Transcription
In saying why I think TFP can help patients, you could look at it in a context where there are other treatments, more traditional analytic or psychodynamic type therapies, and more, um, cognitive behavioral therapies, which might be based less on, you know, the idea of going into the depths of the mind and more focusing on thoughts and actions in the here and now. And I see TFP is somewhere in the middle.
So the short answer, then I'll elaborate, is I think in TFP we bring thought and feeling together. In other words, we are analytic in the sense that we do believe that understanding and finding deeper meanings of things helps people master them, uh, cognitively and and through their, uh, what we call ego functions, the ability, the ability to negotiate one's functioning in the world. But if you only find understanding, this is why we focus on the here and now, not more on the past, although that's relevant. If you only sort of understand things that the patient discusses from outside the room, sometimes it has a kind of an intellectual quality, I was tempted to say a sterile intellectual quality, because it doesn't engage the feeling so much.
So what we do in transference-focused psychotherapy is create a treatment setting where patients are going to just naturally experience intense emotions as they're sitting with us. Some of those emotions are going to involve their interaction and their experience with us, and some of those emotions are going to stir up responses in us that will provide us important information about what we call the internal world of the patient. So it's a matter of helping the person experience the kind of intense emotions that have led to difficulties in many areas of their life, and which we feel are behind a lot of the more overt symptoms. And then understand better through looking at those feelings as they're being experienced, how those feelings emerge in them, how to understand why those feelings are there at that moment in time, and how to put them in a broader context.
To put it simply, because I may have gone into too much detail just now, um, one of my students recently said, "I've come to understand there's two attitudes a therapist can have sitting with a patient. You can either listen to the patient's words and sort of be an outside observer of their mind and make comments that help them understand their mind from the outside. Or, while keeping the role of the therapist, by inviting or creating these circumstances that facilitate the emergence of emotions in the room, in a way, you, the therapist, become a part of the action." Not physical action, but emotional action. You kind of enter into the patient's emotional experience in terms of what you allow yourself to experience and and respond to internally. And that that way, you're not just an outside observer, kind of coldly commenting on what's going on inside this person, but you're part of the experience they have interacting with another person. And you're kind of both in it and hovering above it, trying to make sense of it, and trying to bring the person's mind to a place where they can join you observing and reflecting and thinking, not just reacting and experiencing.
What is an example of transference? Patient, just an example, recent, not a very kind of typical example. Patient comes in for a 45-minute session, and toward the end of the session, I glance at the clock, which I can do rather subtly because the clock is right behind you, so it only takes a very small movement. My patient sees me doing that and says, "You looked at the clock." I said, "Yes, we're, you know, we're together so far, we agree about that." She says, "You hate me." Said, "Oh, um, could you tell me more about that?" Now, that's the transference. And the patient elaborated in this case to say, "Well, you looked at the clock because you can't wait to get rid of me. You can't wait for the session to be over. Um, you clearly don't want me to be here."
So I would give you this as an example of transference because what is being transferred is the internal image of another person who's rejecting, disapproving, not liking the individual. And the poor person tends to transfer this into other situations where it might not correspond to what's really going on. I mean, I look at the clock because if I go over time, the next patient, you know, is sitting in the waiting room, and it's better to keep a regular time. So, but I don't explain right away, you know, "Please don't think I hate you. You know, I just looked at the clock to, you know, timekeeping purposes and just to have some order in the day." Because in my experience, you can't correct this transfer of an internal image, it's too powerful. So if you just say, "Oh, let's be reasonable," well, if the patient could just be reasonable, they wouldn't need an intensive therapy.
So what we try to would say, "Oh, as I said, uh, oh, am I looking at the clock? Man, I hate you. Could you tell me more?" We try to kind of have the person elaborate what's going on in their mind that has such a huge and often negative impact on how they perceive and get along with the world around them. In TFP, it's not just the emotionally dysregulated response to the trigger event, it's what did the person see in the trigger event? How did they perceive the trigger event? So it's, number, it's in the first place, what meaning is attributed to the trigger, which we feel comes from a patient's internal world, their set of images they have of self and others. So what meaning do they read into the trigger? And then what reaction do they have? So we look at both together.
In contrast to mentalization, I think there's a big overlap between TFP and mentalization because we're both trying to help people understand their states, their feeling states, in a way that's more cognitive, that's more grasped in words and and in cognitive understanding, as opposed to like a raw emotional state. But in mentalization therapy, they say you have to be very cautious about looking at the here and now interaction with the patient because if you focus on that, that too much, it does something they call activates the attachment system excessively, or just putting it in simple language, it stirs up too much emotions in the moment, and it overwhelms the capacity of the person to think, reflect, or mentalize, to use that word.
But in our experience, focusing, as I said earlier, on the here and now action, it may stir up emotions, but it does not eliminate the capacity to reflect. And as I said, we feel if there's affect and reflection together simultaneously, it's when there's the most potential for progress and an understanding that can lead to some change.