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 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

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 Other Affects The Self-Other Dyad

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

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 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. S3 O3 S1 O1 S2 O2 a3 a1 a2 Etc.

TRANSFERENCE, and the power of Internal World over External Reality Experience of Self …and of Therapist S1 S2 S3 O1 O2 S1 S2 S3 O3 a1 a2 a3

Victim Persecutor Victim (Oscillation is usually in behavior, not in consciousness) OBJECT RELATION DYAD INTERACTIONS: OSCILLATION Fear, Suspicion, Hate Self-Rep Object Rep

Victim Dependent Child Abuser Gratifying Provider Opposites OBJECT RELATION DYAD INTERACTIONS: ONE DYAD DEFENDING AGAINST ANOTHER Fear, Suspicion, Hate Longing, Love

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 The Relationship of Strategies, Tactics and Techniques in TFP

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 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

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 study. American Journal of Psychiatry, 164, 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:

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), (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), (2007) Yeomans FE, Clarkin JF, Kernberg OF. A Primer on Transference- Focused Psychotherapy for Borderline Patients. Northvale, NJ: Jason Aronson (2002).