Transference-Focused Psychotherapy
Everything the patient cannot yet hold in mind will turn up in the room, between the two of you. That is not a complication of the treatment. It is the treatment.
Transference-Focused Psychotherapy is a manualised, evidence-based treatment for borderline personality disorder and other severe personality disorders. It grew out of contemporary psychoanalytic object relations theory, and it is unusually specific about what it thinks is wrong.
The symptoms of borderline personality disorder, on this account, come from a failure of identity integration. Kernberg's term for that failure is identity diffusion: a chronic, stable lack of integration in how a person holds themselves and the people who matter to them. Because self and other never come together into anything durable, experience has to be kept in separate compartments, and the patient's picture of you, and of themselves, can invert inside a single session.
- Identity diffusion
A stable lack of integration in a person's sense of self and of significant others. Not confusion about facts, but the absence of a coherent, nuanced view of who one is and who other people are.
The treatment strategy follows from the theory almost without a gap. What has been split off is reactivated inside the therapy, where it can be observed and interpreted as it happens. Whatever the patient cannot integrate gets played out between you and them, and that is the material.
What you are practising
The method asks three things of the therapist. This course is organised around them, and around the competencies each one needs.
Maintaining the frame of treatment: the contract you agree at the start, and what you do when it gets tested.
Containing and using your own affective responses: countertransference as an instrument rather than a nuisance.
Engaging in the interpretive process: clarification, then confrontation, then interpretation, in that order.
The evidence
The main evidence for TFP is a randomised controlled trial of three year-long outpatient treatments. Ninety adults with a DSM-IV diagnosis of borderline personality disorder (92% of them women, aged 18 to 50, mean age 31) were randomly assigned to TFP (two individual sessions a week), dialectical behaviour therapy (a weekly individual session, a weekly group, and telephone consultation) or a psychodynamic supportive treatment (one weekly session, supplemented as needed).
Nineteen therapists delivered the treatments. Each was chosen by the senior clinician leading their condition, held an advanced degree in social work, psychology or psychiatry, and had at least two years' experience treating borderline patients. They worked in their own community practices rather than a research clinic, were supervised weekly, and were videotaped and rated for adherence and competence. Raters were blind to treatment assignment and therapists were blind to baseline assessments. Patients were measured at baseline and again at four, eight and twelve months. Medication was permitted, prescribed by study psychiatrists who did not know which therapy a patient was in.
Twelve outcome variables were tracked across six domains. TFP predicted significant improvement in 10 of them, dialectical behaviour therapy in 5, and the supportive treatment in 6. All three improved depression, anxiety, global functioning and social adjustment. TFP and DBT both improved suicidality. Only TFP predicted improvement in irritability, verbal assault, direct assault and attention impulsivity.
TFP also did something the comparison treatments did not. In the same trial it increased reflective functioning, the capacity to think about your own and other people's mental states, along with the coherence of patients' attachment narratives. Neither changed in the DBT or the supportive condition.
A second randomised trial tested TFP against a harder comparison: not another manualised method, but experienced community psychotherapists doing what they already do. One hundred and four women were treated for a year in one arm or the other. TFP held on to its patients, with roughly two in five leaving the TFP arm against two in three of the comparison arm, and came out ahead on borderline symptomatology, psychosocial functioning, personality organisation and psychiatric admissions. Depression and anxiety improved in both, with no advantage either way.
TFP has also lost a head-to-head. Against schema therapy, over three years of twice-weekly treatment in 88 patients, roughly twice as many schema-therapy patients met the trial's recovery criterion, and more than half the TFP patients dropped out against about a quarter on schema therapy.
Sources for this section. Full citations for the course are in the References module at the end.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922-928. DOI 10.1176/ajp.2007.164.6.922. The three-arm trial, its therapists and the 10-of-12 result.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74(6), 1027-1040. DOI 10.1037/0022-006X.74.6.1027. Reflective functioning and attachment, in the same 90 patients.
Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, A., Martius, P., & Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: Randomised controlled trial. British Journal of Psychiatry, 196(5), 389-395. DOI 10.1192/bjp.bp.109.070177. The community-therapist comparison.
Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., Kremers, I., Nadort, M., & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649-658. DOI 10.1001/archpsyc.63.6.649. The head-to-head TFP lost.
How to use the lab alongside this
Read a module, then meet a patient and try the one thing it describes. The point is deliberate use, not coverage. Going into a session having decided this time I will clarify before I interpret will teach you more than a session in which you try everything.