Transcript No Slide Title

April 2008
Transference-Focused Psychotherapy:
An Evidence-based Psychodynamic
Therapy for BPD
Frank E. Yeomans, MD, PhD
PERSONALITY DISORDERS INSTITUTE and
BPD RESOURCE CENTER
Weill Medical College of Cornell University
Director: Otto Kernberg, MD
Co-Director: John Clarkin, PhD
 Ann Appelbaum
 Paulina Kernberg
 Eve Caligor
 Kay Haran
 Monica Carsky
 Mark Lenzenweger
 John Clarkin
 Ken Levy
 Ken Critchfield
 Armand Loranger
 Jill Delaney
 Michael Posner
 Diana Diamond
 David Silbersweig
 Pamela Foelsch
 Michael Stone
 Otto Kernberg
 Frank Yeomans
What is Transference Focused
Psychotherapy (TFP)?
The first manualized psychodynamic treatment
for borderline personality disorder
What is “psychodynamic”?
- A view of the mind as constantly in flux with
conflicts between opposing urges and
inhibitions/prohibitions
- Understanding these conflicts within the
mind as underlying symptoms, in contrast to
seeing a symptom as an “objectified problem”
TFP…(cont’d)

Why bother working at this level?



To achieve both symptom change and change in
psychological structure
To improve reflective functioning
To promote psychological integration to achieve
satisfaction in love and work… a “full” life
Characteristics of Transference
Focused Psychotherapy (TFP)
 Treatment structured by contract setting
 Two sessions per week in an outpatient
setting
 Treatment duration is one year minimum
 Focuses on the immediate interaction
between patient and therapist
 Can be augmented with auxiliary treatments
 Can include periodic contact with family
Who Is TFP For?
Patients with symptoms of depression, anxiety, difficulty
with interpersonal relations, destructive acting out
and/or lack of fulfillment in life that are rooted in
personality disorders (chronic maladaptive
personality patterns)
FIGURE 2
Continuities and clinically relevant relationships among the personality disorders.
Gray lines indicate clinically relevant relationships among disorders.
Borderline Personality Organization:
Defining Psychological Characteristics
 Identity Diffusion. Sense of self and others is:
 Split
and fragmented
 Distorted and superficial
 This leads to:
Difficulty “reading” others… and self
 Sense of emptiness; lack of continuity in
time.
 Primitive Defenses – especially projecting
negative aspects of self to try to avoid anxiety
 Variable reality testing (distortions)

BPO: Clinical Characteristics
The lack of integrated identity underlies:
 Intense affects
 Disturbed interpersonal relations

Difficulty with sexual functioning (“all or
nothing”)
 Self-destructive actions (BPD)
 Emptiness/hollowness (BPD and NPD)
 Moral rigidity or absence of moral code
 Difficulty with commitments to love and work
Goals and objectives of TFP
for BPD
 Phase I: The containment of self destructive
behaviors
 Phase II: Core of the treatment - the
resolution of identity diffusion and the
development of a coherent sense of self and
others

this is done through fostering reflection on
mental states of self and other; - through
exploration of feelings, motivations, & beliefs
in the context of therapeutic relationship
Theoretical Underpinnings of TFP:
Object Relations Theory
Focus of here and now interaction
Self
Affects
The Self-Other Dyad
Other
Dyads as Building Blocks
 The individual identifies with the entire
relationship dyad, not just with the selfrepresentation or the object representation
 The dyad exists within the individual and it’s
basic impact is on how the individual relates
to him/herself, although it regularly gets
played out between self and others
 Dyads of similar affective charge aggregate
together in the mind
Split Organization:
Normal (Integrated) Organization:
Consciousness of Integration/complexity
Evolution of treatment
From the Split Organization (Paranoid-schizoid
position) to the Integrated Organization
(Depressive position)
This is accomplished by: Integrating split and
projected aspects of self
-----------------------------------------Why the focus on the transference (the patient’s
experience of his/her relationship with the
therapist)?
Patient’s Internal World
S1
S = Self-Representation
O = Object - Representation
a = Affect
a1
O1
Examples
S1 = Weak mistreated figure
O1 = Harsh authority figure
a 1 = Fear
S2 = Childish-dependent figure
O2 = Ideal, giving figure
a2 = Love
S3 = Powerful, controlling figure
O3 = paralyzed, controlled figure
a3 = Wrath
S2
.
a2
O2
O3
a3
S3
Etc.
TRANSFERENCE,
and the power of Internal World
over External Reality
 …and of Therapist
 Experience of Self
a1
S1
S1
O1
S2
S2
S3
S3
a2
a3
O2
O3
OBJECT RELATION DYAD INTERACTIONS: OSCILLATION
Object Rep
Self-Rep
Fear, Suspicion, Hate
Persecutor
Victim
Fear, Suspicion, Hate
Persecutor
Victim
(Oscillation is usually in behavior, not in consciousness)
OBJECT RELATION DYAD INTERACTIONS:
ONE DYAD DEFENDING AGAINST ANOTHER
Fear, Suspicion, Hate
Abuser
Opposites
Victim
Longing, Love
Dependent
Child
Gratifying Provider
The Relationship of Strategies, Tactics and Techniques in TFP
STRATEGIES
Long-Term Objectives
TACTICS: Tasks
for each Session that
set the conditions for
Techniques
TECHNIQUE:
Consistent
interventions that
address what
happens from
Moment-to-Moment
Understanding Interpretation
 Interpretation is attuned to the here-and-now
experience of the patient
 Interpretation with borderline patients
depends strongly on the what is not on the
surface in the moment but that is known from
other moments or from non-verbal
communication or countertransference
 Interpretation takes the patient one step
beyond her/her current level of awareness
Steps of Interpretation - I
 Understand/Identify self state in the moment
(first level of mentalization)
 Elaborate understanding of the therapist
 Consider therapist’s/other’s experience of the
moment, and that it may be different from the
patient’s
 If necessary, offer the patient a version of
how the therapist experiences the moment
Steps of Interpretation - II
 Contrast the immediate experience of self
and of therapist with that seen through other
channels or at other times (second level of
mentalization - address splits/conflicts)
 Consider reasons for splits
 Put the above in the context of other relations
When there is Oscillation in the dyad:
elaborating the second level of mentalization
 Observe
 Engage the patient’s observation
 Interpretive process
 “You see yourself/feel ‘x’ (the victim of my cruelty)”
 “You experience me ‘y’ (cruel and uncaring)”
 “If you see me that way, it would make sense…”
 “However, is there any evidence that things could be
otherwise?... That you might be acting ‘y’ (cruel and
attacking?”
 “It’s hard to see/accept that in yourself…”
 “We agree on the affect, but not on its source”
 “If you can acknowledge it, you’re in a position to
control and master it.”
Interpreting the Split
 “So, every time a positive feeling develops
here, we see it quickly turn negative – into
fear, suspicion, anger, even attack. Then the
world seems more in order. It’s disappointing,
but safe. But I’d still suggesting thinking about
your conviction that I’ll hurt you… maybe it’s
based not just on past experience, but on
assuming that my reactions can be just as
stormy and intense as what you feel inside.”
Beyond Symptom Change:
Increased Integration and Differentiation of
sense of Self and Others
 Impaired representations
become transformed through
interpretation, reflection, and
new experiences
 More realistic representations
can be integrated
 Ability to think more flexibly
and benevolently
 Life and Relationships:




A proxy for the above might be
mentalization/reflective
functioning

reduction in selfdestructive behaviors,
less acting out of
aggression aggression is owned
and managed
greater capacity for
intimacy,
increased coherence of
identity,
general improvement in
functioning
Empirical Support for Efficacy of TFP
in 3 Studies
 Study 1: Patients as own controls
17 patients who completed one year of TFP; functioning during
treatment year compared with functioning during year prior
(Clarkin, Foelsch, Levy, Hull, Delaney & Kernberg, 2001, Journal of Personality
Disorders)
 Study 2: TFP compared to TAU
26 patients who completed TFP treatment compared with 17
subjects who had been evaluated for the same treatment but
who did not enter into TFP Treatment. (Levy, Clarkin & Kernberg, in
review)
 Study 3: Randomized Controlled Trial (RCT)
90 patients in three manualized treatments:
TFP, DBT and Supportive Treatment (Clarkin, Levy, Lenzweger &
Kernberg, 2007, American Journal of Psychiatry; Levy, Meehan, Kelly,
Reynoso, Clarkin Lenzenweger & Kernberg, 2006, Jounal of Consulting and
Clinical Psychology)
Funding from the Borderline Personality Disorder Research Foundation
Articles and Books related to TFP - page 1
Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for Borderline Personality:
Focusing on Object Relations. Washington: American Psychiatric
Press (2006).
Clarkin, J.F., Levy, K.N., Lenzenweger, M.F., & Kernberg, O.F. (2007).
Evaluating three treatments for borderline personality disorder: a multiwave
American Journal of Psychiatry, 164, 922-928.
study.
Levy, K. N.; Meehan, K. B.; Kelly, K.M.; Reynoso, J. S.; Clarkin, J. F.; Lenzenweger,
M. F.; & Kernberg, O. F. (2006). Change in attachment and
reflective function in the
treatment of borderline personality disorder with
transference focused
psychotherapy. Journal of Consulting and Clinical Psychology 74:1027-1040.
Article and Books related to TFP – page 2
Levy KL, Clarkin JF, Yeomans FE, Scott LN, Wasserman RH, Kernberg,
OF: The Mechanisms of Change in the Treatment of Borderline
Personality Disorder with Transference Focused Psychotherapy.
Journal of Clinical Psychology , 62(4), 481-502 (2006).
Silbersweig D, Clarkin JF, Goldstein M, et al: Failure of Frontolimbic
Inhibitory Function in the Context of Negative Emotion in Borderline
Personality Disorder. American Journal of Psychiatry, 164(12), 18321841 (2007)
Yeomans FE, Clarkin JF, Kernberg OF. A Primer on TransferenceFocused Psychotherapy for Borderline Patients. Northvale, NJ: Jason
Aronson (2002).