The economic, dynamic, and structural principles are based on psychoan-alytic concepts involving the dynamic forces at work within the mind: the interaction of drives, affects, internal prohibitions, and external reality (Table 4–3). The economic principle refers to the dominant investment of the patient’s affect in any given material, and it guides the therapist to focus on the material in which the patient invests the most affect. The rationale for this principle is that intense affects serve as flags pointing to the dominant object relation in the transference. An issue may be considered affectively dominant either if significant affect accompanies the content or if there is a striking absence of affect appropriate to the content, which indicates that affect is being suppressed, repressed, displaced, or split off. What is affec-tively dominant may appear self-evident at times, such as when the patient is discussing his mother’s diagnosis of cancer with intense affect. However, it could be that a patient brings up his mother’s diagnosis of cancer but in the same session speaks with greater affect about being late for work that day. The therapist should first inquire about and explore the affect.
If the affect is discordant with what the therapist would expect it to be, then the therapist must ask the patient to clarify the apparent incongruity.
For example, “You’re talking about whether you should go on living, yet you don’t seem to be concerned about what you’re saying.” This can lead to discovering the predominant theme. When the patient’s behavior is in-congruent with his or her words and affective dominance is unclear,
behav-ior is probably more important than verbal content and should be explored first. Although it may seem nothing more than a matter of common sense to follow the patient’s affect, it can nevertheless be a very helpful guide—
for instance, in situations where there is a discrepancy between what might logically seem to be the priority issue (e.g., illness in a spouse) and what ap-pears to carry the most affect (e.g., the patient’s perception of the therapist’s demeanor).
If the therapist has difficulty determining an area of affective domi-nance, he or she should next turn to any other indications of transference in the content of the patient’s remarks or in behaviors (transference is fur-ther discussed later in this section in relation to the dynamic principle), and then to the countertransference. If no significant theme has yet emerged, then the therapist should continue to evaluate the ongoing flow of material, waiting until an affectively dominant motif appears. Its absence may indi-cate that the patient is consciously suppressing important material. If so, the guidelines for emergency priorities (see the next section, “Adhering to the Hierarchy of Priorities Regarding Content”), especially those regarding triviality of communication, can help the therapist focus. Absence of signif-icant affective themes can also be characteristic of dismissing narcissistic patients.
When the therapist has determined which material is most invested with affect, he or she then thinks in terms of the dynamic principle. This prin-ciple has to do with the forces in conflict in the psyche and is based on the assumption that the presence of heightened affect signals an unconscious TA B L E 4 – 3 . Three principles that guide the pertinence of interpretation 1. Economic principle Emphasizes that therapeutic attention and
interpretation are linked to the dominant affect.
2. Dynamic principle Involves consideration of the forces in conflict in the psyche and how they are represented in object relations dyads; determines the sequence of interpretation, from surface to depth, from defense through motivation to impulse.
3. Structural principle Highlights an overview of the relations of the principal object relations dyads in the patient’s psyche, with the focus on interpreting the structures involved in both defense and impulse. In neurotic patients these structures are the id, ego, and superego; in borderline patients they are the less clearly formed principal object relations dyads.
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conflict involving a defended-against impulse. As discussed in Chapter 2 (“Treatment of Borderline Pathology: The Strategies of Transference-Focused Psychotherapy”), both the impulse and the defense against it are represented in the psyche by respective object relationship dyads. Since the patient’s internalized relationship dyads are observed most clearly in the transference, the dynamic principle is intimately linked with a therapeutic focus on the transference. The dynamic principle instructs the therapist to work from the defense, which is observable on the surface, to the impulse, which is out of awareness at a deeper level.
What the therapist observes most commonly in the session are trans-ferences that serve as resistances to accessing deeper material. Resistances are the clinical manifestations of defensive operations. Operationally, any difficulty the patient demonstrates in participating in the treatment as agreed to in the treatment contract serves as resistance to accessing deeper material. The task of fully examining one’s inner world is inevitably daunt-ing—especially for patients whose internal world is characterized by in-tense, unintegrated parts—and although it is appropriate to empathize with the patient on the difficulty of that task, the therapist must always be alert to the risk of colluding with resistance. From an object relations point of view, colluding with the resistance consists of the therapist enacting the role of one of the patient’s internal object representations without examining the dyad that is being enacted and the role it plays in defending against—
keeping out of sight—other internal dyads. An example of this is the thera-pist who accepts the positive transference—the role of benevolent helper—
without exploring what other aspects of the patient’s inner world may enter into the relationship.
Resistances are not like walls that need to be removed, but are a part of the psychic structure that must be appreciated for their informational value.
They are defensively utilized dyads that must be interpreted; that is, the rea-son for their presence must be understood in relation to what they are de-fending against. A simple example of such an interpretation would be: “You are experiencing me as a harsh judge, a menacing critic [defense] because it would be too frightening to experience the wish that I be available to nurture and care for you [libidinal impulse being defended against].” Interpretation from surface to depth is discussed further in Chapter 3 (“Techniques of Treatment: The Moment-to-Moment Interventions”). The dynamic prin-ciple is mentioned here as an aid for knowing where to intervene.
The therapist uses the dynamic principle in determining the order in which to address material in making an interpretation. In practical terms, the therapist can ask himself or herself, “What is defending against what?”
and should generally choose interventions that address the defensive level
before addressing the impulse being defended against. Another example of this would be: “You are very insistent on seeing me as cold and depriving in a sadistic way. Even when I offered you an alternative session because you cannot come on Monday, you harshly responded that I was only offering one alternative that was convenient for me. I have noticed that your depic-tion of me as cold and withholding has increased over the past weeks. Can we agree that this is the way you have been seeing me?” This intervention is describing the dyad that is serving the defensive function. If the patient agrees, the therapist could continue: “It seems this intensification of seeing me this way could be covering up other feelings you are having that you are uncomfortable with and that make you very anxious. In subtle ways, such as the look in your eyes at times, you seem to be experiencing me differ-ently. These subtle signs suggest you may be feeling something positive in regard to me, but for some reason this appears to make you anxious, result-ing in a steppresult-ing up in your criticisms of me, as though to reassure yourself that nothing positive could exist between you and me.” The therapist is be-ginning to address the affect and impulse being defended against. The final step in this process would be to understand the need to defend against these feelings (see “Interpretation” in Chapter 3, “Techniques of Treatment: The Moment-to-Moment Interventions”).
If the therapist has difficulty making use of the economic principle—
that is, if he or she does not find a focus of the patient’s affect—he or she is advised to think in terms of the dynamic principle as it may be getting played out in the transference. In operational terms, this means to intervene where there is evidence of transference material. In fact, although affective dominance coincides with transferential dominance most of the time, there are occasions when the dominant affect is not centered on the transference.
Most of the time, however, the transference implication is quite obvious.
For example, if in the first 10 minutes of the session the patient discusses a variety of topics with consistent blandness and without paying attention to the therapist, the predominant focus might be on exploring how the patient may be experiencing and treating the therapist: “You are talking as though I were not here today.” This aspect of the transference becomes the focus of the therapist’s interventions, and while delineating the nature of the re-lationship dyad that is active in the transference, the therapist should also attempt to understand what deeper dyad the patient may be defending against.
If affect and transference diverge—that is, if there appears to be a pre-dominant transference paradigm but some other issue is more affectively weighted—then the latter should be chosen as the focus. Usually the con-nection with transference will emerge at some later point. What makes
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working with the transference subtle is that it is not always communicated through words—either in direct references to the therapist or indirectly through discussion of other significant individuals. Often the transference is communicated through subtle behavioral gestures or an overall attitude.
Examples are the following:
• It may be more important for the therapist to focus on the fact that the patient commented with a slight ironic laugh, and to pursue the trans-ference implications of that, than to focus on the content of the com-ment.
• It may be important for the therapist to first focus on the mistrust he or she observes in the patient’s eyes and then wonder how to link it to the content of what he or she is saying.
The structural principle is also helpful in guiding the therapist’s interven-tions. This principle involves the therapist’s developing understanding of the structure of the particular patient’s conflicts and comes from the ther-apist’s stepping back and getting an overview of how the specific dyads that have been activated in the transference fit together in a larger pattern. With neurotic patients, the structural analysis involves conflicts between the id, superego, ego, and external reality, or with an inconsistent element in an otherwise consolidated identity. In borderline patients, in whom the id, su-perego, and ego have not become integrated as they have in neurotic patients, conflicts are structured around the most prominent internal relationship dy-ads and their relations to each other. Although the number of possible rela-tionship dyads is immense, in clinical practice we find that each individual patient presents with a limited number of highly invested dyads that are fre-quently repeated in the transference. Thus, in each therapy there are a lim-ited number of transference themes. Establishing which transference themes are prominent, and their relation to each other, in a specific patient helps the therapist guide his or her interventions. The structural principle involves determining what object relations dyads have a defensive function against which other object relations dyads and to what extent the patient is able to look jointly at the conflict from the perspective of an excluded other, a triadic principle that introduces the observing part of the patient’s ego represented by his or her temporary identification with the analytic func-tion of the therapist. Because in TFP we are looking at the course of devel-oping psychological structures, thinking in terms of the structural principle also involves the therapist’s thinking in terms of what the patient is becom-ing and can become.
With borderline patients the most effective way of arriving at this for-mulation is to determine the chronic, baseline transference that underlies the shifting transferences observed from moment to moment and that rep-resents the principal conflict at a given phase of the therapy. Although it is not always the case, most borderline patients begin therapy with a chronic paranoid transference—that is, with a self-representation of a weak, vulner-able self who is on guard against any feelings of closeness that he or she may develop because of the belief that the object will inevitably reject, abandon, invade, hurt, or exploit him or her. (See Chapter 2, “Treatment of Border-line Pathology: The Strategies of Transference-Focused Psychotherapy,”
for more discussion of the evolution of typical transferences.)
In summary, these three principles remind the therapist to 1) follow the patient’s affect as an indicator of what the predominant object relations dyad is likely to be at a given moment, 2) look for and address first the ma-terial that seems to be serving a defensive purpose, and 3) look for the over-all organization of dyads in terms of what surface dyad is defending against what underlying dyad.