Flexible and connected: diagnosis, treatment, and supervision in TFP. An interview with dr Sergio Dazzi
Sergio Dazzi, M.D., is a psychiatrist, psychoanalyst and a certified Teacher Supervisor of Transference Focused Psychotherapy. He is the founder and the president of the Associazione per lo studio e il trattamento dei disturbi di personalità “PDlab” (“The Association for the Study and Treatment of the Personality Disorders”) and a former Member Executive of the Board of the International Society for Transference Focused Psychotherapy. He lives and conducts private practice in Parma, Italy.
Mateusz Stróżyński, Ph.D., is a classicist, philosopher, and psychologist, a certified psychotherapist of Transference Focused Psychotherapy, currently, in training for the Teacher Supervisor certificate in TFP. He is associate professor of classics and ancient philosophy at Adam Mickiewicz University in Poznań, Poland. He conducts private practice in the Center for Psychodynamic Psychotherapy “Relacja” in Poznań. He is co-editor of the journal Psychoterapia psychodynamiczna w Polsce (“Psychodynamic psychotherapy in Poland”), published by the Polish Society for Psychodynamic Psychotherapy. The interview will appear, in Polish translation, in the current issue of the journal.
Mateusz Stróżyński: Could you say a little bit about the course of your professional career? How did you become interested in psychoanalysis and psychodynamic psychotherapy?
Sergio Dazzi: I’m a psychiatrist. I began my professional training at the end of the 1970s. At this time in Italy the public mental health system was just beginning to emerge. It means that a huge endeavor in psychiatry was to treat psychiatric patients in social environment, not relegating them to psychiatric hospitals. It was the outpatient treatment that was blooming then and Italy had a strong social psychiatry movement, too. Young psychiatrists were interested very much in the matter of therapeutic technique. That is why psychoanalysis became of great help because we wanted to treat a patient not just as an object of pharmacological intervention and his illness not even as the outcome of social contradictions, but we wanted to understand the patient and many psychiatrists found that psychoanalysis could provide the understanding of severe psychopathology. Especially, in the treatment of very sick patients. So it was from the very beginning that I got involved in psychoanalysis. At this time psychotic patients were treated in special residential settings in the United States, like those in which Otto Kernberg was working. But both the inpatient and outpatient treatments were provided for very sick patients. That is why I got interested in psychoanalysis and, especially, in the clinical side of treating such patients, within the frames of some defined treatment. I was first interested in schizophrenia and major depression, then also in personality disorders. In that first part of my professional career I was in touch with various ways of diagnosing severe cases and treated different patients. Initially, I worked in a public health system, both outpatient and inpatient, and our entire staff was oriented towards the dynamic understanding of those severely sick patients. In terms of psychoanalysis, I was partly trained in the United States. I spent some time in New York, at the very famous psychoanalytic institute, William Alanson White institute. It wasn’t orthodox, because it was first inspired by interpersonal psychoanalysis, Harry Stack Sullivan was one of its co-founders. Then it became more in tune with the British Independent Group. When I studied there, in the 1980s, it was not part of the International Psychoanalytic Association, but, nonetheless, it was very popular and well named. I learned there a lot. Earlier, it was already famous among American psychiatrists, but not so much among psychoanalysts; they preferred institutions like the Columbia psychoanalytic institute, because it was more orthodox. I spent a good amount of time at William Alanson White Institute, a couple of years, and, at the same time, I was receiving my psychoanalytic training here in Italy, which was more in the ego psychology orientation. So those are the two branches of psychoanalysis, which influenced me. Later on, I also had many connections with the places which at this time were treating severe cases, for example, Chestnut Lodge hospital in Maryland, where Harold Searles used to work or Austen Riggs Center in Massachusetts. I went also to the New York hospital in which Otto Kernberg worked and spent some time there too. My American experience was in the 1980s and 1990s. Later on, I left the public health system in Italy and I began to conduct private practice. I did some teaching in different universities, but I have never had a strictly academic career. I also stayed in touch with the American groups I came to know, when I was in the United States. Some ten years ago, me and people I worked with in Italy decided that we wanted to belong to a community, a net, and so we had to choose something. We were already working with severe cases, but we didn’t have a specific identity in terms of belonging to any kind of association. At the time, we were in touch with various groups, for example with John Gunderson. But we saw that substantial research on psychotherapy came out from Personality Disorders Institute at Weill Cornell Medical College where TFP had been developed, so we decided to join them. We began a formal training with dr Kernberg, dr John Clarkin, dr Frank Yeomans and dr Diane Diamond, who used to come to Italy four times in a year. After completing the basic training, we were wondering what to do next. We continued training in individual supervisions to become certified TFP therapists and then TFP teachers and supervisors. At the same time, we established a scientific association, called PDlab, of which I’m still the president. We established branches in different Italian cities and now we have several certified TFP therapists and supervisors. We still belong to and are quite active in the TFP international community (ISTFP). Over the years we noticed that the more we were in touch with this model of psychotherapy, the more we were involved in it. We participated in the very evolution of the model through the years, participated in and organized international conferences and now we really feel we belong to this community. I might say that at the beginning we were confronting dr Kernberg’s approach against other approaches, but now it is a bit different. We still try to stay in touch with other psychoanalytic approaches, but now we confront those approaches against the TFP approach, our approach. For us, TFP is the real bottle and we try if other types of wine fit into this bottle. This is our identity.
MS: Could you tell us a little bit about psychoanalysis in Italy? What is the tradition behind it? What is the most influential school?
SD: What is curious, is that my Italian psychoanalytic training was not within the International Psychoanalytic Association, because in the 1960s there was a big mess, both theoretical and political, in psychoanalytic institutes across Europe. I received my training with a Swiss-Italian group close to ego psychology. But the mainstream in Italy has always been Kleinian. The generation older than me used to fly to the Tavistock Institute to learn psychoanalysis there. So I would say that now the mainstream is neo-Kleinian and neo-Bionian.
MS: Like everywhere. And it seems that the ego psychology approach has been absorbed by TFP.
SD: Yes. To me it seems that the great achievement of dr Kernberg was to integrate ego psychology into his broader model, because it provides us with the idea of the structure of the mind and of the development of structures which can be at different levels of maturation. That’s very important. But this approach, taken by itself, leaves you, in a sense, alone in the clinical work with the patient, so dr Kernberg joined ego psychology to the object relations model and created what can be called “a contemporary object relations theory” of mental functioning. Putting them together helped clinicians to differentiate their diagnoses. Second, ego psychology helps you to understand where you are at every single moment in the therapeutic process. In the Kleinian model the problem is that you don’t have a structure. And in the ego psychology approach you have too much structure, so you can lose the richness of relationship, the development of transferences etc. Dr Kernberg’s genius can be seen in integrating those approaches in a more comprehensive one. It has been paramount for two reasons: one in helping clinicians to better understanding pathology and treatment, and another in allowing exchange and enrichment with neighboring disciplines, like attachment theory, affective neuroscience and social cognition.
MS: And what about the French psychoanalysis? In Poland we have certainly Kleinian influences, but also there people interested very much in the Lacanian approach. Otto Kernberg did not include Lacan himself, but some other French concepts, mainly regarding sexuality, early Oedipal complex and, more broadly, the French openness to art, literature, philosophy. How is it in Italy?
SD: In Italy we don’t have so much French psychoanalysis. What dr Kernberg took from the French psychoanalysis was mainstream ideas. As you know, Lacan is close to the topographic model of the Freudian thought, but dr Kernberg refers very much to André Green whom I read mostly after getting involved in TFP. I know very little of the Lacanian approach.
MS: For Green the British analysis is quite significant as well as for Joyce Mc Dougall.
SD: They are familiar, more than us, with integrating what they call the analytic “space”, so they tend to bring together Winnicott and maybe some concepts of Lacan, the more accessible ones. But using the theories of Winnicott is actually a lot easier. When we become more familiar with the concept of the movement of the primitive structure, then it helps to know the ideas of Winnicott. But after all it may be just a question of placing accents. In Italy we are, for example, inclined very much towards the work of Thomas Ogden. It helps us to a certain degree, but in TFP we have a different structure of the mind for understanding clinical phenomena. Personally, I like reading Ogden and find him interesting, but we have to find much more balance in our approach.
MS: In Poland Ogden has also been read with interest. Now I would like to move to another topic, the one which we have recently been forced to discuss a lot, namely, seeing patients online. What are your thoughts about that?
SD: We will have to invent new methods and to get used to this kind of work. Dr Kernberg says that it’s easy to treat patients online (laughing). But in any case, we have to get used to it.
MS: I think what is difficult here is that since you are not in the same room, you receive the non-verbal and countertransference input in a different way. It’s hard to imagine how to work like this with severely disturbed patients. Some therapists may feel a little more detached from the patient, as if they were not getting all the information they would normally get, if they were in the same room.
SD: I am sure that in the near future many papers will come out to highlight the clinical opportunities offered by online tools. I think that it is greatly possible, but with some difficulties and new things to learn. But that is dependent on the context, not the method. In practice, we have to learn how to collect the same data in a new context. As was recently put, we have to search for the unconscious motivation all the same. I think we’ll have to learn how to manage the non-verbal communication in a more sophisticated way, when we work online, and we’ll have to start by having a good setting with the patient. For instance, you have to sit in a chair, so that I could see you well on my screen – the frame should be correct. But we also have to understand the non-verbal communication in a different way. Patients are dealing with you through the screen, so some of them tend to jump into the screen, while others are more distant. We have to learn how to detect those things and use them. When we are talking now online, I am in my environment, you are in your environment. We are used to a different situation, when you treat a patient who comes to your environment and you try to understand his reactions. But when you see a patient online, both of you have to organize your respective environments, which belong to each of you. It’s almost as if you didn’t have nothing to do with my surroundings, you don’t interact with them. When we meet in the same room, I can see how you dress, what you do with your legs, how you move. But via Zoom it’s different, you don’t have so many information available. The patient allows me to get into his world, but I have to be more active to inquire about his external reality.
MS: You also mentioned once the disturbances of the setting, which are different, when you see patients online, but they still happen. You can, of course, try to establish some setting in terms of where the patient sits, but he starts to change and behave more freely, because he is in his own space. And if the patient comes to your office, you seem to have more implicit control, because, as you said, the patient comes into your space.
SD: That’s why we have to establish very clear conditions. It happened to me that some patients think that all that you have to do is to be reachable via Zoom. And that’s enough to be in treatment. But sometimes I had patients with kids coming and going into the room, where they were sitting or they didn’t have any space just for themselves, so they called me from their bathroom. We have to define the limits and then we’ll see the movements and the breaking of the setting just as in normal treatment. If your patient appears drunk, you say it’s impossible to have a session, we have to stop etc.
MS: I wanted to talk a little bit about diagnosis and the diagnostic process. We can start from your take on the diagnostic process via Zoom, because now we have to do this as well in some cases. Does the diagnostic process online has its own particular difficulties?
SD: In the interaction with the patient, when we diagnose a patient in our office, we have to monitor our countertransference and we have to confront the patient with the contradictions in what the patient tells about himself and what we experience. Online we tend to rely too much on our personal reactions, it seems to me, so we have to come to know the patient not so much by watching, because we can only watch a little, but rather by asking questions. We must investigate a lot. Personally, in the diagnostic sessions, I rely a lot on personal history. In the TFP format for the case presentation personal history is important. We have a narrative and the way in which the patient tells his personal history. So I think that then we have to know very well how he is dealing with external reality and we have to devote much time to that.
MS: I have an impression that our American colleagues tend to stress much more current functioning in work and love over the significance of personal history in the diagnostic process. Would you agree with that?
SD: I think it’s quite correct in the sense that TFP puts a greater emphasis on the here and now as contrasted to the patient’s past. And I’m also very much interested in the current functioning of the patient. But learning about biography or personal history can help us to understand better the level of functioning in the here and now. That is, basically, the way he organizes his subjective experience, which is at the basis of the way he works and loves. To be productive and have a social life is a means, not an end. We have to investigate a lot to learn how he’s managing the external reality right now, but by hearing his personal history we come to know how the patient used to deal with his troubles and vulnerabilities in the past. And we can take a look at his narrative, which is quite crucial, and to understand how he experiences the present. In fact, anyway, all your patients bring to you their personal history.
MS: It gives you a sense of identity integration and the level of organization?
SD: Yes, the continuity of identity. You can also have an idea of the patient as a child, as an adolescent, to imagine him with his friends, doing sports etc. We then can confront this “movie” that we picture in our mind with the “movie” he offers to us when we asked him: “Try to define yourself, try to give me a dynamic photograph of yourself so that I could know you”. And we can confront both of those pictures. The more stable identity is, the more the two images overlap. The more unstable it is, the more discrepancies we will find.
MS: I think the risk is that many patients, when they come to a psychodynamic therapy and they know something about it, they already prepare a narrative about their bad childhood, horrible parents, how it influenced them and how they are sick now because of their childhood. It’s, of course, a defense and it may be difficult to engage the patient in talking about his current life and relationships.
SD: But then you can ask more, even if they come with a prepared history and with the accusations of this kind. We can always investigate a little deeper and the more we investigate, even the issues the patients don’t believe are important, we can discover a lot. Even by Zoom, we can try to get an idea of a person, how he lives in his own world, and the more information we have, the easier it’ll be to answer a question that dr Kernberg used to ask: “If this guy wasn’t sick, how would it be. Without the illness, how would it be now?”
MS: When you read the literature by our American colleagues and when you study the TFP principles, it seems that diagnosis is absolutely crucial. You have to have a solid initial diagnosis in order to treat the patient properly, so you have to devote time to diagnostic consultations. I remember Eve Caligor saying once in supervision: “Don’t start the treatment if you’re not sure about diagnosis. Send the patient to your colleague, if you want a second opinion, because you have to have a diagnosis before you start the treatment.” But if you read some older psychoanalytic literature, there was something called “trial analysis”. You could begin analysis and then you could always revise your diagnosis based on your contact with the patient. What do you think? Do we have to be absolutely sure before we start to do anything? How much is diagnosis important in TFP?
SD: I think it’s important. I think that diagnosis is crucial for two main reasons. One is that many of therapists are psychologists and they could be misled by some psychiatric illness. So differentiating bipolar disorder from borderline personality disorder is quite important. I don’t mean that we have to try TFP in the first case, but we have to have a complete picture. We can also provide a psychodynamically based treatment which is not TFP, even if certainly influenced by it, like what is called TFP-E (extended). But the main reason is that you’re able to distinguish the level of personality functioning. Maybe we can have a discussion, if for me someone has a neurotic personality and for you it’s rather a high-level borderline. I think we can tolerate that level of disagreement. But differentiating between the levels of personality organization is quite crucial, because we manage differently the clinical phenomena we encounter, with regard to the level of personality organization. We won’t do the same things on one level of personality disorder, which we could on another and some of them could be useless or even dangerous on yet another level of personality disorder. Even if we diagnose someone generally as being on the borderline level, we have a set of procedures in mind for our work. If the patient is the higher level, we can further accept the fact that the transference will develop at lower pace and we can treat the transference as it unfolds, understanding its manifestation in external, interpersonal relationships without pushing too much for analyzing it with the patient, just patiently waiting. At the same time, it could be important to differentiate, if the narcissistic dynamic is crucial at this moment of treatment or there are merely narcissistic traits in another kind of personality disorder.
MS: So you would say that the most important thing is to differentiate the level of personality?
MS: And what about the type of character?
SD: I’m very much interested in that as well. It’s a more sophisticated aspect, but it helps you if you have already placed the patient on the spectrum of personality organization. Then you can wonder about, say, the histrionic aspect or you can think and investigate if the patient is more hysterical or more histrionic. It’s good to envisage huge dimensions of personality types. One of them is the highly emotional one – hysterical, histrionic, infantile personalities – and you can further distinguish between them. Another dimension can focus around obsessive, schizoid and schizotypal characters and you work with that later. On the depressive side, you can investigate whether it’s a depressive-masochistic personality with severe superego, but a well-functioning ego or you deal with a more profound depressive personality, in which the level of object relations and the defenses are more primitive. I would say that differentiating between those big dimensions is the easiest part. The more difficult part is to determine the specific character type. But, all in all, I believe that the most crucial is the level of personality organization. Here, the STIPO is important, not because you have to do the STIPO with all patients, but because it’s good to keep in mind, in our clinical work, the domains of the STIPO, because sometimes in the clinical interview we may forget something.
MS: From the supervision experience, I’d say that probably in our community it’s easier for therapists to diagnose the level of organization, but when it comes to the character type, there are usually some discussions, because it depends on the therapist’s personal view of the patient.
SD: Yes. But keep in mind those different dimensions that I mentioned and that the real diagnostic issue is the level of organization, because it means different levels of defense mechanisms, which needs different technical approaches. Our expectations of the treatment depend on that too.
MS: So the initial diagnosis gives you the setting and the structure of the treatment, but in fact, as dr Kernberg says, you always address the current transference. You’re not working with the diagnostic formulation of the patient, but with a real session and a real patient here and now.
MS: And you cannot interpret “narcissistic personality dynamic”, even if the patient has the narcissistic personality structure, but you have to interpret what is going on right now. So sometimes you have to put your diagnosis aside a little bit and be open to what the patient brings into the session, “without memory and desire”, as Bion put it.
SD: Exactly, but when you diagnose the patient, it gives you an idea how you will manage the clinical phenomena which will appear in the treatment. If it’s clear to you that the level is the low level borderline, for instance, and that the patient has a narcissistic personality disorder, you can be prepared to deal with the clinical phenomena in terms of the splitting in the self. So your first task will be to identify the grandiose part of the self and the devalued one. You’ll have a special eye on that as well as some expectations about what comes next.
MS: You’ve just referred to the distinction you also discuss in your supervision groups, namely, the splitting in the self as contrasted with the splitting in object relations. You mean by this, that at the beginning of the treatment of the narcissistic personality disorder, there are no object relations in the transference yet, only the splitting in the self into the grandiose and the devalued parts. Is it the same as what dr Kernberg described in the sixties as the narcissistic transference, in which you can’t detect any real object relationship, because in fact you are not an object to the patient, just the extension of his grandiose self? Only when you work through this, object relations, usually paranoid ones, emerge.
SD: Right. In the case of the narcissistic patient, at the beginning you have a rough idea in your mind that the first part of the treatment will be to handle the grandiose self, which is a pathological structure of the self. Your first aim will be to dismantle the grandiose self, so you can wait from the start for this to manifest itself, knowing what you have to do. You also know that later you can expect better defined transferences as a result of the dismantling of the grandiose self. On the other hand, if you start the treatment knowing that you are dealing with, say, a more typical borderline personality, you work from the very beginning in a very different way. You allow yourself to watch object relations appearing in transference more freely.
MS: Dr Kernberg usually emphasized that the dismantling of the grandiose self can last a pretty long time. Once he wrote that he has never seen it happen before the end of the 2nd year of treatment and if after 5 years of therapy you still haven’t worked it through with the patient, it’ll probably never happen, because the structure is too powerful for that. Is it also like that in your experience?
SD: Yes, it takes a long time.. When you dismantle the grandiose self, you find out already something solid forming in the patient, a better grasp of reality on his side. Maybe he will seem less adapted – like in the so called thin-skinned narcissist – but it is because a superficial adaptation has been dismantled. Even if at the price of a bigger suffering, the patient has a better connection to reality. Then you have to deal with the fact that the relinquishing of the grandiose self brings about either some kind of mourning, or, at another level of personality organization, more paranoid transferences. I’d not define the time so precisely, but it surely takes time for this part of the treatment to take place.
MS: You can also observe shifts. At some periods of time, the patient functions better and object relations are more clear, but then the patients comes back to his narcissistic defenses. So it alternates for some time.
SD: Yes, it alternates. But it’s important to keep in mind that not all patients with narcissistic traits are truly narcissistic in the sense of the narcissistic personality disorder. So feel free to watch other clinical phenomena that strike you in the realm of aggression or sexuality, in which you can find aspects of grandiosity and devaluation, but you can also find other fields in the patient’s functioning.
MS: What can be problematic, I think, is the very high functioning NPD vs. neurotic patients or, alternatively, other types of highly functioning borderline patients. If you have a very clear-cut case of the NPD, this is usually not a problem to diagnose it, but if you have a very well-functioning patient, in a relatively good marriage, with children, with satisfaction at work, with hobbies, social life etc., but with substantial limitations in experiencing intimacy or with the fragility of self-esteem, that’s a tricky issue, whether it’s the true NPD or something else. Do you think that you can find out the difference between the narcissistic and the non-narcissistic structure only in the actual treatment, or you can be sure already at the level of diagnostic process?
SD: In the diagnostic process you can reach the level on which you’re quite confident that you’re dealing with the true NPD. But I would suggest: don’t look only for the dynamic issues of narcissism, feel free to look for other clinical phenomena, involving other aspects of life, like sexuality, dependency, whatever strikes you in the patient. But, again, remember that the most important issue is to try to define the level of personality functioning . How deeply the patient is adapted to external reality, how profound his relationships are, his commitments, everything belonging to psychic life – values, interests etc. The perspective in which you try to see the depth vs. the superficiality, tells you a lot. In sexuality you have to see how much of the libidinal investment there is in relationship or how much aggressivity invades sexuality.
MS: Now I’d like to ask you about the relationship between psychiatry and TFP. You said earlier that diagnosis in TFP is important, among other reasons, because therapists who are psychologists, and not psychiatrists, have to be able to differentiate among severe forms of illness. But another issue is that there are patients who come to us with a very specific disorder from the Axis I of the DSM, for instance, they suffer from anxiety, depression, OCD, what have you. They come to us and we try to show them that they also have personality problems, difficulties in relationships, but there are many patients who just want to feel better. In supervisions you emphasize that our competence is with relationships and the emotional world, and that we are not so competent in treating specific symptoms. Do you think we should just hand it over to psychiatry and focus on personality issues?
SD: I’d say: up to a point, yes. In the sense, that people doing TFP in the process of diagnosing patients should also know a little bit about psychiatry, at least to a point that if the so-called Axis I is prevailing, it should be treated first. But I think that, first of all, many cases in which a personality disorder is prevailing, are underdiagnosed and underestimated, so the general symptoms of the personality disorder are taken as the specific disorders, say, of anxiety or mood, while this is only the surface. A more detailed interview and inquiry will let us see if the so-called characterological depression is dominant rather than a well-defined major depression or dysthymia. And then we can provide a better differential diagnosis and a better of choice of treatment. Second point is that there is a comorbidity. A patient can be bipolar and have, at the same time, a personality disorder. In those cases, when the first one is not so overwhelming, you can take into consideration both aspects and treat both.
MS: But the issue is about the relationship of symptoms to the personality disorder, isn’t it? In the popular culture we have an image of the protagonist of Woody Allen’s movies, going to analysis for 10 years and still suffering from anxiety. How much can we hope that the treatment of personality will affect symptoms, since we know that attacking the symptoms through interpretation doesn’t help that much?
SD: The approach to the use of interpretation in order to eliminate symptoms has changed first by the advent of ego psychology. It introduced the technical idea of moving from the surface to the depth, which helped clinicians very much. In that discovery lies the richness of ego psychology approach. They recommended attacking rather the major defense mechanisms, activated at the moment. In this approach, in fact, you never interpret symptoms, only defense mechanisms, as in character analysis, but you still hope that by working through the mechanisms, deeper layers of the mental life will be affected in time and, among them, also those which directly influence the major symptoms. There are also approaches, like the more orthodox Kleinian one (which is different from the neo-Kleinian approach), in which psychoanalysts interpret the deep unconscious content from the beginning, especially, the unconscious fantasies about the object, in terms of the protection or the attack on the object in every field of the mental life. And they, naturally, thought that this key would open also the way to treating symptoms. But now the development of our knowledge about the primitive defense mechanisms helped us a lot to understand the difference between the body represented in the mind and the body as split off object in the mind, which is something else. I think that we can help with symptoms in some cases by using the treatments devoted to symptoms resolution. In fact, I don’t see anything strange in suggesting a patient to try a period of one kind of treatment, aimed at the resolution of the symptoms, while, at the same time, undergoing a treatment more oriented towards the deeper layers of the mind. In any case, psychoanalysis felt a little too omnipotent in the last century, but now it’s getting more assertive in what it knows.
MS: I guess the period of the omnipotence started to end in the 60s already. I remember I had a friend who was German, a psychiatrist very much interested in Zen meditation, who, at some point, worked in an institution which combined meditation and psychoanalytic therapy in treating patients with depression. Once she told me that her training analyst told her: “If you want to have analysis with me, you have to give up Zen.” And I heard pretty much the same thing from a friend who was trained in France.
SD: In those earlier years, the analysts wanted to keep the entire life of the patient on the couch, to such an extent that you couldn’t even take antidepressant medication during your analysis, because it would have spoiled the richness of the material produced in sessions by influencing affectivity. I don’t think, though, this is the case anymore.
MS: Now, we are on the other end of the spectrum, trying to combine different kinds of treatment – you can be in the TFP therapy and, at the same time, undergoing couple therapy, sexual therapy, substance abuse therapy etc.
SD: And there is a rationale for that. I think combining treatments really helps. Our idea of the patient has changed. In psychoanalysis, a human being becomes a patient as soon as he enters a consulting room. The treatment just starts. Now, he can become a patient only when he has the motivation for therapy, accepts the conditions and constraints of the setting, agrees to the therapeutic contract. So the patient now is defined as the human being who accepts and knows the borders of treatment – this is the moment when he becomes the patient. That’s why I also think that the usefulness of psychoanalysis has to be reconsidered. The psychoanalytic concepts of the mind, the theories of the depressive and paranoid position, transitional object and so on, can be nice keys to thinking about cultural phenomena, but, frankly speaking, I think they are not the only one. The movements of the masses are better understood in terms of unconscious motivations, but there is more than that. And those psychoanalytic concepts are most useful in the clinical setting. I tend to see our theoretical models mainly as a useful and complete, remarkable complete, theory within clinical science.
MS: So the psychoanalytic theory is best limited to the therapeutic work?
SD: You can use it for understanding social phenomena, but this is not the key to them. It’s just one of the keys.
MS: Speaking of how psychoanalysis mourns over the loss of its omnipotence, what I find interesting is the way Eve Caligor writes about the higher level pathology patients. She says we need to give up the idea of analyzing the whole personality to focus on the problems with which the patient came to treatment and which are defined in the therapeutic contracts. We try to cure certain areas of the patient’s personality, but we have to accept that there will remain certain conflicts or pathological aspects, which we don’t touch, because we don’t do a total analysis. It’s rather a psychoanalytic psychotherapy, which treats what the patient wants to change in himself.
SD: I think it’s very important, but I’m not so sure that this is what we really do. We don’t simply give up the rest. To me, TFP just deals with the major conflicts as they appear in treatment, but once you deal with the major conflicts and you solve them, then it’s inevitable that other areas, in which there are different conflicts, will come up, because the patient has done a real psychanalytic or psychodynamic work. I think that the patient after some time gets so used to this kind of therapy that he continues the work and, naturally, goes deeper, like in usual psychoanalysis. This is, at least, what I see in my practice. But at the beginning of the treatment we do have a different approach than in the standard analysis and more than in such psychoanalysis do we tend to apply a rigorous method. The method for us is very important.
MS: In supervision sometimes you mention the existence of two approaches within broadly conceived TFP approach. One is a more interpretive, confrontative, more direct, more intellectual, while the other one – more experiential, more based on a kind of waiting openness to what comes next and on proceeding more slowly. Would you tell us more about those two paths?
SD: It’s the question of placing accents, again. These are both aspects implicit in object relation theory. The experience of the relationship is one aspect and the interpretation of it is another. All depends on how you put those two together and, in a sense, it creates your identity as a therapist. It is important to keep in mind that if you are more inclined to interpret and put into words as soon as you can an object relationship, or, on the other side, if you like a little bit intersubjective approach, even to the point that the material in the session can be seen as co-created by both the therapist and the patient, it makes no difference. You can always and should always meet at some point. Some people are more, by nature, inclined to foster relationship, they are more at ease in waiting for the issues of transference and countertransference to become solid. Others understand those phenomena better, quicker, because they are trained to do so, so they are more inclined to systematic clarification, confrontation and interpretation. But we use both of those approaches. And you can taste the difference in different supervisors. Some are very close to verbal nuances, deal a lot with observing the countertransference and allow things to develop. Others are interested in structuring and providing interpretations. But both types are focused on bringing attention to dominant themes, dominant affects, because it’s the most important things to start with. As long as you stay on the dominant affect you get the dyad activated.
MS: This experiential approach, as you call it, seems to be connected to some of the authors you had mentioned earlier, like Winnicott, interpersonal psychoanalysts and, I guess, also to Bion and Ogden. The followers of the latter two authors sometimes say something like: you don’t have to talk about something with your patient, it’s enough that you think about it and process it. But in TFP it’s clearly not enough to think, you have to name things.
SD: Yes, you have to name the dyads. The great contribution of the American TFP group is that they brought in a new concept of interpretation. I mean what was described in the 2009 paper by Caligor, Diamond, Yeomans and Kernberg about the interpretive process in the psychoanalytic psychotherapy. Interpretation is not an act, it’s a process. Clarification is one aspect of it, confrontation another. And there are different levels of interpretation. You don’t simply shed light on the unconscious of the patient so that he could experience insight. But here it’s a little different. It’s not that we put in words some new information and in such a way enlighten the patient about his unconscious. We rather bring the awareness of the dyad into his consciousness and that awareness will bring more knowledge in time and will allow us to introduce more clarification in turn. And more clarification will shed some more light on the previously unconscious issues – and so on. But I think it’s a step by step kind of work more than it used to be.
MS: So for you, the distinction we’re discussing right now, it’s mostly the question of a personal style and the character of a therapist?
SD: Yes, personal style. Our training will let us avoid falling into a stereotype of a silent, cold psychotherapist, who gives intellectual interpretations or into another stereotype of a good enough Winnicottian mother-analyst, holding the patient etc. In the middle between those two stereotypes, there is a position in which you use the same kind of technique, based on the four technical principles that dr Kernberg summarized. The crucial question is how to follow the process of interpretation in the actual clinical work and this is a real process in which the interaction with the patient and our countertransference are very important. I think that has been the major achievement of TFP model in comparison to other psychoanalytically inspired treatments.
MS: What is also interesting to me, is how different TFP supervisors use the session material provided by their supervisees differently. I remember when Stephan Doering was supervising in Cracow in 2018, he proposed a sort of a hierarchical model of the way you present the case. First, as it used to be at the beginning, the supervisee describes the patient in his own words and maybe describes a single session, but based on his memory of it. The second level would be recording the session and providing a transcript of that recording, which is a more objectified picture of the session. The next level would be playing the audio recording to the supervisor, so that he could hear the voice and have more access to the non-verbal channel. And the best form of supervision, according to this model, would be playing a video recording in which the supervisor would not only hear the words and the tone of voice, but also see the therapeutic couple. While working with you in a supervision training group, I came to appreciate more the use of the transcript, when I see how you handle it. You can pay more attention to the nuances and you can take some time in analyzing the interaction between the patient and the therapist. This is impossible if you only listen or watch a video, because the interaction goes to fast.
SD: I’m interested in both: the forest and the trees. When I ask you all: please, tell me about this patient, what is the phase of the treatment right now, I ask you to give me a general view of what is going on. This enables you to detach from the moment to moment exchange with the patient and it helps me to understand, where you are and where you are heading to in the course of treatment. Then I’m very interested in what we call the microprocess and we can access it by audio or video recording and a transcript. And then I listen to audio or watch the video. The sequence of the passages in the transcript help me to observe the channels of communication, the movement of the session, the atmosphere. But I have to see also how the patient behaves and all the ingredients of the interaction, but my main aim is to see how the process is going. I remember what dr Kernberg said once in a supervision. I don’t remember if I presented or some of my colleagues did, I don’t remember the patient, the session, I don’t remember anything about it. But I do remember one comment made by dr Kernberg. He said something like: “It was a good session, because you were quite flexible and you were connected.” For me this became a mantra. I tried to explore what it means to be flexible and connected in the next supervision and tried to understand it, but I have never asked about it. Rather, I attempted to understand the concept by listening to him work. And I think I know now what he meant. It is quite difficult to explain it in words, but if I tell you that I saw that you are flexible and connected in a session, you will understand me. Even if I would follow a different path in this session than you did, I could tell you that you were connected to the patient or I could say: “you lost the connection there”. The borderline patients have terrible troubles in being connected, so it is crucial that our quality of character should include this capacity to stay connected and to regain this connection when we lose it. This is where our TFP manual cannot go. We need supervision for that.
MS: I like this approach very much because it liberates us from what is often a problem at the beginning, I mean the fixation on “did I say the right comment or a wrong one? Was it correct? Maybe I should say something else or shut up?” In such a case, we fixate on one piece of the process as if it were frozen in our mind and you, as far as I understand, try to say: “Forget about that single piece and look at the whole process in its movement, look at the whole flow of interaction.” From this perspective, you are free to say something “wrong”, but what matters is what comes next and how you handle this later.
SD: The flow means that what is going on now is connected to what was going on before and what will come next. There is a risk in analyzing a transcript of the session, which is that the supervisee waits for a “right” or “wrong” mark from the supervisor. The patients says this, I said this – was it correct? Of course, if we stay on the exchanges between the therapist and the patient, the first thing that comes to your mind is: was it right or was it wrong? And we do have a manual, but our manual is really more than just a book. Following the transcript in the supervision can help the supervisee to see and understand the path he took and to see where the patient went after he took the path he took. But this all happens within the general model, the setting, the contract, the whole structure of the treatment. And yet the quintessential truth of TFP is the exploration of the microprocess and the process is here and now. As Betty Joseph said: we are in the here and now, but the problem is that the here and now is very short in space and time. So our job is to catch this here and now and we miss it many times, but the good news is that we always have many occasions to catch it again. If we could catch the here now every time, our therapies would last a very short time. Since it is as it is, we need a lot of time.
MS: I think this approach is very supportive of the therapist. It seems to provide good holding for the therapist, because makes us more confident in our intuition, experience, and the fact that we know the patient. Sometimes we say things we shouldn’t say, but it’s, like you said, a living relationship. Supervision gives us new light on that and opens up a new space to work, but it’s ultimately not about: “you said it wrong, correct it and come back next time”.
SD: In such a case, the TFP manual would become a bad object. The manual would be hitting you in the head every time you said something wrong to the patient. And you cannot be flexible and connected, if the manual is an object like that. But if you allow the process to go on and if you know that you can always move in different directions, then manual becomes a great help and you can use it as a friend, not as an enemy or a terrible judge.
MS: Our patients sometimes ask us: “What should I say to my wife to make our relationship better? What do I say wrong?” In such a case, we obviously have no idea what to say to them, because there is no formula you could write down for your patient, give it to him and charge him for it some extra money. In such situations, we realize that it’s so much more, that it’s the whole dynamic interaction that is the problem.
SD: I’ll give you an example. A supervisee brings the patient, almost psychotic one. The relationship has been always very difficult, the patient being overwhelmed by the presence of the therapist, not able to think freely, always anguished, scared, reacting with long silences, having little freedom to talk. So the therapist was also overwhelmed by the atmosphere of the sessions. When I was listening to this presentation, I thought it was a symbiotic transference. And the supervision takes place now, when there is the pandemic, so the therapist and the patient can’t meet face to face and the patient has to accept Skype. At the very first session via Skype, the therapist was astonished, because her patient was free, was talking without any problem on exactly the same topics on which she couldn’t talk freely before. The patient seemed very relaxed, sharing how she was afraid in her relationships that her private space would be invaded by the other person and she couldn’t tolerate this. Towards the end of the session, the supervisee said to the patient: “It’s very different today, the way you talk”. She didn’t explore this much, she tried to put it in theoretical terms, saying that the patient is able to think more freely about those issues which she previously couldn’t etc. But even if the therapist was very tactful, the patient quite quickly went back to her old style. She kept asking questions like she used to when they were meeting face to face and so on. So my supervisee was disillusioned, sad and frustrated. She said to me: “I thought we could’ve reached a better kind of exchange and now, after my intervention, everything broke off.” But I didn’t think so and I told her that the patient went back into her old style, because you got in touch with her via Skype. She went back into her old mode at the very minute of the session that you brought something in. And her defense was asking you questions. So the supervisee asked me in turn: “Should I have answered her question?” No, but you could tell her that she repeated what she did, when you were meeting face to face, and that she did that precisely at the moment, when you mentioned her new way of being with you.
MS: Thank you very much for this conversation.
SD: Thank you.