Applied Transference Focused Psychotherapy

We often wonder about the future of Transference Focused Psychotherapy (TFP) and the challenges that lie ahead, as well as the directions we would like to pursue. The paper featured this month examines the recent developments of our technique, observing how specific principles of TFP have naturally met the needs of the broader community of mental health providers.

Over the past four decades, there has been a gradual increase in attention given to the personality component of various pathologies and pathological or quasi-pathological circumstances. For instance, the study of pathological dynamics in large groups.

The author of the paper, Richard Hersh MD, is a psychiatrist, psychoanalyst, certified TFP supervisor, and a well-known figure for his contributions in expanding the applications of TFP to different clinical settings. This includes settings that do not primarily focus on psychotherapy-based interventions. You can find more information about Dr. Richard Hersh at this link: https://www.columbiapsychiatry.org/profile/richard-g-hersh-md

Indeed, as Dr. Hersh points out, certain core principles of TFP lend themselves to a variety of practical applications that may differ significantly from the traditional psychoanalytic foundations from which TFP originated. TFP principles are characterized by hierarchy of importance, common sense, pragmatism, and reproducibility.

Some of the most valuable, yet perhaps most distinctive and challenging, principles to learn include openness to consider and share a diagnosis of personality disorder, early involvement of significant others in treatment, clear definition of roles and responsibilities for both the patient and therapist, and continuous, dynamic attention to the therapeutic alliance that allows for adjustment and analysis as the relationship between patient and therapist evolves.

These core principles make TFP a labor-intensive modality for both the patient and therapist. It requires constant observation of countertransference, best achieved through continuous supervision or contact with peers and, when possible, the use of video recordings. Not all clinical cases are motivated enough to adhere to long-term individual TFP treatment. In addition, practical circumstances may not all for long-term individual treatment. Due to its labor-intensive nature and the constant need for supervision and attention to the therapeutic relationship, therapists are limited in the number of patients they can effectively treat in long-term individual therapy compared to other modalities. However, as Dr. Hersh notes, the core principles mentioned above can easily be translated to different settings, such as psychopharmacology or supervision of different treatment modalities, providing significant benefits (Carsky and Yeomans, 2012).

Dr. Hersh’s contribution, “Fundamentals of Transference Focused Psychotherapy: Applications in Psychiatric and Medical Settings” was published in 2016 and written for a broad audience. In addition, TFP diagnostic tools have been applied and taught in a weekly curriculum for internal medicine residents (Petrini, 2017) who often encounter patients with personality disorders but lack training in how to handle these patients and their own emotions in response to these patients. As Gunderson has pointed out, overprescribing in response to patients with Borderline Personality Disorder (BPD) is a common countertransferential response, one that physicians in medicine and other sub-specialties are often unaware of and likely to fall into. TFP principles are also beneficial for psychopharmacologists who frequently treat patients with personality disorders. By understanding how medications can serve as a vehicle for expressing transference feelings, these providers can contextualize treatment non-compliance, possible side effects, and acting out between visits. Most importantly, they can discern the genuine needs and benefits of medications.

Another important aspect highlighted by Dr. Hersh is the evolution of TFP with regards to the incorporation of its basic concepts in different clinical contexts. TFP has been applied to geriatric patients, users of psychoactive substances, trauma patients, adolescents in day hospital units, liaison psychiatric services, forensic patients, and minority communities. Many of these initiatives have been adapted by various authors to contexts where they have had to accommodate case management and other evidence-based therapies, such as dialectical behavior therapy and mentalization-based therapy. The experiences have been promising, facilitating access to therapy, minimizing psychosocial impact, and establishing achievable goals.

Undoubtedly, TFP, as applied in our time, has garnered interest from clinicians who approach the principles of modern psychoanalytic approaches with flexibility and respect. This contributes to dispelling the stigma associated with this therapy and opens it up to the scientific community.

Silvia Bernardi and Glauco Valdivieso