Empirical Developments in Transference-Focused Psychotherapy

The treatment of borderline personality disorder has been dominated by a focus on development of coping skills with cognitive-behavioral therapy (CBT) (2). A major question has been whether a complex psychodynamic treatment, in contrast with a very specific CBT-based skills approach, could be articulated in a manual and be reliably delivered by therapists trained in the process.

Many decades ago, a few senior psychiatrists under Kernberg’s leadership video-recorded their psychotherapy sessions with the goal of generating principles of intervention, which led to the first published manual describing the strategies, tactics, and techniques of TFP (3). In contrast with treatment manuals that describe a set pattern of techniques and foci of an intervention applied uniformly to all patients, the TFP manual is principle driven, providing the therapist with not only a structure for the primary targets of intervention but also flexibility in how to relate to each unique patient.

TFP was originally articulated as an intensive individual treatment for adults with the categorical diagnosis of borderline personality disorder. However, as research and treatment experience have accumulated, TFP has been refined and extended to a wide range of patients with a personality disorder (4, 5), with treatment focused on the common problems related to self-functioning and functioning with others.

The object relations model of personality organization (17) has traditionally contrasted with the descriptive approach of the DSM-5 (18), which differentiates personality disorders by manifest type rather than by underlying psychological structure. Central to how people experience personality is the organization of their internal representations. During childhood, with maturation of cognitive and affective systems, individuals experience an increase in differentiation, integration, and hierarchical organization of representations of self and others. When consolidated in a stable identity, perceptions of oneself and the capacity for relatedness with others are balanced and emotionally integrated. In contrast, manifest symptoms of borderline personality disorder (i.e., affective, interpersonal, and behavioral instability) arise from poorly integrated representations corresponding with unstable affects and polarized perceptions of self and others (18).

Based on Kernberg’s extensive clinical experience, the specificity of the model lays the groundwork for assessing the relevance of conceptions of personality pathology rooted in object relations and for direct comparison with other current conceptualizations of personality and its pathologies (19). This model has found recent influence in the Alternative DSM-5 Model for Personality Disorders, in section III of DSM-5, with its emphasis on self-functioning and functioning with others (see Caligor et al. [19] in this issue). A direct line can be drawn from an object relations model of personality organization to a model of treatment. TFP leads to symptom change through a focus on the patient’s identity functioning and relatedness as manifested in the therapeutic interaction (20, 21).

The object relations model has direct implications for patient assessment, which has led to the development of self-report questionnaires (22) and semistructured interviews to assess personality organization (23, 24). However, borderline personality pathology is unique in its “stable instability.” The possibility for enormous variability in function (that can change by the minute, hour, or day) cannot be adequately captured by questionnaires and semistructured interviews. Yet, impairments in self-functioning and interpersonal functioning remain generally consistent throughout adulthood (25).

Because the unstable aspects of borderline pathology may not be adequately captured via cross-sectional self-report data, our research group has used laboratory assessment of personality functioning (e.g., fear vs. trust, rejection sensitivity) and electronic diary studies of the flow of and variation in patients’ daily lives. Experience-sampling methods represent advances over self-report methods, which are susceptible to memory bias, in that participants are asked to provide brief but immediate ratings after specific events or random prompts at specified intervals. Such methods allow researchers to move away from aggregate ratings of a given behavioral or emotional experience to evaluate intraindividual variability. Ratings of the perceptions of others’ behaviors, the perception of one’s response, and the associated affects may provide a simple construction of a self-other dyad. However, when the participant’s experience in specific contexts on specific days is intensively sampled by using daily diary methods, the setting of specific representations of self and others and related affect begins to emerge (26, 27).

Object relations theory postulates that representations of self and others that are characterized by negative affect, aggression, and splitting lead to both a tendency to reject others and a co-occurring perception of being rejected by others. How the internal experience of rejecting and being rejected manifests itself in interpersonal behavior depends in part on the level of a person’s effortful control. Effortful control represents the “voluntary” aspect of temperament that allows individuals to successfully resolve conflicts between immediate reactive tendencies and long-term demands and to overcome a dominant response to produce a more appropriate, valued, and goal-directed nondominant response (28).

The interpersonal and object relations dynamics that characterize individuals with BPO may be understood within the framework of current theories and empirical evidence on how individuals self-regulate when experiencing a relational conflict (29). According to cybernetic models of self-regulation, conflict emerges when a discrepancy is detected between one’s goal or desired state and the actual behavior in a particular context (30). This potential mismatch leads to negative affect (i.e., anxiety, frustration) and to a cascade of neurophysiological responses signaling alarm, including the activation of the anterior cingulate cortex (ACC) and of fight-or-flight responses fostered by the autonomic nervous system (ANS). Importantly, this aversive nature of conflict signals to the individual the need to reprioritize his or her own valued goals and pursue additional goal-directed actions to decrease the mismatch between the individual’s desired state and the current one (31). Therefore, self-regulation begins with conflict.

The intense negative affects experienced by patients with BPO may be conceptualized as a prolonged state of inner conflict that is not counterbalanced by the recruitment of successful self-regulatory abilities (Figure 1). According to object relations theory (17), patients with BPO exhibit an unconscious, idealized need to find a perfect relationship with a totally accepting and caring other. In a self-regulation view, this need represents the desired, although unconscious, state of patients with BPO (i.e., their motivating goal). In the desperate attempt to protect this unconscious hope for a perfect relationship, individuals with BPO need to project their own negative affect onto others, whom they thus consciously perceive to be malevolent and excluding, even when they are not. This constellation prevents patients with borderline personality disorder from accurately perceiving interpersonal exchanges. Any partner, even one who is benign or neutral toward the patient, may be perceived as threatening when he or she does not match the unconscious, split-off representation of an idealized, perfectly loving other.

Importantly, this appraisal of neutral or even accepting social stimuli as threatening, which is central to the conceptualization of BPO in object relations theory, has been well documented empirically. For instance, those with features of borderline personality disorder show a bias toward undernoticing trustworthiness in others (32) and misinterpreting neutral facial expressions as negative (33). Within a self-regulation framework, the resulting discrepancy between one’s own goal or desired inner state (i.e., being involved in a perfectly caring relationship) and the perception of the interpersonal environment (i.e., the biased appraisal of others as malevolent toward the self) generates a state of goal conflict that triggers a variety of neural, physiological, and subjective responses aimed at signaling the conflict and promoting resolution. For those with borderline personality disorder, this “alarm cascade” is activated even in the presence of objectively benign social stimuli.

At the neural and physiological levels, during social exchanges, patients with borderline personality disorder exhibit increased ACC activation, enhanced P3b event-related potential (34–36), and a withdrawal of the ANS vagal brake on the heart (37). These findings indicate an inappropriate activation of the neural social pain circuitries and of fight-or-flight physiological states for those with borderline personality disorder during fair or even inclusive interpersonal exchanges that do not match the implicit, unconscious goal of finding perfect relatedness. This conflict is consistently associated with negative subjective reactions, such as increased negative emotions and feelings of social disconnection (34, 36–39). Usually, the aversive outcomes of conflict signal the need to increase self-regulation by activating goal-directed behavioral responses aimed at reducing the mismatch between one’s current and desired states (31). However, increasing evidence also shows that this does not occur for those with borderline personality disorder, for whom the neural, physiological, and subjective responses to fair or inclusive social interactions are also associated with maladaptive behaviors. For instance, studies of behavioral economics indicate that patients with borderline personality disorder react to others’ fair and accepting behavior as if it were unfair, often by punishing them and exhibiting uncooperative, distrustful, and hostile attitudes (40–43). These findings are in line with object relations theory’s understanding of the relationship between the subjective experience of patients with BPO, who have a tendency to feel intense negative affect and to perceive a self rejected by untrustworthy others, and their observed behaviors, which show a tendency to act rejecting and mistrustful of others (17). From a self-regulation perspective, this behavioral output is not effective in reducing the aversive experience of inner conflict; rather, it is likely to perpetuate conflict by enhancing the discrepancy between one’s own desired state of a perfect relationship and the real-world interpersonal context. In other words, a failure in self-regulation is at work.

Enhancing the ability of patients with borderline personality disorder to accurately reflect on their perception and their emotional and behavioral responses to interpersonal relationships is a fundamental and well-validated mechanism of change in TFP. In TFP, increased mentalization and reflective functioning abilities are critical to the promotion of patients’ understanding and improvement of their internal representations of self and others (9, 44). The ability to self-regulate is closely related to such processes, as indicated by the association between executive attention and therapeutic alliance during therapy (45). Distorted perceptions of others as malevolent and subsequent maladaptive responses may be reduced among patients with borderline personality disorder by the deployment of effective self-regulation strategies, as indicated by higher levels of effortful control. In fact, a high level of effortful control buffers the tendency to misinterpret neutral facial expressions as negative among those with severe features of borderline personality disorder (33) and buffers negative behaviors related to perceptions of interpersonal rejection (46). These findings support the clinical utility of focusing on patients’ self-regulation abilities, especially at times of intense negative affect, to foster reflective rather than reflexive patterns of social cognition. Specifically, increased self-regulation may reduce the prolonged state of inner conflict by promoting an accurate appraisal of positive social cues, an ability that appears to be impaired in people with borderline personality disorder. This appraisal will decrease the mismatch between patients’ motivating goal of establishing a positive relationship with others and their distorted perception that no positive relationship exists in reality, ultimately fostering the successful integration of their inner, conflicted, and partial representations of self and others.

Preliminary research evaluating changes in brain functioning after TFP treatment is supportive of this model (47). In a pilot study, patients with borderline personality disorder (N=10) manifesting prominent affect dysregulation received TFP treatment and underwent functional magnetic resonance imaging (fMRI) assessment before treatment and after 1 year of treatment (48). In a comparison of pretreatment and posttreatment fMRI scans, changes in brain functioning suggested that treatment with TFP was associated with relatively increased activation in the emotional and cognitive control areas of the brain and relatively decreased activation in areas of the brain associated with emotional reactivity and semantic-based memory retrieval.

After years of programmatic clinical and empirical development, TFP has emerged as a manualized, empirically supported, transdiagnostic psychotherapy for problems of self-functioning and functioning with others that span the range of severities of personality pathology. An initial treatment development study showing the promise of symptom change and cost-effectiveness was followed by RCTs that demonstrated the comparative effectiveness of TFP versus an alternative cognitive-behavioral approach (i.e., DBT) and expert treatment in the community. The mechanism of change occurs through intense focus on patients’ difficulties with containing affect and maintaining a coherent sense of self in affectively charged conflictful interactions with others. TFP is solidly based on an object relations conceptualization of personality dysfunction and provides the clinician with a clinical assessment methodology that goes beyond assessment of symptoms to explore the personality organization of the patient, with guidelines for treatment intervention matched to the level of personality organization.