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.
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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
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”
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)
Continuities and clinically relevant relationships among the personality disorders.
Gray lines indicate clinically relevant relationships among disorders.
The lack of integrated identity underlies:
The Self-Other Dyad
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)?
S = Self-Representation
O = Object - Representation
a = Affect
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
…and of TherapistTRANSFERENCE,and the power of Internal World over External Reality
Fear, Suspicion, Hate
Fear, Suspicion, Hate
(Oscillation is usually in behavior, not in consciousness)
ONE DYAD DEFENDING AGAINST ANOTHER
Fear, Suspicion, Hate
TACTICS: TasksforeachSession that set the conditions for Techniques
TECHNIQUE: Consistent interventions that address what happens from Moment-to-Moment
Impaired representations become transformed through interpretation, reflection, and new experiences
More realistic representations can be integrated
Ability to think more flexibly and benevolently
A proxy for the above might be mentalization/reflective functioning
Life and Relationships:
reduction in self-destructive behaviors,
less acting out of aggression - aggression is owned and managed
greater capacity for intimacy,
increased coherence of identity,
general improvement in functioningBeyond Symptom Change:Increased Integration and Differentiation of sense of Self and Others
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)
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)
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 interpretation, reflection, and new experiences - 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 study. American Journal of Psychiatry, 164, 922-928.
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.
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), 1832-1841 (2007)
Yeomans FE, Clarkin JF, Kernberg OF. A Primer on Transference-Focused Psychotherapy for Borderline Patients. Northvale, NJ: Jason Aronson (2002).