Transference Focused Therapy (TFP) is one of the therapies that over time has been strengthened with scientific evidence and enriched with the findings of its learning process. Just as supervision in many therapeutic currents is necessary to help with the application with the theoretical and practical elements necessary to address our patients’ needs, in the case of TFP, supervision is an essential element throughout the therapist’s life. Why is that? Supervision, which means “looking from above”, allows the therapist to see aspects of his or her experience in the session and application of technique that are not clear during the therapy itself. Simply put, too much is being experienced in the therapy session for the therapist to be aware of it all. Supervision combines attention to structure and boundary setting (the macro level, as Luis Valenciano describes it) with a careful attention to the unconscious processes that unfold in the session and how the therapist explores them with the patient in relation to the activated object relations (the micro level). All this is in the service of maximizing the mechanism: enhancing understanding of the transference and the ability to reflect of it and on the deep conflicts that become clear in reflecting on shifting transferences.
Research and development of TFP was conducted at the Personality Disorders Institute at the Weill Cornell Medical College. In an RCT by Clarkin et al., which compared TFP with dialectical behavioral therapy and supportive psychodynamic therapy. All therapists were monitored and supervised weekly by more experienced therapists. They observed video recording sessions, provided feedback, and evaluated therapists on fidelity and adherence to the principles and techniques of the treatment they were providing. Given the emphasis on affect and nonverbal communication in TFP, video recordings of the sessions were essential to effectively supervise and study the clinical cases. It was concluded that observation of the video recordings helped to understand aspects of the technique that had not been fully appreciated when supervision only used progress notes in the clinical records. Thus, Yeomans highlights that one of the principles of TFP theory and technique is the importance of non-verbal, as well as verbal, communication, in a therapy that emphasizes the central role of splitting defenses in personality disorders at the borderline level. Additionally, authors such as Valenciano-Martinez, in accordance with the importance of supervision, highlight the first 3 minutes at the beginning of a session as crucial in considering the dominant countertransference as the session begins, in evaluating the dominant affect in verbal and non-verbal communication in those moments, and in assessing the client’s ability to speak freely and diagnosing at difficulty they have with speaking freely. All this is reflected upon while keeping in mind the objectives they wish to work towards (the macro level).
During the COVID-19 pandemic, something unprecedented happened that resulted in more useful tools for the supervision process in TFP. Due to the emphasis on non-verbal communication in therapy, switching to teletherapy was initially challenging. However, experience showed that the virtual sessions could be recorded and provided sufficient data on non-verbal communication, thus aiding the practice and learning of TFP. Nevertheless, we encourage in person sessions as the ideal.
To help the supervisor address the multiple aspects of treatment, Kernberg and Yeomans have developed a checklist that covers all necessary aspects of supervision. It is called “The Pilot’s List” since it is analogous to the list of items a pilot must keep in mind before taking off and while flying. When it has been established that the fundamental “macro” elements of therapy on the checklist are in place, the focus can turn to refinement in the supervision process that emphasize analysis of the “here-and-now” interaction and interventions, and can include analysis of group and parallel processes in supervision groups that can be used to deepen understanding of the patient’s dynamics as reflected in group reactions. The “Pilot’s list” ensures that all necessary conditions are present for meaningful therapy to take place, monitors the therapist’s adherence, and helps refine the TFP exploratory process.
Specifically, the “Pilot’s list” addresses the following elements: clarification of the diagnosis, treatment goals, description of the therapeutic method and treatment framework, as well as ensuring how the therapist explores the patient’s internal world as it develops in the transference or in extratransference relationships. In this way, the supervisor helps the therapist remain faithful to exploratory work with the goal of identifying and interpreting the affectively charged maladaptive representations of self and others in the patient’s mind.
The role of the supervisor occupies an important place in the therapist’s training. The supervisor’s interventions help shape the therapist’s ability to apply technical interventions such as maintaining technical neutrality, using countertransference reactions, and applying interpretive interventions. In sum, it strengthens the ability to pay attention to the nature of one’s own interventions and encourage reflection on the nature of the patient’s speech. And finally, the group at the PDI has found that supervision groups are the best laboratory for advancing our understanding of the therapeutic process in TFP.
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Glauco Valdivieso
Glauco Valdivieso is a Peruvian psychiatrist, psychotherapist, and researcher based in Lima, Peru. He completed his medical degree at the Universidad Nacional Mayor de San Marcos and specialized in psychiatry at the Hospital Nacional Víctor Larco Herrera, becoming a board-certified psychiatrist in 2018.
He is a certified psychotherapist in Transference-Focused Psychotherapy (TFP), trained by the International Society of Transference-Focused Psychotherapy (ISTFP). In addition, he has completed formal training in Cognitive Psychotherapy, Dialectical Behavior Therapy (DBT), and Mentalization-Based Treatment (MBT).
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Dr. Valdivieso is the co-founder and medical director of the Instituto Peruano para el Estudio y Abordaje Integral de la Personalidad (IPEP), where he also coordinates the TFP Peru division. He founded and currently leads the Chapter on Personality Disorders within the Peruvian Psychiatric Association (APP), and works at the Mental Health Unit of Hospital de Villa El Salvador in Lima.
He is also a co-founder and editorial board member of the Latin American Journal of Personality, a collaborative initiative with the Instituto Argentino para el Estudio de la Personalidad y sus Trastornos (IAEPD). Additionally, he serves on the editorial board of the Peruvian Journal of Psychiatry. Internationally, he is a Board Member of the International Society for the Study of Personality Disorders (ISSPD), where he chairs the Communications Committee and leads the Latin American Regional Group.
His main clinical and research interests include the treatment of personality and mood disorders, with a particular focus on advancing research in Transference-Focused Psychotherapy (TFP).
Silvia Bernardi
Silvia Bernardi, MD, is an Assistant Professor of Psychiatry at Columbia University. After graduating from medical school in Florence Italy in 2006, Silvia emigrated to the USA to work intensively in neuroscience research, studying the bases of the interaction between emotions and cognition. Silvia completed her residency in Psychiatry at Columbia and has since practiced privately in New York. She trained in Transference Focused Psychotherapy and continues to see patients for medication management and psychotherapy while conducting her research to unlock further knowledge to support the biological underpinnings of TFP and borderline personality disorder.
