Transference-Focused Psychotherapy (TFP)
Our approach to personality disorder treatment and research is based on the understanding of personality disorders in general and BPD in specific that is described in our Overview section of this website. Transference-Focused Psychotherapy is grounded in contemporary psychoanalytic theory since we believe that psychoanalytic thinking has much to offer in terms of understanding and treating personality disorders. However, our approach includes specific modifications of technique to address the therapeutic needs of patients with borderline and other personality disorders. Our patients do not lie on the couch, do not come to see us four or five times per week, and we, the therapists, are far from silent and removed from the process. Two beliefs that inform our work, that we share with most other psychoanalysts, and that distinguish our work from that of say, a cognitive-behavioral therapy (for example, Dialectical Behavior Therapy [DBT], another treatment for BPD) are that:
- "Symptoms," the observable, behavioral manifestations of any disorder, are explained significantly by internal, mental or emotional factors, not generally visible to the naked eye, and that attention to these internal emotional factors or states is an essential part of the treatment process; and
- Over the course of a psychotherapy, some of the emotional factors that influence the problematic behaviors or symptoms and that had previously been unclear to the patient and therapist become clear to both through their mutual, careful attention to the goings on in the treatment relationship, which includes the transference of images within the patient's mind, which they may not be fully aware of, to the person of the therapist (and others in their life). So with this overview, let us now proceed to build on our understanding of personality disorders to explain how we conceptualize treatment.
Within the International Society for Transference-Focused Psychotherapy, one of the more challenging aspects of our work, as therapists specializing in the treatment of personality disorders, is the process of sharing with patients our impression of their diagnosis, and outlining for them the type of treatment we are proposing. Albeit difficult, this process is an essential, and legally required aspect of the process of starting treatment, called "informed consent." Generally, we start with an explanation of the term: Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person's subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships.
We explain that, while the world is enriched by the variety of personality styles that exist, when a person personifies and lives out a particular personality style in an extreme and inflexible way that causes a certain level of distress in one's emotional and interpersonal life, they meet criteria for a personality disorder. We find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones). We also, in reviewing the particular symptoms of BPD that we have noted in the diagnostic phase we have just completed with the patient, note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more "under the radar," characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms and we inquire as to whether this understanding makes sense to the patient.
With this understanding of personality disorders and BPD described in another section of this website, our treatment model, Transference-focused Psychotherapy (TFP), logically follows. This twice-per-week individual psychotherapy combines many of the elements described in the Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association with a deep understanding of mental processes. TFP has demonstrated efficacy across two randomized clinical trials to date in the treatment of the symptoms of BPD. In contrast to other models of treatment, models that tend to focus on reducing symptoms through behavioral control, skill-based teaching, and overt therapist support, coaching, and guidance, TFP has a very different mechanism of action. Although TFP, like other models, places special emphasis on patient assessment / evaluation, and on setting up a treatment contract (a mutually agreed upon set of conditions that serve as a framework for the work of the treatment), the emphasis in TFP is on helping patients understand the shifts in their experience of themselves, and in their experience of others, as this split sense of identity plays out through their experiences in work and relationships, and, importantly, as it plays out in the treatment relationship itself.
The work of TFP is roughly divided into an initial phase of establishing a structure for the treatment that includes limit-setting with respect to the patient's destructive behaviors and a longer phase of exploration of the patient's mind and sense of identity. In reality, the two phases overlap since there is observation and exploration from the beginning, and limit-setting may continue far into the treatment.
After confirming the patient's diagnosis, the therapist and patient work to identify factors in the patient's life that might interfere with the consistency and conduct of the treatment. Factors such as drug abuse or addition, chronic misuse of medication, a severe eating disorder, and self-injury and suicidality - each of these factors constitute not only a threat to the patient's safety and well-being, but also to the treatment, and therefore, must be contained in order for the therapist and patient to do the work of TFP. Whereas some therapies work to provide concrete support in the moment that the patient is about to engage in one of these behaviors, TFP works differently. In TFP, we presume that the patient can largely take responsibility for these behaviors, at times with the help of adjunctive treatment such as Alcoholics Anonymous or an eating disorders support group, and in other cases simply through an agreement about how suicidality and self-injury are to be managed, with the understanding that the patient is in conflict about these urges and can try to stay with and strengthen the side that wants to refrain from the behavior.
As behavioral symptoms of personality disorder are contained through the discussion of and limit setting associated with the treatment contract, the psychological structure that is believed to be the core of the disorder is observed and understood as it unfolds in the transference, i.e., the relation with the therapist as perceived by the patient. The focus of treatment is on the patient's difficulties tolerating and integrating disparate images of the self and of others and on the misunderstandings that arise when the patient mistakenly sees aspects of his/her own feelings that are difficult to acknowledge as coming from the other person.
While we call our treatment Transference-Focused Psychotherapy because of the centrality of the exploration of the patient's experience of self and others through observation of the patient's experience of the therapy and the therapist, the treatment also focuses on the patient's difficulties in work and relationships outside the treatment. These areas are important in the exploration of the experience of self, others, and relation to the world. These areas are also where, along with improvement in the patient's sense of self, we will see the benefits of treatment. Nevertheless, the therapist's attention is ultimately directed to transference because we believe that observation of the patient's moment-to-moment experience of the therapist provides the most direct access to understanding the make-up of the patient's internal world. As the un-integrated representations of self and other get played out in the patient's life and in the treatment relationship itself - often accompanied by the intense experience of emotion - the therapist helps the patient contain the emotions and observe the representations and understand the reasons, the wishes, fears and anxieties that support the continued separation of these fragmented senses of self and other. The therapist also helps the patient to observe shifts in the dominant self experience, using therapeutic techniques that include 1) clarification of internal states, 2) confrontation of contradictions that are observed, and 3) interpretation that help explain the divisions and links between different states.
For example, when a meek and unassuming patient suddenly shifts into an overtly dissatisfied or hostile stance, the therapist might start by inquiring: "Have you noticed a shift in your feelings?" The therapist might continue: "Let's see if we can understand what you were experiencing in me as your feeling in the room shifted, and how the way you were experiencing yourself also shifted at that moment." Through this type of "detective" work (we sometimes use the image of the TV detective Colombo who calmly and quietly explored the evidence), we can begin to flesh out the patient's inner world of representations of self and other, to track the shift, usually a volatile and chaotic shift, between the patient's various self states, and ultimately help them to reach a more reflective stance about his or her emotional life – the fundamental goal of the treatment is to help the patient learn to reflect on emotional states that were previously not understood and were acted upon without reflection. The combination of understanding within the context of emotional experience can lead to the integration of the split-off representations and the creation of an integrated sense of the patient's identity and experience of others. This integrated psychological state translates into a decrease in emotional turbulence, impulsivity and interpersonal chaos, and the ability to proceed with effective choices in work and relationships. In other words, there is a positive cycle in which understanding of one's representational and emotional world leads to an increased ability to modulate emotions and, in turn, the enhanced modulation of emotions helps the patient further increase his or her capacity to reflect and understand.
Ultimately, our experience is that the integration of the initially fragmented psychological structure can result in the resolution of the personality disorder and help establish stable and deep relationships and commitments to work and other life activities.
By Barry Stern, PhD
Frank Yeomans, MD, PhD