of such habits is not easy, but it can usually be done successfully if the therapist is aware of the need for them.
Therapists often have the impression that if prior to TFP therapy was long and supportive, the transition to a new method will be difficult or impossible. This opinion is erroneous, since the therapeutic alliance formed on previous experience becomes the base that is able to withstand all the difficult moments of the transition to TFP.
The effectiveness of the use of TFP, whether in a new or in an already ongoing therapy, directly depends on the abilities of the therapist.
The full version of this article provides data from a survey of TFP therapists conducted on the percentage prevalence of the transition, the difficulties encountered during this process, and data regarding which patient is easier to make this transition with.
CONCLUSION
Transfer-focused psychotherapy is a dynamic evidence-based psychotherapy that reveals not only the inner world of the patient, while revealing problematic feelings, thoughts and emotions, but also works with a balanced understanding and perception by the person of himself and those around him.
TFP is often used by both experienced psychotherapists and those who are still studying its key aspects, under the supervision of a case supervisor.
When working with a new patient, the basic provisions of the TFP should be observed and a clearly defined therapy plan should be followed.
The transition to the TFP model is primarily a learning issue: it should be taught during a formal training course, before trainee therapists begin working with patients in TFP, and should not leave the issue solely for consideration within the framework of supervision.
When switching to TFP from another type of therapy, we recommend that you first discuss these changes with the patient. The transition should begin with a structural interview, even if the patient gave enough information about himself before the transition. Switching to TFP does not exempt the therapist from the steps that are described for the initial stages of this therapy. All of them are key and create the basis that has a tangible effect of therapy.
The entire process of transition to TFP in therapy that has already been started should be carried out under supervision, which will provide the therapist with confidence in their actions and prevent mistakes or omissions that may occur during the transition.
(c) Julia Goloporova,
Ukrainian Association of Transfer-Focused Psychotherapy