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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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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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Interdiscipliary Collaborators

Ann Appelbaum

Eve Caligor

Monica Carsky

John Clarkin

Ken Critchfield

Jill Delaney

Diana Diamond

Pamela Foelsch

Otto Kernberg

Paulina Kernberg

Kay Haran

Mark Lenzenweger

Ken Levy

Armand Loranger

Michael Posner

David Silbersweig

Michael Stone

Frank Yeomans


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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”


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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


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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


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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)


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FIGURE 2

Continuities and clinically relevant relationships among the personality disorders.

Gray lines indicate clinically relevant relationships among disorders.


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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)


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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


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Goals and objectives of TFPfor 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


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Theoretical Underpinnings of TFP:Object Relations TheoryFocus of here and now interaction

Self

Other

Affects

The Self-Other Dyad


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Dyads as Building Blocks

  • The individual identifies with the entire relationship dyad, not just with the self-representation 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



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Normal (Integrated) Organization:Consciousness of Integration/complexity


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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)?


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Patient’s Internal World

.

S1

a1

O1

S = Self-Representation

O = Object - Representation

a = Affect

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

O2

a2

O3

a3

S3

Etc.


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Experience of Self

…and of Therapist

TRANSFERENCE,and the power of Internal World over External Reality

S1

S1

O1

a1

S2

S2

a2

O2

S3

O3

S3

a3


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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)


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OBJECT RELATION DYAD INTERACTIONS:

ONE DYAD DEFENDING AGAINST ANOTHER

Fear, Suspicion, Hate

Abuser

Victim

Opposites

Longing, Love

Gratifying Provider

Dependent

Child


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The Relationship of Strategies, Tactics and Techniques in TFP

STRATEGIES

Long-Term Objectives

TACTICS: TasksforeachSession that set the conditions for Techniques

TECHNIQUE: Consistent interventions that address what happens from Moment-to-Moment


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Understanding Interpretation TFP

  • 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


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Steps of Interpretation - I TFP

  • 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


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Steps of Interpretation - II TFP

  • 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


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When there is Oscillation in the dyad: TFPelaborating 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.”


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Interpreting the Split TFP

  • “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.”


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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 functioning

Beyond Symptom Change:Increased Integration and Differentiation of sense of Self and Others


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Empirical Support for Efficacy of TFP interpretation, reflection, and new experiences 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


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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.


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Article and Books related to TFP – page 2 interpretation, reflection, and new experiences

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).


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