New Developments in Transference-Focused Psychotherapy


New Developments in Transference-Focused Psychotherapy



What follows is a capsule description of the basic aspects of transference-focused psychotherapy (TFP) and new developments of this therapeutic approach that are derived from both our research findings and the clinical experience gathered in the various centers where it is being studied. Please keep in mind that this treatment is indicated for patients whose severity of illness, urgency of related life situations, and lack of capacity to participate in the therapeutic frame required by standard psychoanalysis would induce most experienced clinicians to carry out a supportive treatment. TFP, derived from psychoanalytic theory and technique, expands the realm of psychoanalytic therapeutic approaches with severely disturbed patients.

While abundant clinical evidence of positive developments in fundamental personality change with TFP is now available and justifies focused research efforts to study empirically these effects in long-term follow-up studies, this chapter is an effort to update aspects of the basic techniques of TFP as described in the third edition of our manual (Yeomans et al. 2015). These developments essentially represent an expansion of the exploration of transference by focusing on sharply dissociated expressions of severely self-destructive tendencies in the patient’s external life. This focus is reflected in various technical approaches to be outlined in this chapter. These new developments stem from our clinical observations of patients treated in our various research projects as well as from the consistent study of the most difficult cases in weekly group meetings of the Personality Disorders Institute in New York and with our colleagues there.

TFP is a manualized, empirically validated psychoanalytic psychotherapy derived from a synthesis of contemporary object relations theory and modifications of psychoanalytic technique to treat patients whose severity of pathology contraindicates standard psychoanalysis (Clarkin et al. 2007; Doering et al. 2010; Kernberg et al. 2008; Yeomans et al. 2015). The specific objective of TFP is the modification of the personality structure of patients with severe personality disorders, particularly borderline personality disorder but also narcissistic, paranoid, schizoid, and schizotypal personality disorders. We have also had success in treating personality-disordered patients with significant antisocial traits and behavior but not antisocial personality disorder proper, patients with milder borderline features (the infantile or histrionic personalities), and patients with a specific hypochondriacal syndrome.

TFP focuses on reducing the symptoms typically seen in severe personality disorders, such as chronic suicidal behavior, antisocial behavior, substance abuse, and eating disorders (Zanarini et al. 2010a, 2010b). It also has the ambitious goal of modifying the personality structure of the patient sufficiently to meaningfully improve the functioning in the arenas of work, studies and profession, and intimate relations, such that the patient develops a fuller capacity to integrate emotional commitment, sexual freedom, and tenderness. Such integration leads to improvements in the capacity for genuine friendships as well as investment in creative and cultural pursuits (Yeomans et al. 2015).

The treatment is conceptualized as applying basic strategies, tactics, and techniques (Kernberg et al. 2008) as outlined in this chapter.


Our assumption was that patients with severe personality disorders or borderline personality organization have a chronic, fixed internal split reflecting the lack of integration of the concept of self and of the concept of significant others (identity diffusion) and that the ultimate cause of that syndrome is the failure of psychological integration resulting from the predominance of aggressive internalized object relations over idealized ones. In an effort to protect the idealized segment of experience, the ego is fixated at a level of primitive dissociative or splitting mechanisms that are reinforced by a variety of other primitive defensive operations (predating the dominance of repression)—namely, projective identification, omnipotence and omnipotent control, devaluation, denial, and primitive idealization.

The main strategy in the treatment of patients with borderline personality organization consists in the facilitation of the (re)activation of split-off internalized object relations of contrasting persecutory and idealized natures that are then observed and interpreted in the transference. TFP is carried out in face-to-face sessions, with a minimum of two, and usually not more than three, sessions per week. The patient is instructed to carry out free association while the therapist restricts his or her role to careful listening and observation of the activation of regressive, split-off relations in the transference and to helping identify them and interpret their segregation in the light of these patients’ enormous difficulty in reflecting on their own behavior and often on the maladaptive, turbulent interpersonal interactions in which they find themselves. The interpretation of these split-off object relations assumes that each reflects a dyadic unit comprising a self representation, an object representation, and a dominant affect linking them, and that the activation of these dyadic relationships determines the patient’s perception of the therapist. Not infrequently, rapid role reversals of idealized and persecutory aspects appear in the transference, providing the clinician with a vital window into the patient’s internal world of object relations. Thus, the patient may identify with a primitive self representation while projecting a corresponding object representation onto the therapist, whereas 10 minutes later, for example, the patient identifies with the object representation while projecting the self representation onto the therapist.

This oscillation of the roles of the dyad must ultimately be differentiated from the split between opposite dyads carrying opposite (idealizing and persecutory) affective charges—that is, a surface dyad may be defending against a deeper, more dissociated structure. The final step of interpretation consists in linking the dissociated positive and negative transferences, which leads to an integration of the mutually split-off idealized and persecutory segments of experience with the corresponding resolution of identity diffusion. The overall strategy is facilitated by the fact that unconscious conflicts are activated in the transference mostly through the patient’s behavior rather than in the emergence of preconscious subjective experiences reflecting unconscious fantasy. The intolerance of overwhelming emotional experiences is expressed in the tendency to bypass such emotional experiences, predominantly by acting out in the case of most borderline patients and somatization in some patients with other personality disorders (Green 1993).


The tactics are rules of engagement that permit the application of a modified psychoanalytic technique that corresponds to the nature of the transference developments. The essential tactics are 1) establishing with the patient a treatment contract, 2) choosing the priority theme to address in each session from the material the patient is presenting, 3) maintaining an appropriate balance between exploring the incompatible views of reality between the patient and therapist in preparation for interpretation and establishing common elements of shared reality, and 4) regulating the intensity of affective involvement.

In the establishment of an initial treatment contract, in addition to the usual arrangements for psychoanalytic treatment, any urgent difficulties in the patient’s life that may threaten the patient’s physical integrity or survival, other people’s physical integrity or survival, or the very continuation of the treatment, are taken up and structured with the patient in such a way as to give the treatment the optimal chance of succeeding. The combination of limit setting and interpretation of the corresponding transference developments is an essential, highly effective, and, at times, lifesaving tactic of the treatment. Yeomans et al. (1992) have described in detail the techniques and vicissitudes of initial contract setting, and the manual of the technical aspects of TFP (Yeomans et al. 2015) describes in detail the priorities to address in carrying out the therapy.

With regard to choosing which theme to address at any given moment, the most important tactic is the general analytic rule that interpretation has to be carried out where the affect is most intense: affective dominance determines the focus of the interpretation. The most intense affect may be expressed in the patient’s subjective experience, in the patient’s nonverbal behavior, or, at times, in the countertransference. One’s countertransference reaction in the face of what on the surface seems a completely frozen or affectless situation can be especially helpful to understand what is going on. The simultaneous attention to the patient’s verbal communication, nonverbal behavior, and the countertransference permits identifying what the dominant affect is at the moment—and the corresponding object relation activated in the treatment situation. Every affect is considered to be the manifestation of an underlying object relation.

Still another tactical approach relates to certain general priorities that need to be taken up immediately, whether they reflect affective dominance or not, although they usually do. These priorities include, in order of importance 1) suicidal or homicidal behavior, 2) threats to the continuation of the treatment, 3) severe acting out that threatens the patient’s life, 4) dishonesty, 5) trivialization of the content of the hour, and 6) pervasive narcissistic resistances that must be resolved by consistent analysis of the transference implications of the pathological grandiose self (Kernberg 1984; Levy et al. 2006). When none of these priorities seem dominant, the general tactic of privileging affective dominance and transference analysis prevails.


Whereas strategies refers to overall, long range goals and their implementation in transference analysis, and tactics to particular interventions in the session, techniques refers to the general, consistent application of technical instruments derived from psychoanalytic principles. The main technical instruments of TFP are those referred to by Gill (1954) as the essential techniques of psychoanalysis—namely, interpretation, transference analysis, technical neutrality, and countertransference analysis. We have made some modifications to these techniques, but they otherwise define our treatment (see also Chapter 6, “The Spectrum of Psychoanalytic Techniques”).

Interpretation is applied systematically but with heavy emphasis on its preliminary phases of clarification and confrontation, and the interpretation of the “present unconscious” (Sandler and Sandler 1987). It is only in the later stages of TFP that the “past unconscious” is prioritized and interpreted, although the therapist will remain attuned to ways in which it relates to the present unconscious.

Transference analysis in TFP differs from standard psychoanalysis in that it is always closely linked with the analysis of the patient’s problems in external reality to avoid the dissociation of the psychotherapy sessions from the patient’s external life. Transference analysis also includes an implied concern for the long-range treatment goals that, typically, are not the focus in standard psychoanalysis unless they emerge in the transference. In TFP, an ongoing concern regarding dominant problems in the patient’s life is reflected in the occasional introduction of reference to major conflicts that brought the patient into treatment or that have been discovered during the treatment, bringing such conflicts into the treatment situation even if they are not transference-dominant at that point.

Technical neutrality is the optimal position from which to make interventions, but at times it must be abandoned when an urgent requirement for limit setting takes priority, such as when a threat arises to the patient or to the continuation of the treatment. Such deviation from technical neutrality may be indispensable to protect the boundaries of the treatment situation and protect the patient from severe suicidal and other self-destructive behavior and requires a particular approach to restore technical neutrality once it has been abandoned. Once the treatment situation is stabilized, it is very important to address with the patient the transference implications of the therapist’s abandoning neutrality and the analysis of the implications and meaning of the crisis. Technical neutrality, in short, fluctuates throughout the treatment but is constantly worked on and reinstated as a major process goal.

Countertransference utilization as a major therapeutic tool has already been referred to as an important source of information about affectively dominant issues in the hour. The internal tolerance of countertransference permits its analysis in terms of the nature of the self-representation or the object representation that is being projected onto the therapist at that point, facilitating full interpretation of the dyadic relationship in the transference, so that countertransference is used in the therapist’s mind for transference clarification.

As Green (1993, 2012) has pointed out, the avoidance of traumatogenic associations drives borderline patients to jump from one subject to the next, thus expressing their “central phobic position,” and this may seem bewildering to an analyst used to expecting the gradual development of a specific theme in free association, thus leading to clarity about the subject matter that is being explored. Here, waiting for such a gradual deepening of free association is useless because of this defensive use of free association, which is also related to the splitting operations that affect the very language of the patient.

The corresponding technical approach in TFP consists of an effort to interpret the implication of each of the fragments as they occur in the therapeutic hours, with the intention of establishing continuity by the very nature of the interpretive interventions that gradually establish a continuity of their own. This approach may be compared with the interpretive work with dreams, in which the analysis of apparently isolated fragments of the manifest dream content leads gradually to the latent content that establishes the continuity between the seemingly disparate elements of the manifest content.

Relationship of TFP With Other Psychoanalytic Modalities of Treatment

TFP applies a contemporary psychoanalytic object relations theory approach but, in its application of an interpretive technique, differentiates itself from other versions of this general theoretical view. The basic TFP theory of pathology derives from the Kleinian developmental concepts referring to the paranoid-schizoid and the depressive positions. Borderline personality organization refers to the fixation at a primitive intrapsychic structure characterized by the predominance of defensive operations centering on splitting mechanisms. Idealized and persecutory internalized dyadic units of self and object representations constitute the building blocks of the later, tripartite structure based on the dominance of the depressive position. TFP conceptualizes the activation of dyadic relations in the transference, in the sense of not only projection of a representation of self or of an object (significant other) onto the therapist, but always a simultaneous enactment of the reciprocate object or self representation on the part of the patient. It needs to be stressed that what is being projected or enacted by the patient is an affectively charged representation, and in the reciprocity of the now-enacted object relation the entire intensity of the dissociated or split-off, conflictual unconscious relationship is played out.

Countertransference is an important source of information for understanding the patient’s internal world of object relations and is used to interpret the total transference situation. We do not disclose these reactions to the patient. The therapist’s capacity to contain, metabolize, and interpret the intolerable split-off aspects in ways that enable the patient to tolerate and reintegrate them in less toxic form profoundly engages the therapists’ subjectivity, but requires continual meticulous monitoring of what belongs to the patient, the therapist, and/or their interaction. Insofar as neither patient nor therapist is free of internal relations with unconscious significant others, unconscious triadic situations enter the picture, in parallel to the triangulation described by Kleinian authors (Britton 2004). At the same time, insofar as the activation of these dyadic and triadic relations is split off from other experiences of the patient in his or her external world, TFP pays consistent attention to what is going on in the patient’s external reality, particularly, of course, the split-off expression of destructive and self-destructive urges dominant in severe personality disorders.

We believe that in treatment it is a “relationship” that is activated and projected, and not just an “alien” part of the self. This view differentiates TFP from an essential aspect of the mentalization-based therapy approach (Bateman and Fonagy 2004). TFP interprets conscious and preconscious defensively split-off experiences of the patient, rather than assumed “repressed” or “pretend mode” formulations, which bypass a patient’s subjectivity. Our emphasis on attention to the patient’s conflicts in external reality has the predominant objective not of raising the patient’s mentalization process regarding these external circumstances, but of exploring the transferential significance of the dissociation of potentially dangerous developments in the patient’s life from the treatment situation. Our efforts are not oriented toward directly influencing the patient’s behavior through better understanding his or her motivation and those of others in such external situations; rather, they are oriented toward acquiring an awareness of the transferential significance of keeping potentially self-destructive developments from potentially therapeutic understanding and help.

TFP adopts an ego psychological approach in exploring defensive operations in the transference from a “surface-to-depth” perspective, evaluating the activated object relationship in the transference in gradual deepening of the patient’s subjective experience. However, the systematic dyadic and triadic focus on primitive object relations and defenses differentiates TFP from the ego psychological psychoanalytic psychotherapies that also tend to combine interpretive and supportive technical techniques. This same difference applies with respect to German depth psychology–based psychoanalytic psychotherapy (Tiefenpsychologisch fundierte Psychotherapie), which in many ways is similar to the American expressive-supportive psychotherapy developed in the 1960s and 1970s (Rudolf 2002) and to recently developed short-term treatment, dynamic interpersonal therapy (DIT; Lemma et al. 2011), which seeks to modify symptomatology, particularly in affective disorders, by identifying and working with the dominant maladaptive self-object affect units that underlie and sustain both symptoms and personality pathology. DIT incorporates several TFP tactics and techniques, including in the early stages the identification of and consistent attention to a dominant object relational dyad (called, in DIT, the interpersonal affective focus) constituted by a self representation, object representation, and linking affect. In the middle stages, DIT pays attention to role reversals as the individual identifies alternately with both self and object poles of the dyad and to the defensive functions of the object relations dyad, and at all stages DIT focuses on the myriad ways the interpersonal affective focus manifests itself in both extratransferential and transferential relationships (the latter being particularly salient when the patient has comorbid personality disorder). However, the brevity of DIT treatment (16 weeks) and the consistent focus on one dominant object relational dyad necessarily limit the full exploration and interpretation of the panoply of regressive and often contradictory split-off object relations as they emerge in the transference. Previous research has confirmed that such consistent focus on the transference in TFP leads to the integration of polarized affect states and split, contradictory representations of self and others into a more coherent stable identity reflected in significant symptomatic improvement and increased capacity for reflective functioning (Fonagy et al. 1998). In addition, improvement has been found in narrative coherence and psychosocial functioning in work and intimate relationships (Clarkin et al. 2007; Levy et al. 2006).

TFP’s technical approach is closer to the London Kleinian focus on primitive defensive operations and object relations. Apart from the systematic dyadic approach to the transference, the consistent focus on dominant problems in the patients’ external reality—beyond the “total transference” interpretation of the patient’s material—most clearly differentiates TFP from the London approach.

New Developments


In our efforts to test the therapeutic potential of TFP, we have expanded the selection of patients to include very severely disturbed patients whose functioning in their environment was marginal. We also discovered that patients who initially presented a façade of rather stable functioning were actually masking an ever more threatening deterioration of their psychosocial adjustment. What was most striking was how often the patients managed to keep the severity of their condition and of their deteriorating social adaptation dissociated from the material that emerged in the therapeutic situation. In most cases, this appeared to be an unconscious maneuver, a dissociated or split-off part of their destructive and self-destructive potential, often as an expression of an unconscious identification with an internalized sadistic/masochistic object relationship. At times, the discovery of this occurred too late to prevent disastrous consequences for the patient and for the treatment. Resisting the temptation to shift the treatment approach from an analytic to a supportive modality (many of these patients already had a history of failed supportive approaches to their pathology), we examined the transference implications of these developments.

Applying Betty Joseph’s development of the Kleinian concept of the transference as a total situation, the central need to explore the patient’s unconscious attempts to influence the analyst in the transference/countertransference bind (Joseph 1985, 1989) and the expansion of the analyst’s evenly suspended attention into Bion’s approaching the session “without memory or desire” (Bion 1967, 2013), we developed an expansion of our technical approach. We concluded that the focus on the total transference situation might not incorporate particular dissociated aspects of the patient’s interaction in his or her environment, the unconscious acting out of severely destructive and self-destructive tendencies well sheltered from his or her awareness and capacity of concern. There was an effective primitive denial of any concern on the patient’s part that emerged dramatically on discovering and elaborating that dissociated material. But how to incorporate that exploration without affecting the need to let the unconscious elements of the transference/countertransference bind emerge undisturbed in the initiation of each session? Our response was to acquire very solid, detailed information about every aspect of the patient’s present life situation at the time of the initial diagnostic evaluation and then maintain an ongoing, current review of his or her present life situation as a constant background to our thinking about the patient. That meant occasional inquiry about strange moments of the patient’s experience or a sense of significant gaps in our awareness of the external situation. An ongoing concern for the patient’s life, the therapist’s fantasy about what the patient might be doing to improve his or her lot in contrast to remaining paralyzed in his or her suffering, might be part of that concern.

The therapist must attempt to be completely open to what may emerge in the session and only draw on awareness of external factors when it is powerfully activated in his or her countertransference because of the transferential developments in the hour. In other words, it will have to enter the experiential subject matter that, in the therapist’s mind, becomes affectively dominant because of the confluence of the patient’s verbal communication, nonverbal communication, and the countertransference. It is, in short, an amplification or expansion of the awareness of the total transference situation. André Green’s sober description of failed analytic cases (Green 2010) corresponded to our own experience that typically, in such cases, a significant self-destructive area of acting out had remained unrecognized or untouched during years of analytic treatment.

The question may be raised: How could the therapist’s knowledge of an external life situation or crisis not influence the therapist’s “memory nor desire?” Obviously, there are situations in which, given the severity of the illness of the patients under consideration, this may be an unavoidable occurrence. However, a solid knowledge of the patient’s life situation at the initiation of the treatment, the establishment of individualized conditions for the treatment, and the firm demands that these conditions be met for the treatment to begin should provide the therapist with a sufficiently strong frame for the protection of the patient and the treatment to permit the therapist to maintain his or her position of technical neutrality and to have the mental space for working through countertransference pressures and face the individual sessions “without memory or desire.” We believe that this paradox must be tolerated and elaborated continuously. It needs to be kept in mind that the patient population we are considering here have severe personality disorders with chronic failure and dangerous breakdown in their social life, work, and intimacy and have potentially catastrophic self-destructive behavior. A two-sessions-per-week frequency of treatment, which we have found to be a generally satisfactory arrangement, at times adds pressure to the concern for these patients’ social and physical survival.

We have found that an attitude of starting each session “without memory or desire,” in the sense of the therapist’s honest openness to the new and unexpected elements that may evolve, is made possible and facilitated by the therapist’s ongoing mapping and working through his or her countertransference to the patient’s external life outside the treatment sessions. This contributes to maintaining or restoring a position of technical neutrality and facilitates the therapist’s openness to the patient’s communications. This stance is a limitation to the ideal “blinding” oneself to whatever is not emerging in the session, but it protects the therapist from excessive countertransference pressures given his or her possibility to elaborate in between sessions the implications of patients’ dangerous, self-destructive acting out. Bion’s (2013) ideal position is not reached, but technical neutrality—in the sense of intervening outside the transference/countertransference bind, from a position as “excluded third party”—is strengthened.

In this connection, it also needs to be stressed that technical neutrality refers not to what material is selected, but to the analyst’s attitude of objective inquiry—that is, his or her trying to clarify an issue without taking a stance of either approval or disapproval. This requires freedom to experience and elaborate countertransference reactions internally and to use them as elements for interpretive interventions when such a point of technical neutrality has been reached or restored.

This paradox is much less intensively activated in standard psychoanalysis, in which the combination of higher frequency of sessions and less severe chronic regression and threats to the patient’s social and physical survival shifts the material significantly from acting out to communication of subjective experience.

In what follows, some practical technical innovations reflecting the expansion of our theoretical frame are outlined.


Initial and Continuous Evaluation of the Patient’s Conflicts in Terms of Current Functioning in Social and Personal Life Outside the Sessions

We have found that it is essential in the initial diagnostic evaluation of patients to assess consistently four major areas of their present functioning: a) studies, work, or profession; b) love and sexuality; c) family and social life; and d) personal creativity. In fact, the evaluation of these areas during the initial diagnostic interviews not only contributes significantly to diagnostic precision in the assessment of the personality but also pinpoints where the patient stands in terms of overall present functioning, what the gap is between where the patient is now and where the patient might be ideally if he or she did not suffer from the personality disorder.

This Promethean attitude toward the patient is an important balance to certain countertransference reactions to the severity of the dysfunctionality of the patient, such as a sense of despair or even pity in the mind of the diagnostician, implying a sense of hopelessness about the patient. It can be difficult to resist a sense of pity in the presence of the most severely disordered patients, many of whom may seem to have destroyed almost all opportunities in their life and present with an aura of helplessness and resignation about the terrible life situation in which they encounter themselves. But such a reaction may limit the therapist’s therapeutic evaluation of the patient’s principal problems: What should be the goal of treatment in terms of resolving them, and where could this patient be ideally if he or she were not subjected to this pathology? I am not referring here to a furor sanandi, an unrealistic aspiration for perfection imposed on patients in terms of some abstract general therapeutic goal. I am referring to a realistic assessment of what a specific patient might have achieved and might still achieve if freed from the burden of illness, which would sharpen the diagnostic definition, therapeutic goals, and prognostic assessment. It would not be necessary to stress this point if, in practice, many severely ill patients were not able to create around them an atmosphere of pessimism and resignation that in turn may limit the efforts involved in therapeutic interventions.

This same assessment, however, becomes an important aspect of the psychotherapeutic technique with these patients in terms of the rapid evaluation, practically at the beginning of most therapeutic hours, of where the patient stands in terms of his or her relation to important domains of external life—love, work, social life, and creativity. The patient requires an alertness to urgent problems that he or she is ignoring or neglecting, or where self-destructive forces are active in undermining or destroying the patient’s possibilities. It is a consistent finding in the intensive psychotherapy of patients with severe personality disorders and pervasive self-destructive tendencies that ongoing temptations to self-destructive behavior in those four areas are an almost unavoidable complication of the treatment. This naturally becomes a major area of transference acting out. The therapist’s alertness to self-destructive temptations or acting out permits him or her to bring this subject matter into the focus of the hour, particularly the transference implications. This may make a fundamental difference in situations in which such acting out becomes a definite tragedy of opportunities lost or destroyed, life goals curtailed, and self-destructiveness achieving its purpose before it is detected in the content of the therapeutic hours.

We have learned that this attention to external life adds a crucial aspect in determination of the “selected fact” (Bion 1967) in the sessions (i.e., what urgent or threatening issue may be evolving in the patient’s life that is being withheld, disguised, or ignored by the patient, particularly, the transference). Therefore, the selection of what is affectively dominant in each hour and each segment of the hour on the basis of verbal communication, nonverbal behavior, and countertransference must be enriched by the consideration of what, if any, issues are urgently developing and threatening the patient’s life or the treatment. One implication of this ongoing diagnostic assessment is the question of what could be done about this particularly urgent, threatening issue. What would the therapist consider doing under identical conditions that the patient seems, at this point, to ignore, suppress, mask, or deny? The problem is complex, because the action the patient would need to undertake to avoid an urgent danger in his or her life outside the sessions may seduce the therapist into countertransference acting out, attempting to direct the patient to carry out certain behaviors or avoid certain behaviors and adopting a “supportive” stance, which in turn might correspond to a transference/countertransference acting out—the projection of the responsibility of the patient from himself or herself onto the therapist.

In our experience, shifting to a supportive, re-educative mode may be eagerly incorporated into the patient’s self-destructive, and at times markedly masochistic, transference and gratify the patient’s dependency needs, but there remains no authentic concern for himself or herself and an abdication of personal responsibility. It is important, under such circumstances, first, to bring the urgent issue in the patient’s life that has been kept out of the manifest content of the hours into focus. We must analyze the reasons for which the patient may have been unaware, unconcerned, ignoring, or “hiding” an issue that seems of utmost urgency and importance. It is important to help the patient become aware of his or her collusion with the unconscious need to destroy opportunities and to examine the extent to which such awareness stimulates a real concern on the patient’s part over what is occurring in him or her. The absence of such concern would be the first issue to explore, because only after the development of an authentic concern of the patient for himself or herself may it become possible to then explore the patient’s thoughts or feelings about what he or she would need to do to avert danger, correct self-destructive behavior, or prevent some potential disaster from occurring.

A typical example of such situations is represented by one of our patients with significant narcissistic personality features and marked derogatory attitudes toward coworkers. He had entered a highly competitive new field of work within which, he trusted, his intelligence would bring about rapid promotion. However, his derogatory attitude and dismissive reaction to early criticism of his performance led to his being dismissed from this highly desirable and competitive situation before he even suspected that he was at risk.

Another patient, a woman with a borderline personality disorder and marked histrionic features, presented with chronic intense anxiety that precluded her from attending parties and participating in social life or even dating. She was able, however, to work efficiently in an office where her boss, a rather maternal woman, attempted to help her develop her expertise. This patient experienced crying spells at work, for no clear reasons, requiring the direct intervention of the boss to reassure her. Over time, aware that only the boss was able to reassure her, her coworkers decided to call the boss directly during the patient’s inexplicable crying spells. The boss then would cross the large office space where several people were working and observing the scene to console the patient at her desk. It proved to be quite embarrassing for the boss. This brought about a gradual distortion of a realistic working relationship that seemed gratifying to the patient but, from an objective viewpoint, clearly indicated an unsustainable situation that over the long run threatened her position, which the patient ignored completely. At first, the therapist also ignored how those “little scenes” during business hours threatened the future of the patient’s work situation, the only area in her life in which she had been functioning relatively well. The therapist was able to intervene, only at the very last moment, to clarify the risk that the patient’s unstable behavior potentially would eventually lead to the end of her employment.

Another patient presented with the symptom of chronic lateness to all engagements, thereby threatening her employment, which was essential to permit her to continue financing her treatment. Yet another patient with profound ambivalence toward his girlfriend, toward whom he behaved in a childlike, chronically attention-demanding way, ignored the developments in their relationship indicating that she was getting tired of him and probably would leave him, thus repeating the traumatic experiences he had suffered with several women before.

In each of these cases, the most impressive, common element characterizing their sessions was the tendency not to discuss—to ignore, in fact—their self-destructive behavior, thus shielding the therapist from a growing awareness of an impending major crisis potentially induced by the patient’s behavior.

In this regard, a general principle may be very helpful: the therapist should maintain a high degree of alertness and “impatience” with a patient’s self-induced threats to his or her well-being within each hour while remaining patient over the long term in analyzing self-destructive and other major characterological problems of the patient. Patience over the long term and “impatience” in each session are complementary tactical approaches.

Life Goals and Treatment Goals

Many years ago, Ernst Ticho (1972) pointed to the importance of differentiating realistic treatment goals from patients’ life goals. A typical example of a life goal would be the female patient who comes to treatment because she wants to get married and has not been able to find a mate. A thorough assessment of the patient’s personality organization reveals a severely masochistic or narcissistic personality pathology that has interfered with her establishing gratifying relations or her willingness to settle down in a stable relationship and have a family. Now, concerned with the biological limits of fertility, she wishes to have a child or to get married with that purpose. Naturally, men with similar pathology may enter treatment with that objective as well, particularly men with narcissistic personalities and severe, chronic failure in previous marriages or love relationships. As Ticho pointed out, it is very important to clarify that the treatment may help the patient resolve whatever conflicts exist in the establishment of stable and satisfactory love relationships, but it can offer no guarantee that the patient will find such a person in external reality. This may sound trivial, were it not so often a manifest expression of negative transference or disappointment in the therapist who has not provided the patient with an appropriate mate.

In this connection, it has proved very helpful to clarify at the beginning of the treatment what the patient expects to get out of treatment and what the therapist thinks the therapy can reasonably accomplish. Common goals and expectations, along with a clear delineation of responsibilities, should be part of the treatment contract. This may also be a very good moment for the therapist to explore reasonable life goals that, for some reason, the patient has not considered and may present the first opportunity to help the patient envision a better life situation that may be within the realm of possibility. Such a discussion may be of help when the patient, under conditions of severe negative transference developments, threatens to interrupt the treatment or loses complete perspective of what initially the treatment was all about. Realistic, agreed-on treatment goals become, in short, an important component of the treatment frame and may be helpful under conditions of severe regression in the transference.

Patients’ Potential Versus Reality of Their Life Situation

We have found that patients with borderline personality organization frequently present a remarkable discrepancy between their past—their background, education, family support, and the social and cultural environment of their childhood and adolescence—and their present existence as adults in a shadowy, nondescript, empty lifestyle that is devoid of meaningful investment in friendship, love relationships, or work. Not only do they present with a remarkable lack of ambition and concern over this discrepancy between past and present, but they do so unconsciously, with an attitude implying that any effort by the therapist to question where they stand in life represents an unwelcome invasion of their space and present reality. Sometimes one finds the opposite—a rather ambitious fantasy that is incongruent with the nature of their daily life or work and behavior and that stands for what could have been, given their potential and opportunities.

At the initiation of treatment, it is important for the therapist to consider whether the patient is really on the road to achieve what, given his or her background, personality, and potential, might be reasonable for success and gratification in life. Sometimes it helps for the therapist, when informed about the patient’s apparently hopeless life conditions, to wonder how the therapist would deal with such a challenge if not compromised by the kind of pathology presented by the patient. There exists the danger, of course, of the therapist’s imposing his or her own social biases and life goals on the patient and distorting the therapeutic relationship in that regard, so this concern also involves a self-reflective process in the therapist that requires careful attention. Over time, patients tend to “brainwash” their therapist into internally settling down with the patient’s life as he or she presents it, particularly because chronic self-restrictive and self-limiting behaviors do not usually emerge in an active, conflictual way in the context of the transference.

Defenses Against the Sense of Personal Responsibility

As mentioned previously, a patient’s denial of his or her own responsibility in creating and maintaining highly self-destructive situations in major areas of his or her life may become a major focus of the sessions once urgent issues in those areas have been discovered and brought into the transference analysis. Confronting the patient with his or her irresponsible behavior from the viewpoint of realistic survival, rather than from a “superego,” moralistic perspective—the therapist must be moral but not moralistic (Ticho 1972)—may lead, nonetheless, to the patient’s experiencing it as a moralistic assault. This may evolve particularly in the case of patients with significant antisocial features and corresponding projection of their own, intolerable superego functions. This situation requires working through of the patient’s paranoid transference reaction before he or she becomes able to recognize his or her own responsibility in self-sabotaging behavior. Patients who present a chronically shifting, passive, parasitic lifestyle or a level of work that does not correspond at all with their background, education, intelligence, and social support system should alert the therapist to such a chronic acting out of self-destructive behavior and motivate the therapist to bring this issue into the analysis of the transference (Kernberg 2007).

The reference to the therapist’s “moral but not moralistic” stance may be interpreted as a stress on correcting patients’ “bad behavior,” an obvious infringement of interpretive interventions from a technically neutral standpoint. The therapist’s sense that his or her ethical convictions are being called into question by a patient’s behavior constitutes an important alarm signal in his or her countertransference: Is the patient’s behavior indicating an act of unacknowledged, potentially dangerous aggression against others or self? Or is the therapist being tempted to impose his or her own value system over the patient’s value system? Are there objective dangers for the patient or others involved in what, at face value, appear to be unethical acts or intentions? These issues need to be examined, and the therapist’s morality implies a diagnostic function, not an imperative to action. Patients’ “immoral” behavior may have practical implications that they are denying and represent a defensive denial of reality. Confronting patients with the denial of reality, including the consequences of their actions for self and others, may be an important first step to investigate the unconscious functions of that behavior and should not be part of an effort to impose changes to the patient’s behavior. Obviously, if there is a simple clash of culturally determined differences between patient and therapist, the therapist’s task is to explore the countertransference. However, if the patient engages in concretely dangerous behavior—for example, one of our HIV-positive patients engaged in unprotected sex with partners whom he did not inform of his HIV status—the indication is for limit setting as a condition for carrying out TFP, combined with immediate interpretation of the transference implications of this radical abandonment of technical neutrality. This is the first step in later explorations of the unconscious meanings of this behavior and the interpretive restoration of technical neutrality. In short, setting limits is seen not as an end in and of itself, but as necessary precursor, under extreme circumstances, to exploration of the meaning of this behavior. This also may significantly reduce the therapist’s anxiety over dangerous acting out.

In long-lasting treatments, the therapist needs to be alert to the possibility of being seduced into an implicit acquiescence with a stable, yet highly unsatisfactory life situation as if it were perfectly normal. It is helpful for the therapist to maintain a concerned attitude regarding what a “normal” person would do, under the patient’s life circumstances, to enrich his or her experience, effectiveness, and satisfaction with life. This question may be raised in the therapist’s mind with patients presenting a chronic parasitic lifestyle or a severely self-restricting lifestyle reflecting a defensive narcissistic isolation from their psychosocial reality, or with some severely masochistic patients, and with patients presenting the unconscious need to defeat the efforts of those who try to help them.

One patient with severely masochistic personality features functioning on a borderline level was an efficient lawyer at a leading law firm. After the end of a love affair with a high executive of the firm, she experienced herself as being pushed aside from participation in major strategic decisions and got involved in discussions with her ex-lover that escalated to the point of threatening her future at the firm. In one session, she mentioned casually that in a recent argument with the ex-lover, she had triumphantly told him that the leader of a major competing law firm had offered her an important job: other people, she told the now hostile and potentially dangerous executive, did appreciate her capacities. As she went on complaining over the present mistreatment at her firm, I raised with her whether she had considered the possibility of accepting the offer. No, she said, she had not thought about it and only used it as an argument. I confronted her with the combination of her worsening situation and prospects in her present job, the fears she had expressed about being fired, and her remarkable dismissal of what seemed to be an important opportunity. Obviously, there were significant transference implications to the patient’s unconsciously “tempting me” to “force her” to overcome her self-defeating behavior, but it seemed important to keep the external reality in mind in detecting her masochistic acting out.

This contingency highlights the relationship between technical neutrality, ordinary common sense, and the therapist’s image of the patient as capable of functioning at a higher level than perhaps the patient can envision. Keeping all this in mind will counteract the effects of a patient’s relentless, chronic pathology and offer some protection from the temptation to give up on a patient, as well as help patient and therapist come to terms with life goals that the patient realistically would not be able to achieve. In any case, the principle that “psychotherapy starts where common sense ends” should be helpful to reevaluate, at least from time to time, where the patient stands within his or her overall relation to reality. To confront a patient’s serious neglect of “real-life concerns” should not be confused with traditional “supportive” interventions made on the patient’s behalf; rather, it provides the opportunity for exploration of the meaning of such neglect and how this can be understood.

Contract Breaches and “Second Chances”

What follows is a description of our technical approach to contract setting, extensively explored by Yeomans (Yeomans et al. 1992). We frequently find that therapists have a difficult time, after giving patients a second chance following a contract breach, systematically analyzing the risk of a second contract breach, and the related risk of sabotaging and ending the treatment, as part of transference interpretations. A typical example is the case of a patient who understood that if she experiences strong suicidal urges she should either discuss them in the following session or, if not able to control such an urge, consult or apply to a psychiatric emergency center or a general hospital emergency room, but who then carried out a severe suicidal attempt without having complied with this contractual understanding. The therapist, following protocol, offered her a continuation of the treatment with the understanding that a second breach of this contract would definitely end it. Both therapist and patient were clearly aware that this provided the patient with an omnipotent control: the means to dramatically and easily end the treatment. The temptation to do so may be a powerful aspect, for example, of a dominant negative transference, a negative therapeutic reaction, the impulsive acting out of aggression against third parties unconsciously displaced onto the therapist, and so on.

It may be difficult for the therapist to hold consistently in mind the urgency of this issue, despite its coloring all other aspects of the treatment developments, and it may in fact represent a chronic, yet acute, severe risk of interruption of the treatment, which is a “highest priority” issue codetermining the “selected fact” in any session. The patient may not refer again to the contract breach and may present other issues as affectively dominant, distracting the therapist’s attention from a potential breach. Yet, remaining vigilant to this risk may be extremely helpful to the patient and prevent a failed treatment. Concretely, this implies linking the potential threat to the continuation of the therapy when it appears that transference developments are consonant with this threat, interpreting the implicit acting out of destructive transference impulses by repetition of the specific contract breach. Particularly in the case of patients with chronically suicidal tendencies, this concern needs to be maintained through all sessions until it becomes clear in the patient’s material that suicide has become a completely irrelevant issue and that it is no longer meaningful in the context of the patient’s present functioning. In short, the shifting transference implications of the same threat of a second treatment-ending contract breach need to be included, whenever appropriate, in the interpretive interventions of the therapist. When a patient convincingly tells a therapist that he or she should stop talking about suicidal threats and ideation because they have not been on the patient’s mind for months, and which the patient no longer can imagine would be able to control him or her, the therapist may stop bringing up the subject again and again in different transferential contexts! However, as a safety measure, the therapist needs to maintain in mind the constant presence of the risk of temptations to end the treatment when a “second chance” period evolves in the treatment.

By the same token, these same considerations apply when new limit setting or modification of the initial contract is called for in light of new developments—for example, in the case of a patient with a severe anorectic disorder, in which a contract is set regarding the consequences of the weight of the patient fluctuating beyond mutually established limits, or in patients with drug abuse or dependency, with whom limit setting regarding drug abuse has become part of the overall structure of the treatment during the course of it.

Perhaps the most difficult, and quite frequent, situation is that of a patient who presents with chronic threats of suicidal behavior, who accepts the conditions of the treatment, which is either to discuss suicidal behavior in the sessions or to go to an emergency room, but who nonetheless continues to frighten friends and relatives with statements or actions implying that he or she has decided to commit suicide. This may be causing sufficient alarm to generate pressure on the therapist from outsiders as well as his or her own concern as to whether such limit setting around these threatening statements ought to be structured as a condition for continued treatment.

When faced with a patient’s chronic suicidality or self-harm, we have found it most helpful to have a joint session with the patient and concerned family members (or friends). Such chronic self-destructiveness may necessitate a frank discussion with relatives about the unavoidable but serious risk, given that it is not a reflection of a depressive illness but, rather, deeply rooted in personality traits and characterological predisposition, and can be neither prevented nor predicted. Therefore, it constitutes a constant risk that must be accepted as one of the conditions required by this treatment. Alternatively, the family, in the face of this chronic unpredictable risk of suicide, may have to consider long-term hospitalization or residential treatment, but this provides only the illusion of safety.

The disadvantages of such a disruption of the patient’s life, which interferes with the patient’s carrying out his or her ordinary responsibilities instead of facilitating the normalization of functioning in all areas with the help of the therapist, would represent a major complication of long-term hospitalization. Therefore, despite the chronic risk of suicidal behavior, continuing in TFP (two times per week) may be preferable to long-term hospitalization. This kind of psychotherapeutic treatment can be carried out only if patient and relatives accept the risk that despite all efforts, the patient may end up committing suicide or suffer from self-destructive behavior.

Contracting around issues of severe lethality, wherein the patient accepts the conditions necessary to carry out the treatment and all parties accept the inevitable inherent risks, provides a degree of security to the therapist and an adequate frame to the treatment. This may permit the treatment to be carried out even if the patient continues behavior that may be upsetting or frightening to third parties. In the United States, given the litigious nature of the American culture, it would be absolutely essential to set down a written record of the full communication of these risks and the acceptance of these risks by the family. Sometimes, even a letter of understanding with family and patient may be indispensable. Behind these arrangements, then, lies the need to assure the security of the therapist in carrying out the treatment. The security of the therapist—physical, emotional, social, and legal—and the protection of his or her property and personal life are essential preconditions for the possibility of treating patients with severe personality disorders. The therapist must feel safe to conduct the treatment and free of the omnipotent control of the patient’s destructive impulses, or the treatment may not be viable. If this is not possible, it may be preferable to discontinue the treatment and refer the patient elsewhere. One other important advantage of full discussion of the risks and corresponding contract arrangements is the effectiveness of this approach in reducing the secondary gain of the symptoms that prevents the symptoms from becoming a powerful mechanism of omnipotent control and transference acting out.

Technical Neutrality and Antisocial Behavior

We continue to confirm our experience that severity of secondary gain of illness and of antisocial behavior are the overriding indicators of negative prognosis. One might add to these two features the poor prognosis in cases of overwhelming, chronic wishes to die accompanied by chronic, severe, self-lacerating, suicidal, or parasuicidal behavior.

Patients with antisocial tendencies evince psychopathic transferences in the form of chronic deceptiveness in the transference (Kernberg 2007). Under optimal circumstances, the systematic analysis of dishonesty in the relation with the therapist transforms these transferences into paranoid ones: the open exploration of the paranoid reasons behind the patient’s dishonesty. But there are cases in which a radical split evolves between antisocial behavior—now fully acknowledged and still ego-syntonic—and another segment of the patient’s psychic experience in which feelings of guilt and anxiety over this antisocial behavior emerge. For example, a patient was stealing instruments and material from his workplace but professing guilt and shame over this behavior at other times. Similarly, the alternation between ego-syntonic, enjoyable sadistic abuse toward a sexual partner and feelings of guilt and shame over the abuse is not infrequent.

Here the authenticity and strength of concern that evolve during the exploration of the transference implications of this split crystallize cases in which the capacity for tolerance of superego functions and for a residual investment in the relationship with the therapist allows resolution through interpretation. To the contrary, other patients evince an unresolvable secondary gain from that split and behave as if expressed feelings of regret or concern over their antisocial behavior have redeemed them from further guilt or need to explore or change their behavior. This is a manifestation of the syndrome of perversity: the recruitment of love at the service of aggression (see Chapter 13).

One patient repeatedly presented his girlfriend with questions regarding her behavior and her understanding of the behavior of her family and friends. What at first seemed friendly inquiries regularly turned into sadistic attacks and merciless devaluation, leaving his girlfriend in tears. In the sessions, the patient acknowledged the enjoyment of his aggressive, provocative behavior and reflected on the possibility that it might relate to his past intense hatred of his mother. This understanding, however, did not influence his present behavior. It turned out that he was convinced that his past frustrations with his mother justified his present behavior toward his girlfriend. Although he presented himself as feeling guilty about his behavior, he expected the therapist to acknowledge that his suffering under periodic guilt feelings presented enough of an expiatory action to erase any need for future concern. For the therapist, the syndrome of perversity generates pressures on his or her position of technical neutrality: how can he or she maintain a moral stance without becoming moralistic? Some cases permit limit setting and subsequent analysis of the need for departure from technical neutrality. Other cases need to be terminated because the limits the therapist considers essential to the therapeutic relationship cannot be maintained. At bottom, it becomes a question of whether the patient, in not wanting to lose the therapist, is able to acknowledge his or her despair over an existence of total loneliness and abandonment, caused by his or her own aggression.

Sex and Money: Two Taboo Subjects

Two common problems we have frequently encountered in the training of therapists, even very senior therapists, are 1) a reluctance to fully explore the patient’s sexual experiences, fantasies, and activities; and 2) a reluctance to discuss in detail the patient’s management of his or her financial situation. The therapist’s misguided avoidance of these important areas of the patient’s overall functioning may develop into a transference/countertransference enactment that has the potential to limit the progress of, or even possibly threaten, the continuation of the treatment. It is extremely important to get a comprehensive picture of the patient’s sexual and love life as part of the initial evaluation. The patient’s capacity or incapacity to fall in love and to establish satisfactory love relations, to experience fully a sexual intimacy, to integrate or to keep strictly separate tenderness and emotional relations from sexual gratification; the nature of the patient’s masturbatory fantasies; and the relation between the masturbatory fantasies, sexual activities, and predominant nature of sexual dreams—all provide important information about the patient’s psychological organization. The patient’s expression of sexual behavior and sexual fantasy in the transference is, generally, more easily thought about and conceptualized but, again, sometimes difficult to fully explore, particularly under conditions of highly sexually seductive behavior on the part of the patient. Perhaps, particularly with severely narcissistic patients for whom sexual seduction may become a way of asserting their superiority or control over the therapist under the guise of sexual interest, this may lead to an inhibition in the therapist’s full exploration of the patient’s sexual conflicts.

Similarly, we have found great reluctance on the part of therapists to discuss in detail the patient’s financial circumstances, particularly with patients who have great difficulty in dealing with their financial needs and commitments and who present significant irresponsibility, secondary gain, or even antisocial behavior in the management of their finances. When financial problems affect the treatment situation itself—for example, a patient’s rationalizing his or her wishes to interrupt the treatment due to financial difficulties—the therapist’s countertransference reactions, derived from his or her own anxieties over finances, may inhibit full exploration of the transference situation and from clarifying objective reality and its potential distortion in the light of transference developments (Berger and Newman 2012). It is essential to assure realistic conditions for carrying out the treatment from the very start and to be alert to masochistic behavior being acted out by unrealistic commitments on the part of the patient, and the potential for narcissistic and antisocial features to be manifested in the patient’s exploitive tendencies.


The primary new development in the technique of transference-focused psychotherapy consists of an expansion of the concept of the total transference situation to include exploration in the transference of dissociated and apparently “unaware” expressions of severely self-destructive tendencies in the patient’s external life. The subtlety and slowly accumulating gravity of this acting out may be detected by an ongoing in-depth exploration of the patient’s functioning outside the treatment situation. The therapist’s alertness, concern, and common-sense approach to analysis of apparently confused or confusing “innocent” or “trivial” episodes or developments may provide essential cues that illuminate a dangerous reality. The clarity and firm stability of the treatment frame facilitate the therapist’s maintenance of technical neutrality while he or she remains consistently concerned for the patient and aids in approaching each session “without memory or desire.” Systematic transference analysis, under such circumstances, is more effective than the countertransference temptations to supportive shortcuts of problematic, threatening acting out.

The development of new ways to approach severely regressive narcissistic transferences constitutes an additional important area of new technical TFP developments. These are explored in Part III of this book.


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on New Developments in Transference-Focused Psychotherapy
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