Transference-focused psychotherapy (TFP) is a manualized, empirically supported, outpatient psychotherapy designed specifically to treat patients with severe personality disorders, such as borderline personality and narcissistic personality disorders. TFP was developed by Otto Kernberg and his colleagues, most notably Frank Yeomans and John Clarkin, at the Personality Disorders Institute at Cornell University’s Weill Medical College, who modified standard exploratory psychodynamic psychotherapy to conform to the developmental psychopathology and clinical needs of those with severe personality disorders (Yeomans et al. 2015). The efficacy of TFP has been demonstrated in several studies, both with regard to symptom change and change in personality. Based on these studies, a number of treatment guidelines and reviews, including the Society of Clinical Psychology Committee on Science and Practice, the United Kingdom’s National Institute for Health and Care Excellence guidelines, the Cochrane Collaboration reviews, and the Netherlands’ Multidisciplinary Directive for Personality Disorders, now recognize TFP as one of the “big four” psychotherapies for treating borderline personality disorder (BPD). The following entry describes the goals of TFP, its indications, underlying theory, and its general structure and techniques. It also summarizes the existing empirical support regarding symptom and personality change in TFP.
Goals of TFP
The broad goals of TFP are better behavioral control, less impulsivity, increased affect regulation, a greater capacity for intimacy and satisfaction in relationships, and the ability to achieve satisfactory life goals that are consistent with one’s capacities and interests. More specific goals include a reduction in the symptoms associated with BPD, most notably suicidality, parasuicidality, hostility, and angry outbursts. Reductions in these areas of dysfunction lead to a corresponding reduction in emergency room visits, hospitalizations, and relationship difficulties with social supports. The symptom change is hypothesized to occur through the integration of disparate, contradictory, and incoherent internal mental representations of self and others. Central to the TFP conceptualization is that BPD results from a failure to develop complex and realistic internal representations of self and others that characterize mature psychological development. These fragmented representations interfere with the patient’s capacity to reflect on interactions with others as well one’s own beliefs and to behave in a thoughtful and consistent goal-directed manner. Additionally, this lack of integration leads to fluctuations between extreme positive and negative affect that impairs an individual’s perception of day-to-day interactions, often distorting these in a way consonant with extreme “black and white thinking.” This lack of a complex and coherent sense of self and others is referred to as identity diffusion and is similar to identity disturbance described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). From a TFP perspective, identity diffusion is believed to be the basis for the emotion affect dysregulation experienced by individuals with BPD. Thus, the treatment is geared toward the integration of one’s sense of self, one’s sense of others, and the associated affect states. This integration is believed to lead to representational and affective experiences becoming more nuanced, enriched, and modulated. The increased differentiation and integration of these internal representations allow patients with BPD to think more flexibly and benevolently about their therapists, significant others, and themselves. In the TFP model, the integration of these internal representations is achieved by observing, exploring, and containing the patient’s disparate experiences of self and others, but particularly of the therapist.
Structure and Techniques of TFP Treatment
TFP is conceptualized as a twice weekly individual outpatient form of psychotherapy. Consistent with most treatments for severe personality disorders, TFP is a long-term treatment lasting at least 12–18 months, administered by qualified therapists that are trained and certified through the International Society for TFP (ISTFP).
TFP is suitable for outpatients with a Section II DSM-5 diagnosis of BPD, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, and antisocial personality disorder (in some cases). For patients with traits of the above disorders from the DSM-5 alternative model of personality function (AMPF), TFP is suitable for severities above 0 (little or no impairment) ranging from Level 1 (some impairment) to Level 4 (Extreme Impairment) with the following personality disorder types: borderline, narcissistic, antisocial, schizotypal, and avoidant. These personality disorders have in common an underlying borderline personality organization or personality structure that is characterized by disturbed identity, largely intact reality testing that can become impaired under severe stress, and a tendency for “black and white” thinking and feeling (splitting) as the principal defense against intense emotions. Those with obsessive-compulsive personality disorder and low level severity are conceptualized at a neurotic level of organization and as such are probably best treated with a modified version of TFP designed for those with higher level of personality pathology (Caligor et al. 2007).
Clinical writers are also exploring how TFP can be modified for patients with a complex posttraumatic stress disorder or dissociative disorders and for working with children and adolescents (e.g., Draijer and Van Zon 2013).
Theory Underlying TFP
TFP views those with borderline personality structures as lacking complex and realistic internal representations of self and others that characterize mature psychological development (i.e., identity diffusion; Kernberg 1984). Fragmented and polarized (“all good” or “all bad”) representations of self and others are thought to underlie extreme fluctuations between positive and negative emotions, which in turn, impair an individual’s interpretation of day-to-day interactions.
Integration of these representations is achieved through observing, tolerating, exploring, and working through the patient’s disparate experiences of the therapist in sessions, resulting in increased awareness and understanding of the fragmentation. With successful treatment, the internal representation of self and other become increasingly differentiated and integrated, in a way that allows patients to have a more positive and flexible view of significant others and themselves. Consequently, the emotional experiences that are associated with those representations become more enriched and modulated and patients develop richer and more harmonious relationships with significant others. At the same time, reductions in self-destructive behaviors and symptoms, and improvements in functioning facilitate increased intimacy and independence.
Structure, Strategies, and Techniques
Assessment. Using semistructured and structured interviews, the therapist establishes the patient’s diagnoses, difficulties, and life structure. An initial case conceptualization is formulated and the patient is provided with feedback regarding their diagnosis and regarding an understanding of their challenges and psychological structure (ways of perceiving self and others).
Establishment of a treatment frame. The therapist and patient collaboratively set treatment goals that are as specific and attainable as possible, encompassing issues of work, responsibility, interpersonal relations, and leisure. A treatment frame is established that articulates the therapist and patient’s roles and responsibilities in the treatment. The patient’s responsibilities typically include attending to sessions regularly, working toward the treatment goals, reducing self-destructive behaviors, making an effort to report thoughts and feelings freely without censoring, and making an effort to reflect on those thoughts and feelings, as well as on the therapist’s comments.
The active phase of treatment. The therapist addresses themes according to the following hierarchy of priorities: (a) addressing threats to the safety of the patient, of the therapist, or of the treatment (such as suicidal behaviors or treatment-interfering behaviors); (b) understanding the internal world of the patient as it is manifested in the relationship with the therapist (“transference”); (c) addressing other affect-laden material that is not directly related to the relationship with the therapist.
In sessions, the focus of treatment is on the dominant relational patterns as they are experienced and expressed in the present relationship with the therapist. The therapist follows the patient’s affect and helps explicate their experience, with special attention to contradictions and aspects of the patient’s experience of which they are unaware. In a typical sequence of interventions that may span over several sessions (Caligor et al. 2009), the therapist starts by assisting the patient in clarifying the patient’s subjective experience. The therapist then tactfully points out discrepancies between what the patient is saying, doing, or expressing nonverbally, and asks for the patient’s reflections on those discrepancies. Then, the therapist utilizes timely, clear, and tactful interpretations of the themes and enactments in the relationship with the therapist. These interpretations typically address the patient’s hypothesized motivation in maintaining those discrepancies and fragmented representations of self and others. These motivations may include, for example, attempts to defend positive aspects of self and others by splitting them from negative ones. The goal is to facilitate awareness and acceptance of representations of self and others and of emotional states that were previously experienced as intolerable and pushed out of awareness. This process results in increased reflection ability, more integrated and benign perception of self and others, and improved intimate relationships.
In addition to a number of pre-post studies, TFP’s efficacy in patients with BPD has been demonstrated in three independent, international randomized controlled trials (RCTs).
In the first RCT (Clarkin et al. 2007), TFP was compared to both dialectical behavioral therapy (DBT) and a supportive form of psychodynamic therapy. Whereas all of the treatments were efficacious in domains such as depression, anxiety, functioning and adjustment, TFP led to a more consistent change in a larger number of symptom domains, and especially anger and aggression. In the second study (Doering et al. 2010), TFP was compared to treatment by therapists who were experienced in using a range of other therapies to treat patients with BPD. In this study, TFP was superior in reducing suicide attempts and psychiatric admissions, and also had a lower rate of dropout. In addition, TFP was superior in improvements in the borderline symptoms, psychosocial functioning, and personality organization. Both groups improved similarly in depression and anxiety, and self-harming behavior did not change in either group.
In another RCT (Giesen-Bloo et al. 2006), TFP was compared with schema therapy (ST). Both methods were efficacious with large effect sizes. ST in this study showed better results in the intent-to-treat analyses, due mainly to the difference in dropout rates. In addition, the randomization had failed, as patients in the TFP group were more self-destructive on average than those in the ST group and, therefore, more seriously ill in a manner that is related to worse outcome. Based on these studies, the Society of Clinical Psychology, Science and Practice committee concluded that TFP is a treatment with strong evidence.
Changes in Personality
In addition to symptom change, TFP focuses on personality change. Personality change is particularly important for disorders in which the central problems are conceptualized as rooted in personality proper, such as personality disorders. Despite this, personality change has rarely been examined as an outcome in psychotherapy research. TFP is unique in that personality change is one area of functioning in which TFP has consistently demonstrated specific benefits. In two of the RCTs mentioned above and in a pre-post study (Diamond et al. 2003; Fischer-Kern et al. 2015; Levy et al. 2006), significant increase in attachment security and mentalizing (the ability to make sense of one’s and others’ mental states) was found only in TFP but not in control conditions. Of note, of the patients that were classified as insecurely attached at the beginning of treatment, 29% were classified as securely attached at the end of TFP, compared to none of the patients in the control conditions. These findings suggest improved relational patterns as well as increased insight among patients into themselves and their relationships with other people. These results are potentially important because changes in personality are believed to be associated with lasting changes in terms of coping better with self, others, and major life challenges of love and work.
TFP is an empirically supported psychodynamic psychotherapy for patients with various personality disorders, and especially BPD. TFP focuses on consolidation of identity, increased emotion regulation, and improved relationships. These changes are achieved through exploring and working through the patient’s fragmented and disparate experiences of the self and others (and especially the therapist), resulting in increased awareness and understanding of the fragmentation. The efficacy of TFP for BPD has been empirically demonstrated in several studies so far, showing consistent changes in broad symptom domains of BPD, as well as personality changes such as attachment security and mentalizing capacity.
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