A Novel Approach to Supervision of

Transference-Focused Psychotherapy (TFP):

Examining the First Three Minutes of
the TFP Session

Luis Valenciano Martinez and Richard G. Hersh

Abstract: Transference focused psychotherapy (TFP), an empirically validated,

manualized treatment for patients with borderline personality disorder (BPD),
is arguably the most challenging to learn of the evidence-based treatments for
BPD. Following an introduction to the TFP manual and the treatment’s central
tenets, ongoing individual, group, or peer supervision of case material, ide-
ally with recorded video sessions, would be expected when the clinician’s goal
is fidelity to the prescribed approach. Our proposal for a novel supervision
intervention emerges directly from the basic theoretical foundations of TFP,
the process of research investigation, which has evolved over the years, with
its goal of assessing both measurable patient outcomes and research clinician
adherence to the model, and collective clinical experience. A deliberate assess-
ment of the initial minutes of TFP as a supervision or self-assessment method is
not meant as a substitute for more comprehensive supervision, nor is it offered
as an exclusive path to mastering TFP. This approach to TFP supervision aims
to distill and focus in a common-sense, accessible way the process of practicing
TFP, thereby facilitating therapist consistency. Our proposed, more limited and
concise tactic for TFP training can be used as an instruction building block,
incrementally extending the access for practicing and mastering this interven-
tion to a broader group of motivated providers.

Keywords: transference-focused psychotherapy, psychodynamic, supervision,

audiovisual technology, personality disorders

Transference-focused psychotherapy (TFP) is an empirically vali-

dated, manualized treatment for patients with borderline personality
disorder (BPD) (Clarkin, Yeomans, & Kernberg, 2006; Yeomans, Clar-
kin, & Kernberg, 2002). This treatment evolved from research that

Luis Valenciano Martinez, M.D., Personality Disorders Program, Day Hospital Fran-
cisco Román Alberca, Murcia, Spain. Richard G. Hersh, M.D., Columbia University
College of Physicians and Surgeons, New York.
Psychodynamic Psychiatry, 49(1), 110–130, 2021
© 2021 The American Academy of Psychodynamic Psychiatry and Psychoanalysis

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 SUPERVISION OF TFP   111

acknowledged the limitations and pitfalls of using a traditional psycho-

analytic approach for a group of patients with more global, rather than
circumscribed, areas of dysfunction who might be prone to dangerous
behavior that is not often responsive to interpretation. While TFP has,
at its core, certain elements of a traditional psychoanalytic orientation,
it nevertheless differs in fundamental ways from standard psycho-
analysis and even from many psychoanalytically informed psycho-
therapies. The distinction between TFP and a traditional, more ortho-
dox, analytic approach is most clearly highlighted in the treatment of
patients meeting criteria for BPD by DSM-5 description. Randomized
controlled trials of TFP for patients with BPD have been conducted in
the United States and in Europe (Clarkin, Levy, Lenzenweger, & Kern-
berg, 2007; Doering et al., 2010). While there have not been randomized
controlled trials of TFP for patients with other personality disorder pre-
sentations, key figures in the field have proposed the extension of the
TFP approach, based on an extrapolation of certain essential features
of TFP, to patients with other moderate-to-severe personality disorder
presentations, as well as to “healthier” patients with more limited areas
of psychopathology (Caligor, Kernberg, & Clarkin, 2007; Caligor, Kern-
berg, Clarkin, & Yeomans, 2018).
It is notable that the late John Gunderson, a pioneering BPD researcher,
described TFP as “the hardest to learn” of the evidence-based thera-
pies, suggesting a logical rationale for innovative teaching methods
(Gunderson & Links, 2014). So it is in this context—the aforementioned
development of a psychoanalytically informed intervention, validated
by research that is both challenging to learn and provide to patients in
a way that meets standards set by its originators and thus benefitting
from ongoing individual, group, and peer supervision—that one of the
authors (L.V.) has proposed a specific supervision process that focuses
on a review (often a repeated review) of the first three minutes of a TFP
session using recorded video material. This proposal grew out of the
author’s extensive experience as a TFP supervisor; while it had been
his habit to review TFP sessions in their entirety with supervisees, the
process of limiting the supervision to the first three minutes of the ses-
sion only allowed for a systematic, direct exercise in attending to core
TFP principles.
A TFP treatment unfolds in a very specific and deliberate manner,
beginning with the assessment phase. It is not within the scope of
this article to include all the critical details of TFP; key texts, includ-
ing Clarkin and colleagues, Yeomans and colleagues, Caligor and col-
leagues, and Diamond and colleagues, supply information about TFP
for patients with BPD, TFP-E or TFP extended for patients with higher
level personality pathology and those defined, in TFP parlance, as in

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 112   VALENCIANO AND HERSH

the “neurotic” range, and TFP for patients with primary or co-occur-
ring narcissistic disorders (Caligor et al., 2007; Caligor et al., 2018; Dia-
mond ,Yeomans, Stern, & Kernberg, in press; Yeomans et al., 2015;). All
of these volumes share the hallmarks of the initial stages of TFP: 1) an
assessment process using Kernberg’s Structural Interview (Kernberg,
1981, 1984); 2) a jargon-free discussion with the patient (and with the
patient’s family, when possible) about the clinician’s diagnostic impres-
sion; 3) contact with prior treaters, and/or with family members, when
that is deemed necessary; 4) an elucidation of the patient’s personal
goals and treatment goals, and discussion of treatment options con-
sistent with an informed consent process; and 5) the crafting and pro-
posed maintenance of a treatment agreement that outlines the respec-
tive responsibilities of both patient and therapist and that directly
addresses, in advance, inevitable treatment-interfering behaviors.
While research findings in recent decades have supported the emer-
gence of multiple empirically validated interventions for patients with
BPD, nevertheless there remains a significant gap between the number
of patients seeking treatment for this disorder and the number of clini-
cians adequately trained in any of these modalities (Choi-Kain, Finch,
Masland, Jenkins, & Unruh, 2017; Iliakis, Sonley, Ilagan, & Choi-Kain,
2019). Along with TFP, other evidence-based treatments for BPD
include dialectical behavioral therapy (DBT), mentalization based ther-
apy (MBT), schema focused therapy (SFT), good psychiatric manage-
ment for borderline personality disorder (GPM), and systems training
for emotional predictability and problem solving (STEPPS) (Bateman &
Fonagy, 2010; Blum, Pfohl, St John, Monahan, & Black, 2002; Gunder-
son, Masland & Choi-Kain, 2018; Linehan, 1993; Young, 1990). The well-
described heterogeneity of BPD presentations, as well as the variability
of symptoms over time for any individual patient, has underscored the
clinical necessity of sometimes sequencing treatments or integrating
elements of different treatments, when indicated (Choi-Kain, Albert,
& Gunderson, 2016). Thus, TFP has emerged as both a first-line treat-
ment for patients with BPD and other personality disorder diagnoses,
as well as a treatment for some patients who may have first accessed
other treatments and then sought TFP. In addition, the use of TFP prin-
ciples in settings other than an extended individual psychotherapy has
evolved; in some circumstances, this evolution has been out of neces-
sity (Lee & Hersh, 2019). This approach of “applied TFP” has been used
in training and treatment situations as a way of extending the utility
of TFP theory and practice, with an eye on the practical needs of edu-
cational programs and specific clinical settings (Hersh, Caligor, & Yeo-
mans, 2016).

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 SUPERVISION OF TFP   113

This proposal for supervision limited to the initial minutes of a ses-

sion is not intended to serve as a replacement for review of entire ses-
sions; that said, even in TFP research settings, it is not customarily pos-
sible to review in supervision all the material recorded as part of the
study. (TFP studies assessing its efficacy all require audiovisual record-
ing of every session.) The repeated supervision of TFP work in this
novel, yet standardized, way can be conceptualized as an organizing
process, a ritualized first step that does not preclude attention to mate-
rial later in a session but anchors the supervision process by requiring
attention to irreducible elements of the psychotherapy.
It may be useful to consider how our proposal for this novel approach
to TFP supervision fits in the broader contemporary perspectives on
supervision of psychodynamic psychotherapy. Three important cur-
rents relate directly to our proposal: 1) a concerted effort by academic
clinicians to assess psychotherapy supervision generally and, for some
experts, psychodynamic psychotherapy supervision in particular
(Cabaniss, Arbuckle, & Moga, 2014; Dewald, 1997; Rojas, Arbuckle,
& Cabaniss, 2010; Sarnat, 2012); 2) the emergence of manualized psy-
chotherapies, including some, like TFP, with a psychodynamic orienta-
tion, and the associated requirements for supervision specific to those
structured treatments (Karterud et al., 2012; Waltz, Fruzzetti; & Line-
han, 1998); and 3) a focus on the particular challenges of psychotherapy
supervision of trainees early in their careers working with patients
with moderate to severe personality disorder pathology (Merced, 2018;
Occhiogrosso & Auchincloss, 2012).
Calls for a comprehensive review of psychotherapy supervi-
sion, from multiple perspectives of supervisor development theory,
research, and practice, have coincided with the proliferation of psy-
chotherapies in use as the dominance of psychoanalytic thinking has
waned, and a pluralistic approach to psychotherapy has become the
norm (Wampold, 2001; Watkins, 1998). It remains early in the develop-
ment of an empirical base of psychotherapy supervision, with signifi-
cant room for its enhanced training and practice. Our proposal does
not directly address the majority of the active debates in this area,
such as the need for supervision measures, outcomes, or the develop-
ment of a supervision manual. It does, however, lend itself to pos-
sible research endeavors, and it addresses the aspiration for increased
training in supervision.
Because TFP is a treatment offered in a manualized format, it there-
fore follows that supervision would aim to encourage adherence, while
accepting the likely wide variation in practice, even by clinicians com-
mitted to this modality. TFP’s unusual hybrid status, both primar-
ily psychodynamic and also manualized and empirically validated,

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 114   VALENCIANO AND HERSH

therefore requires supervision that builds on both the tradition of

supervision in psychoanalysis and psychoanalytic psychotherapy,
and the supervision expected in manualized treatments like cognitive
behavioral therapy and DBT. DBT has a well-described expectation
for ongoing supervision for its practitioners, and MBT also has seen a
comparable movement for the development of instruments for super-
visors to monitor adherence. TFP supervision is similarly anchored
by the treatment manual and the explicit treatment goals, format, and
moment-to-moment interventions described therein.
In general, the treatment of patients with moderate to severe person-
ality disorder pathology, including BPD, has been seen as expectedly
challenging for novice clinicians (Zerbo, Cohen, Bielska, & Caligor,
2013). Supervision of trainees working with this population is custom-
arily understood as a labor-intensive endeavor for the supervisor, often
fraught with anxieties for the trainee and splitting between parties
involved in the treatment. Our very detailed and deliberate roadmap
for supervision of the initial part of a TFP session has the goal of pro-
viding supervisors with a practical way to manage these predictably
thorny situations.
Where would our proposal for supervision fit into the contempo-
rary understanding of what factors best support effective psychody-
namic psychotherapy supervision? Cabannis and colleagues stressed
the importance of anchoring learning objectives in the psychotherapy
process. Their conjecture about how these objectives facilitate super-
vision include: (1) enhancing the supervisee’s experience of supervi-
sion; (2) assisting supervisors as they direct learning in supervision; (3)
equipping those in the supervisory role in measuring whether goals for
the process are obtained; and (4) aiding in fine-tuning the supervision
process as necessary (Cabannis et al., 2018). The foundation of our pro-
posal rests on specific learning objectives related to core principles of
TFP. Our proposal offers supervisors a relatively concrete approach in
assessing the clinician’s command of these principles, using recorded
material to determine the clinician’s level of adherence and compe-
tence. TFP is a manualized treatment; therefore, the supervision process
understandably differs from that offered in those modalities without
comparably clear guidelines and expectations. Because our proposal
does focus on the basic tenets of TFP, it could lend itself to a process
of measuring supervision. In particular, our proposal should support
effective supervision of those clinicians first introduced to TFP as they
wrestle with the differences between the TFP model and either more
overtly supportive and directive treatments or more singularly explor-
atory models, as might be the case for those introduced to TFP after
psychoanalytic training.

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 SUPERVISION OF TFP   115

As TFP has evolved over the years, clinicians from around the world
have worked together through the International Society for Transfer-
ence Focused Psychotherapy (www.ISTFP.org) to establish standards
for adherence and competence. Yeomans and colleagues (2015) stressed
the sequence of mastering TFP first through seminar instruction and
then through sustained supervision using videotaped material. Use
of a standardized adherence and competence rating scale has aided
supervisors as clinicians in this process. Caligor and colleagues (2018)
also emphasized the necessity of clinical work under the supervision
of a senior clinician, again using videotaped therapy sessions as a cor-
nerstone of this process. They stressed the particular value of discuss-
ing recorded sessions as an essential tool in elucidating elements of a
patient’s verbal and non-verbal communication, noting that standard
process notes, or audio recording alone, would not likely provide com-
parable material (Haggerty & Hilsenroth, 2001; Topor, AhnAllen, Mul-
ligan, & Dickey, 2017). TFP supervision tracks closely to the treatment’s
underlying theory of borderline pathology; use of recorded material
reviewed in individual or group formats allows for close attention to
affectively laden material and rapid shifts that novice therapists often
find overwhelming or overlook entirely.
In one pilot program offered to psychiatry residents at Weill Cornell
Medical College, the introduction of TFP for patients with BPD was seen
as a useful training opportunity with multiple advantages. A review of
this training experience underscored the particular values for trainees
in learning the diagnostic and treatment essentials of TFP and applying
these elements to a group of patients broader than only those with BPD
as defined by DSM-5 criteria (Bernstein, Zimmerman, & Auchincloss,
2015). A commentary on this pilot program recognized the value for
psychiatry trainees in learning TFP but cautioned about the reality of
limited availability of TFP–trained supervisors in many locations out-
side of a few specific academic medical centers (Chambers, 2015). It is
possible that the recent explosion in virtual treatment and supervision
necessitated by the COVID-19 pandemic may have paved the way for
more widespread dissemination of TFP by way of remote teaching and
supervision opportunities.

TFP SUPERVISION KEY ELEMENTS

The specific focus on the first three minutes of a TFP session has an
objective of aiding supervisors helping therapists learn TFP so that the
clinical work aligns with the treatment as explicated in the manual, there-
fore improving adherence; at the same time, attention to the first three

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 116   VALENCIANO AND HERSH

minutes of the TFP session can also work as a kind of self-­assessment

procedure for the clinician intent on hewing to key theoretical compo-
nents, aware of the various pressures to drift from the ostensible goals of
TFP treatment as designed. A focus on the beginning of the TFP session is
not meant to convey a magical act that divines the material of significance
that is to come; instead, this exercise is a kind of checklist. The therapist
and supervisor should together attend both to those components of the
treatment necessary to increase the likelihood of its success and to those
interventions understood as a priority as the treatment unfolds.
What are the essential elements of TFP that distinguish it from psy-
choanalysis or from other psychoanalytic psychotherapies? As noted,
because TFP was developed originally for patients with BPD, by design
it includes extensive steps, with the safety of both the patient and the
therapist as priorities, that are required to be in place before the therapy
begins. Once these initial steps have been traversed, the therapist bal-
ances multiple tasks, some particular to this model. These tasks include:

1. First and foremost, monitoring for any material that would sug-
gest compromised safety for the patient ot those around him or
her. This might include any material reflecting active suicidal or
homicidal thinking or serious co-occurring diagnoses with pos-
sible self-destructive aspects (mood disorders, eating disorders,
substance use disorders, medical conditions requiring adher-
ence to treatment, for example). Other issues of high priority
could include self-defeating or self-destructive behaviors, such
as undermining performance at work, failing to pay important
bills, neglecting schoolwork with inevitable consequences, or any
behavior that could jeopardize the continuity of treatment.
2. Addressing challenges to the integrity of the treatment frame, or
the agreement between patient and therapist in advance regarding
their respective responsibilities. The TFP agreement would include
many elements of a customary treatment arrangement, for exam-
ple, duration of session, payment, cancellation policy, and interses-
sion contact, among others. In TFP, there are commonly additional
stipulations: management of suicidality and para-suicidal acts
(including suicidal ideation and non-suicidal self-injurious behav-
ior), requirement for meaningful activity, expectation for speaking
freely and honestly, and prioritization of focus on material that is
linked to the patient’s articulated goals. A patient’s failure to vol-
unteer information that relates directly to the goals outlined at the
start of the treatment would be considered a high priority focus for
the therapist. Of particular salience for the TFP therapist are any
behaviors undermining the continuity of the treatment, such as

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 SUPERVISION OF TFP   117

missed sessions, delays in rescheduling, or chronic lateness; such

incremental threats are considered important, although sometimes
overlooked, manifestations of transference patterns.
3. Monitoring the patient’s three channels of communication: 1) what
the patient says, 2) how the patient behaves, and 3) the therapist’s
countertransference. Of note, in TFP the therapist will attend as
closely, if not more closely, to how the patient behaves and how the
therapist feels than to what the patient says. Weighting communica-
tions in this way distinguishes TFP from a more traditional psycho-
analytic practice. The therapist’s ability to stand back and reflect on
the interaction between patient and therapist as it unfolds might be
considered yet another channel of communication of value.
4. Monitoring the patient’s communication for the most pronounced
affective state. While a patient’s affect could be most pronounced
in expressions of anger, despair, or joy, alternatively a discrepancy
between the stated content and an incongruous associated affect
would be another cue to the therapist for salient material.
5. Monitoring for the emergence of dominant object relations dyads
as conveyed in the patient’s behavior or the content of the patient’s
speaking freely. The object relations dyad consists of the patient’s
self-representation, or how he or she experiences himself or herself
in that moment, the representation of another, sometimes the ther-
apist, sometimes someone else in the patient’s life, and an associ-
ated affect. For example, a patient comes late to the therapy session,
the patient has a look of dread on her face, apologizes profusely,
and sits apprehensively on the edge of her chair; a possible object
relations dyad in this moment could be the vulnerable patient, a
disapproving and menacing therapist, and the pronounced affect
of fear. TFP’s approach begins with the therapist’s expectation of
“tolerating the confusion” or accepting that material brought by
the patient to his or her attention at the start will very often seem
confusing, elliptical, or disorganized. The next step would be to
put into words the parts of the emerging dominant object rela-
tions dyad most obvious to the therapist; this process is sometimes
known as “naming the actors” or offering a conjecture about the
patient’s self-representation, experience of another (sometimes the
therapist, sometimes another in the patient’s life), and an associ-
ated affect. This act of naming the actors is considered an invita-
tion to the patient for engagement and reflection; it is not meant
to come across as a pronouncement. Over time, the therapist will
listen for evidence of a role reversal or some pattern that suggests
that the patient is ascribing to someone else a quality he or she
exhibits, but that is mostly out of the patient’s awareness.

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 118   VALENCIANO AND HERSH

6. Monitoring the interplay between emerging dyads that becomes

evident over time. It would be expected that dyads most likely evi-
dent on the surface—for example, an experience the patient might
have of the therapist infused with distrust—would alternate with
a dyad that emerges only with time, which suggests a wished-for
closeness or dependency. The more evident surface dyad, marked
by mistrust, can be understood as protecting the emergence of the
dyad marked by both yearning and vulnerability. This interplay
between dyads would usually become more evident as the treat-
ment advances. This phenomenon might be revealed in the situa-
tion of a patient who repeatedly expresses disappointment with,
or suspicion of, the therapist. Only when the therapist plans a
vacation a few months into the treatment does the patient reveal
a covertly experienced dependence and hoped-for closeness with
the therapist, perhaps by protesting the therapist’s vacation as a
threat of abandonment. The first three minutes of a TFP session
would most reliably likely capture aspects of the interplay between
dyads as the patient and therapist develop a working alliance and
settle into a mid-phase of treatment.

THE MECHANICS OF SUPERVISION OF

THE FIRST THREE MINUTES OF A TFP SESSION

Considering the Dominant Countertransference Present

Before the Session Begins

Before the therapist first encounters the patient in the waiting area
or via audiovisual telemedicine platform, the therapist can reflect on
his or her primary countertransference experience at that moment. The
therapist’s countertransference might reflect a sustained experience of
the patient, associated with a longstanding countertransference posi-
tion, or possibly a newer manifestation of the countertransference,
informed by recent events. Is the therapist filled with dread, or with
excitement, or with resignation? This self-assessment of the dominant
countertransference should lead organically to considering the domi-
nant object relations dyad that might be in play. For example, the thera-
pist is consistently accused by the patient of trying to exert control and
faulted for failing to help her; even before the session begins, the thera-
pist reflects on the simmering hatefulness expressed by the patient and
his or her sense of futility. This process leads to consideration of the
dyad of ill-treated patient reacting to a useless therapist, with a domi-
nant affect of rage. In addition, such self-reflection can serve as a clue

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 SUPERVISION OF TFP   119

to possible chronic countertransference patterns that are not necessar-

ily fully in the therapist’s awareness. This phenomenon, described as a
chronic countertransference enactment, can reflect repeated patterns of
behavior on the therapist’s part that are linked to particularly troubling
issues for the therapist.

In her group supervision, Dr. A.* describes her growing dread of meet-
ing with her patient, Ms. B., and her reluctance to present clinical mate-
rial to the group, given her chronic sense of frustration with Ms. B. and
her concerns that perhaps TFP is not an appropriate treatment modal-
ity for her. The supervisor, Dr. C., suggests Dr. A. pause and explore in
the supervision her sense of the dominant countertransference elements
in play before the most recent session began, hoping that might help to
explain the therapist’s dread and frustration. Dr. A. reflected that behind
her dread was a persistent fear that Ms. B. would act on her longstand-
ing threats of suicide, leaving Dr. A. feeling guilty and incompetent.
With the help of the group, Dr. A. was able to explore critical elements of
her countertransference experience, including a sense of powerlessness
and fear related to the patient’s implicit threat. This exercise helped to
elucidate a chronic object relations paradigm in play, allowing Dr. A. to
move beyond her inchoate anxiety. Dr. A.’s ability to think about this key
element of her countertransference experience in advance of the session
made it more possible for her to engage in the initial minutes of the ses-
sion with an attitude of curiosity and engagement, rather than retreat
and resignation.

Assessing the Dominant Affect as Expressed in Words or Non-

Verbal Communication at the Beginning of the Session

When the therapist greets the patient, the focus is on a preliminary

assessment of the dominant affect expressed by the patient, weighting
non-verbal communication. The patient’s facial expression, posture,
grooming, and eye contact are key elements of this assessment phase.
The TFP therapist maintains a consistent attitude of warmth and curios-
ity; this attitude remains consistent regardless of the patient’s dominant
affect. The goal at this juncture is for the therapist to take in information
in a way that will optimally guide his or her interventions, while con-
veying to the patient not just a tolerance for, but an interest in, a wide
range of expressions of affect. The therapist’s attention to that material
of affective dominance begins when the therapist greets the patient in
the waiting area and continues for the duration of the session.

*. All names and details have been changed to protect patient privacy.

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 120   VALENCIANO AND HERSH

Dr. D. is treating a patient, Mr. E., in a residential program for patients

with dual diagnosis substance use and mood disorders. Mr. E. has
diagnoses of cannabis use disorder and depressive disorder, both long-
standing. Dr. D. is aware that Mr. E. consented to participation in this
residential program only when his parents made gainful employment a
requirement for their continued financial support. When reviewing her
recorded session with her supervisor, Dr. F., Dr. D. stresses the content of
the material offered by Mr. E. in the first minutes of their session. Mr. E.
speaks at length about his resentment toward his parents who insisted
he enter this residential treatment program, and his grievances related to
the lack of autonomy he experiences because of the program’s rules and
restrictions. Dr. F., the supervisor, points out to Dr. D. the discrepancy
between Mr. E.’s spoken material and its focus on distress and dyspho-
ria, and his non-verbal communication. She notes that Mr. E. appears
generally relaxed, stretches out comfortably when he is talking, smiles
easily, and from time to time puts his feet on the ottoman. Dr. F. uses
this example to underscore for Dr. D. the importance of identifying ways
that a dominant affect, in this case the patient’s expressions of comfort or
satisfaction, might be communicated non-verbally, as well as the risks for
the therapist of reflexively prioritizing what the patient says over how
the patient behaves.

Observing the Patient’s Ability to Speak Freely

and Monitoring Possible Inhibitions

One of the central elements of the TFP treatment agreement is an

expectation that the patient will speak freely. This is distinctly differ-
ent from those psychotherapies that are more structured and directed
by the therapist. The therapist’s monitoring of this aspect of the agree-
ment can be complicated by both superficial pleasantries offered by the
patient or more important, concrete content—for example, related to
details of their schedule or management of medications that may arise.
The therapist can risk getting drawn into an exchange of pleasantries,
possibly, or spending an inordinate amount of time on certain con-
crete details, which would then preclude exploration of the patient’s
free association or serve as an apparent resistance to speaking freely.
As with all elements of the treatment agreement, the therapist does not
expect complete adherence on the patient’s part, and challenges to any
aspect of the agreement are understood as opportunities for explora-
tion of important object relations dyads in the transference. When the
patient exhibits challenges in speaking freely, this can be seen as a win-
dow into some aspect of the patient’s experience of the therapist, and
therefore a valuable line of investigation.

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 SUPERVISION OF TFP   121

Mr. G. is in the early weeks of treating Ms. H., a young woman with BPD
with prominent narcissistic traits, and shares their recorded session with
his supervisor, Dr. I. in their TFP supervision group. When watching the
recorded session with his peers, Mr. G. is struck by how active he is in the
first minutes of the session, introducing topics and asking questions repeat-
edly, rather than expecting Ms. H. to speak freely, as had been established
during their period of reviewing the treatment agreement. Mr. G. reflects
that he had found periods of sustained silence in their earlier sessions
to be uncomfortable, and acknowledges an impulse to “work hard” and
structure their sessions to address Ms. H.’s implicit disapproval and dis-
satisfaction, often conveyed by her bored demeanor and withering looks.
The supervision group helps Mr. G. explore the meaning of Ms. H.’s stance
of being either unwilling or unable to work within their agreement and
speak freely. The supervisor, Dr. I., speculates that the pattern observed
in the recorded session, that of an indifferent patient and an earnest, anx-
ious therapist, could be useful to Mr. G. as he begins to explore prominent,
recurrent object relations dyads as they emerge in the transference. The
supervision process helps Mr. G. move from his pattern of deviating from
expectable practice to a more direct exploratory path, as he brings to the
patient’s attention the pattern he observes and comments that it is at odds
with the agreement they had forged just weeks earlier.

Intervening with a Goal of Attending to Areas

of Possible Dangerousness

The adjustments made to the more traditional approach to psycho-

analytic exploration for patients with BPD or other moderate-to-severe
personality disorder presentations would include a role for the thera-
pist, at times, to be more active and directive than would be expected in
the psychoanalytic work done with a higher-functioning patient. Given
the defining criteria of BPD, including repeated suicidal thoughts and
actions, as well as other impulsive behaviors, including substance use or
eating disorder activity, it therefore stands to reason that the TFP thera-
pist will be compelled at times to directly address risk of dangerousness.
In the first three minutes of a session, the TFP therapist will raise, if the
patient has not, any material that has come to his or her attention that
suggests some kind of compromised safety. A common scenario might
be the patient who does not spontaneously reveal endangering behav-
iors, even when the therapist has stressed the importance of an honest
and forthcoming attitude. In addition, the therapist would be open to
bringing up in the early part of a session material related to the patient’s
compromised safety that was raised in a prior session, but not directly
addressed in the opening minutes of this follow-up encounter. When

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the therapist learns of anything along these lines from contact with a
family member or another clinician involved in the case, he or she will
introduce these matters in a direct way, even if the patient appears to
evade doing so by introducing content somehow unrelated to this more
pressing concern. One pattern might be the patient who describes esca-
lating suicidal ideation in the last moments of the previous session; the
patient and therapist have a treatment agreement outlining the patient’s
responsibilities for managing suicidality between sessions, and the
therapist has not heard from the patient since that previous meeting.
When the patient begins the session with seemingly unrelated material,
say, related to conflicts at work, the therapist will be moved to bring
up the material not addressed by the patient. For example: “I’m aware
that you described feeling more suicidal at the end of our last session,
with some thoughts about stopping your medications for diabetes and
seeing if you became more symptomatic. Today, you are talking about
work, but not bringing to my attention anything about the impulses
you described at our last meeting. What are your thoughts about that?”
Similarly, if the therapist has learned from another source about some
aspect of the patient’s behavior that suggests dangerousness, he or she
would be compelled to introduce this material early in the session. A
typical example might be the patient who is avoiding work by calling in
sick, risking the patient’s job security and introducing a broader threat
to the patient’s financial and familial stability, and therefore the ability
to pay for treatment. The patient’s wife leaves a message for the thera-
pist expressing concerns about this behavior. The patient does not reveal
this to the therapist as the session begins; the therapist expeditiously
interrupts the patient and says: “I’ve heard from your wife that she is
concerned that you are not going to the job. This sounds important and
I’m aware you’re not bringing this to my attention. It seems that this is
a pressing matter requiring our attention now, more than the topic you
raised about the conflicts in your bowling league.”

Dr. J., working with Ms. K. for almost a year, received a phone call from
Ms. K’s mother alerting her to the escalating conflict between Ms. K. and
her new girlfriend and the girlfriend’s threat to call the police during a
recent argument. When Dr. J. and Ms. K. meet next after this phone call,
Ms. K. begins their session with an extended story about a particularly
thorny problem at work and her concerns about an upcoming annual
review. Because Dr. J. had worked with his supervisor, Ms. L., on a number
of TFP cases, he listened attentively to the concerns raised by Ms. K., while
simultaneously considering his obligation to interrupt Ms. K. and raise
with her his concerns about the phone call he had received and the associ-
ated risks should this conflict with her girlfriend lead to involvement with

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 SUPERVISION OF TFP   123

the police. While working together on other cases, Dr. J. and Ms. L. had
discussed comparable clinical situations that involved patients’ acute and
chronic self-defeating or self-destructive behaviors. Dr. J. had been trained
in psychoanalysis before learning TFP and he had assumed a default posi-
tion, informed by psychoanalytic training, of “letting the material unfold”
by taking cues from the patient as to where to intervene. In his supervision
with Ms. L., informed by his understanding of the particular quandaries
associated with treating patients with moderate to severe personality dis-
order pathology, he became more comfortable directly addressing mate-
rial that might be associated in any way with dangerousness. With Ms. K.,
dangerousness was associated with persistent denial about the possible
adverse effects of her behavior; when working with patients with promi-
nent suicidal thoughts and acts, Dr. J. became more comfortable over time
raising any concerns he might have at the outset of a treatment session, an
intervention consistent with his appreciation of TFP’s directive that the
therapist him- or herself requires a sufficient sense of safety in order to be
able to think clearly and work effectively.

Intervening as Additional Challenges to

the Treatment Agreement Emerge

So far, specific challenges to the treatment agreement, including

introduction of dangerousness as a threat and barriers to speaking
freely, have been referenced. These challenges can often surface in the
initial minutes of a session, although sometimes such areas of focus
can emerge only later as particular content or conflicts are revealed.
The treatment agreement in TFP is designed to invite challenges; the
TFP therapist’s understanding of the fundamental nature of moderate
to severe personality disorder pathology informs an expectation that
the patient will not easily trust the therapist, speak freely without self-
censorship, or directly and exclusively address his or her most press-
ing conflicts. Certain material that might come to light in the initial
part of a psychotherapy hour could suggest other types of threat to
the treatment agreement. A common pattern is the patient’s confus-
ing attention to relatively trivial subjects, meaning those subjects not
clearly linked to the patient’s overarching personal goals and treat-
ment goals. The TFP therapist who appreciates this pattern in the ini-
tial minutes of a session might intervene by commenting: “I’m hear-
ing your detailed conversation about your frustration with your dog
walker, but it’s not clear to me how this is linked to your continued
pattern of alienating supervisors at work to the point that your promo-
tion has been delayed. Can you appreciate my confusion about this?”
Another prototypical encounter in this vein could be a therapist’s

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observation about a patient’s challenge in being honest. A therapist

might check in with a patient about her commitment to alcohol absti-
nence at the beginning of the session, if this has been a pressing topic
in the patient’s history. In one circumstance, a patient was often late
to a morning session because of late night alcohol use. When a patient
is uncharacteristically late for his appointment, the therapist can say
directly: “You haven’t spoken much lately about your participation in
your 12-step meetings. I’m aware that today you are late, and in the
past, this has often resulted from late night drinking. You haven’t con-
veyed to me that you’ve had a relapse, but your behavior causes me to
reflect about that possibility.”

Ms. M. carries diagnoses of both Bipolar Disorder, Type II, most recent epi-
sode depressed, and BPD. Dr. N. provides management of the medication
regimen for her BPD, as well as acting as her TFP therapist. In his super-
vision, Dr. N. shares his most recent session with Ms. M., which begins
with the account of her tumultuous dating life. Dr. N.’s supervisor, Mr. O.,
notes that Dr. N. appears somewhat disengaged in the first minutes of their
session. Mr. O. speculates that Dr. N. might be either bored or frustrated
with Ms. M., as he seems generally flat and only minimally interested. Dr.
N. agrees with Mr. O.’s observation, and recalls that during the opening
minutes of the session reviewed, he was flummoxed by Ms. M.’s delay
in obtaining needed laboratory testing, given some concerning adverse
effects likely associated with her mood stabilizer regimen. Mr. O. points
out that it may be that during the course of their therapy a new kind of
challenge to the treatment agreement had emerged. In this case, the treat-
ment agreement had touched on adherence to the medication regimen, but
not specifically described the necessity of adherence to periodic labora-
tory testing. Mr. O. encourages Dr. N. to bring up this newest challenge
at the start of their next session. Rather than minimizing or ignoring this
behavior, the therapist is strongly encouraged to address it directly and to
begin to formulate the possible meaning of the behavior in the transfer-
ence. When Dr. N. does raise the issue of the outstanding blood test at
the start of the following session, the patient’s reaction leads to a fruitful
exploration of an emerging paranoid transference, specifically the patient’s
experience of the clinician as controlling and demanding.

Sustaining a Keen Appreciation of All Three Channels

of Communication

As described, the TFP therapist will aim to juggle active consider-

ation of the multiple channels of communication. Even before the
session begins, the therapist might be contemplating his or her most
pronounced countertransference reactions to the patient. From the first

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 SUPERVISION OF TFP   125

moment of the therapy hour, the therapist is taking in the non-verbal

communication (the patient’s grooming, posture, facial expression,
clothing, tone of voice, and eye contact, among other transmissions of
information), and the patient’s verbal content. It is often challenging
for therapists trained in other psychoanalytic modalities to focus less
on what is said and more on how the patient behaves, what elements
emerge in the countertransference, and which chronic patterns in their
interactions emerge over time. The initial minutes of a TFP session can
be a trove of information about non-verbal communication; in TFP
supervision, it can often be fruitful to explore the therapist’s relative
passivity in commenting on non-verbal communication or subtle, yet
meaningful, undermining of the frame. This phenomenon can some-
times reflect a persistent countertransference myopia, as the therapist
wishes the patient were functioning at a higher level than perhaps
the patient actually is capable of doing. By leaning more heavily on
what the patient says, and paying relatively less attention to how the
patient behaves, the therapist may be perpetuating a chronic idealizing
transference, at the expense of a valuable exploration of a defended-
against negative or paranoid transference. One of the most frequently
described challenges that reflects this pattern is the patient who may
be chronically late for his or her appointments. The therapist who does
not first register and then describe this non-verbal communication,
while instead focusing intently only on what the patient says, would
be at risk for ensuring a continued positive or idealizing transference.
Doing so would therefore result in forfeiting a chance to delve into the
patient’s negative or devaluing experience of the therapist, missing this
element of the transference as it is reflected the patient’s communica-
tion about his or her attitude about the frame.

Dr. P. is in the very early stages of learning TFP and brings to her group
supervision, led by Dr. Q., a recorded session she considers to be a good
reflection of her first meetings with Mr. R. Dr. P. considered Mr. R. to be a
good candidate for TFP treatment, given her initial diagnostic impression
of a patient with prominent narcissistic pathology, but nevertheless with
genuine areas of strength, including a solid work history and emotional
investment in his young children. The recorded session includes the first
moments of their meeting as Dr. P. greets Mr. R. at the door and ushers him
into her office. The supervisor, Dr. Q., replayed multiple times with the
group these first moments and commented on Dr. P.’s unusually gregari-
ous greeting and beaming smile, as the two exchange pleasantries about
the weather. Dr. P. was initially defensive in response, explaining that she
felt it was appropriate for her to be cheery and encouraging. Dr. Q. and the
group worked with Dr. P. to explore more the countertransference currents
underlying her reflexive behavior with Mr. R. Upon further consideration,

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Dr. P. described her anxiety about starting TFP, a modality new to her, and
her apprehension about treating a patient she considered to be a “prize,”
given his level of education and accomplishments. The concerted focus
on the initial moments of the session as reflected in the recorded material,
something that might otherwise have been lost had Dr. P. presented with
process notes only, allows for an incisive and productive discussion.

IDENTIFYING DOMINANT OBJECT RELATIONS DYADS,

ROLE REVERSALS, AND THE INTERPLAY BETWEEN DYADS

The definitive description of the details of TFP, most importantly

how to set up the treatment, how and when to intervene, and how to
employ clarification (the therapist’s request for more information about
any material that is somehow opaque or incomplete), confrontation (the
therapist’s process of bringing to the patient’s attention material of any
kind that is somehow inconsistent or discrepant), and interpretation (the
therapist’s offering of a hypothesis about motivation and behavior that
may be outside of the patient’s awareness), are provided in the treatment
manual. The first moments of a TFP session will provide the supervisor
and trainee enough material to begin to consider the dominant object
relations dyads as they come into focus in the exchange between patient
and therapist. The dyads dominant at the beginning of a session may
not be sustained throughout; however, the material offered at the start
can be mined for significance and serve as a guide for the therapist for
avenues of investigation. Imagine a case that includes details already
described in different settings: the patient who continually faults her
therapist for seemingly trying to control her, while failing to help, who
brings up material related to suicidal thinking at the end of a session,
and who is chronically late for her sessions. Consider the therapist who
is waiting for this patient; her countertransference is one of anxiety,
imagining the patient has acted on her suicidal urges. Perhaps the thera-
pist also feels devalued and controlled, interpreting the patient’s chronic
tardiness as an expression of aggression. When this patient walks into
the session late, with apparent indifference to the consequences of her
behavior, the therapist might begin to consider introducing a comment
about an active role reversal. In this situation, the therapist’s awareness
of her anxiety and her sense of feeling controlled by the patient’s late-
ness might prompt an observation about ways the patient might be con-
trolling the therapist, something not necessarily in the patient’s aware-
ness. As outlined, the focus on supervision of the initial stages of a TFP
psychotherapy hour will likely evolve over time, with an early focus
on issues like dangerousness or challenges to the treatment agreement,

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 SUPERVISION OF TFP   127

and with later attention to role reversals and defended-against positive

sentiments.

Dr. S. is routinely berated by his patient, Mr. T., for failing to provide symp-
tom relief for Mr. T.’s longstanding low self-worth and chronic passive sui-
cidality. Mr. T. begins their most recent session by stressing his resentment
at having to continue in a treatment he feels does not provide him with
the support and “answers” he feels he deserves. He starts the session by
detailing the effort required to come to Dr. S.’s office, and how he feels
the requirement for twice-weekly meetings, as expected in TFP, amounts
to an excessive burden, reflecting the therapist’s outsized demands. Dr. S.
hears Mr. T.’s complaints as fitting into a familiar dyad, that of a victim-
ized patient feeling overburdened by an indifferent, even sadistic, thera-
pist, with an associated affect of resentment and anger. As is his pattern,
Mr. T. threatens vaguely to end the treatment abruptly, saying, “I may just
have to stop coming if I can’t get what I need from you.” The supervi-
sor, Dr. U., asks Dr. S. to describe his impression of the dominant object
relations dyad in play. Dr. S. outlines his impression, that of the victim-
izing therapist and neglected or poorly treated patient. Dr. U. comments
on his observation of the non-verbal communication of the recorded ses-
sion, notably the patient’s relative calm and satisfaction when delivering
his veiled threat to end treatment, and the expression on Dr. S.’s face, one
of trepidation and unease. The supervisor invites Dr. S. to consider the pos-
sibility of a role reversal in play, meaning that the qualities the patient had
routinely ascribed to the therapist, that of a controlling and empowered
figure, were now evident in the conduct of the patient. The supervisor, Dr.
U., encourages Dr. S. to consider remarking on this possible role reversal,
evident in these initial moments. This intervention would be central to the
goal in TFP of bringing into the patient’s full consciousness the expres-
sion of aggression that might otherwise remain fully outside the patient’s
awareness.

CONCLUSION

Learning TFP is a relatively labor-intensive process, aided by fre-

quent review of recorded sessions in supervision settings. Because
TFP is a manualized treatment with multiple “benchmarks” consid-
ered necessary for execution of the treatment, the supervision process
can focus on the therapist’s management of these elements, requiring
repeated review of the therapist’s adherence to the model. Supervision
of psychodynamic psychotherapy work has traditionally left much
open to the serendipity of the supervisory process, with relatively few
guidelines or expectations for standardization. That said, an apprecia-
tion of the importance of the initial interventions in psychotherapeutic

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 128   VALENCIANO AND HERSH

treatment, as in a metaphor of the initial “moves” of a chess game, date

back to writings by Freud (Busch, 1995). In reviewing the first three
minutes of a TFP session, the supervisor and therapist are presented
with an opportunity to investigate together certain core elements of
the treatment modality. As discussed, this proposal is not intended
as a substitute for supervising a complete session, or as a supervision
focused on certain content in a session believed by either the therapist
or supervisor to be of import. One aspiration of this proposal would be
a demystification of the supervision process, helping to move some-
thing that is generally highly subjective and random, to an endeavor
with a clearly defined purpose and a structure that would support that
effort.

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Richard G. Hersh, M.D.

25 West 81st Street
New York, NY 10024
Rh170@cumc.columbia.edu

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