The patient tells the story of their inner world—not just through their words, but through their way of relating to you.
—Otto Kernberg
It’s a Monday afternoon. Your client enters the room, eyes narrowed. They sit in silence. You ask how they’re doing. They cross their arms. “Why do you even care?” they mutter.
You feel a flash of frustration—then confusion. Just last week, they thanked you for being the only person who truly listens. What happened?
This is transference. And if you’re practicing Transference-Focused Psychotherapy (TFP), this is not a disruption in the treatment. It is the treatment.
Understanding Transference in TFP
In TFP[1], transference is not seen as a relic of the past projected onto the present. It is a living relationship—a dynamic reenactment of the client’s internal world as it plays out, moment by moment, in the therapeutic encounter.
Each idealization, suspicion, silence, or outburst is a doorway into the patient’s deepest internal conflicts—particularly the split self- and object representations that define borderline and narcissistic personality organization.
TFP doesn’t just interpret these projections—it seeks to activate them, observe them, and then integrate them with the client, inside the room.
The Role of the Therapist: Observer, Containment, Interpreter
In standard therapy, we often hear, “Don’t take it personally.”
But in TFP[2], you must take it personally—with awareness.
You are not being devalued because of your haircut, or ignored because you asked a tough question. You are being cast in a role—often unknowingly—as the abandoning mother, the controlling father, the neglectful lover, the persecuting authority.[3]
Your job is not to correct the projection, defend your ego, or offer reassurance. Your job is to stay in role just long enough to gently hold up the mirror—to help the client see that what they’re experiencing is not about you, but about them.
This requires patience, emotional maturity, and finely tuned timing. But it is transformative.
The Three Levels of Interpretation
One of TFP’s most powerful tools is its three-tiered interpretive framework[4], which allows you to meet the patient at their current level of psychic structure:
- Descriptive Level (Level 1): “Right now, I notice you seem angry with me for asking that question.”[5]
- Affective/Defensive Level (Level 2): “Could this anger be a way of protecting yourself from feeling judged or ashamed?”
- Integrative Level (Level 3): “It seems like part of you sees me as someone safe and helpful, but another part feels I might hurt you. Maybe we can hold both parts together.”
This layered approach allows you to titrate the intensity of the interpretation to match the client’s capacity—and gently guide them from fragmentation to integration.
Common Transferential Patterns in Personality Disorders
TFP clinicians become experts in recognizing recurrent patterns.[6] Here are a few:
- Idealization-Devaluation: One moment, the therapist is viewed as perfect; the next, as completely harmful.
- Dependency-Fear of Control: The client longs to be held but resents any suggestion.
- Testing and Retesting: The client frequently breaks the frame or misreads neutrality as rejection.
- Silent Withdrawal: Affect is withheld as a defense against vulnerability.
Each of these patterns is a living representation of split object relations.[7] The goal is not to eradicate them—but to help the client recognize that these parts can coexist, be named, and eventually reconciled.
From Enactment to Insight
TFP therapists often find themselves enacted into these roles. One day, you feel heroic. The next, you feel attacked or helpless.
This is where supervision and self-reflection become crucial. You cannot help the client integrate their representations if you are unwittingly caught inside them.
The therapist’s calm, consistent ability to observe, name, and interpret the transference in the moment is what allows the client to step outside of the repetition—and begin to see it as something they can change.
[1] Levy, Kenneth N., et al. “Transference-focused psychotherapy (TFP).” Current treatment options in psychiatry 6 (2019): 312-324.
[2] Hersh, Richard G., Eve Caligor, and Frank E. Yeomans. “Fundamentals of Transference-Focused Psychotherapy.” Cham, Switzerland: Springer (2016).
[3] Austria, Fleeing Nazi. “Transference Focused Psychotherapy & Personality Disorders with Dr. Otto Kernberg.”
[4] Trias, Tuulikki. “Transference-Focused Psychotherapy for Adolescents with Personality Disorders: A Case Example with a Focus on the Interpretative Process and Transference Analysis.” Journal of Infant, Child, and Adolescent Psychotherapy 22.3 (2023): 253-267.
[5] Yeomans, Frank E., John F. Clarkin, and Otto F. Kernberg. A primer of transference-focused psychotherapy for the borderline patient. Jason Aronson, Incorporated, 2002.
[6] Bradley, Rebekah, Amy Kegley Heim, and Drew Westen. “Transference patterns in the psychotherapy of personality disorders: Empirical investigation.” The British Journal of Psychiatry 186.4 (2005): 342-349.
[7] Levy, Kenneth N., et al. “Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.” Journal of consulting and clinical psychology 74.6 (2006): 1027.