Front Matter

The specificity of TFP-A includes a focus on facilitating identity integration and personality consolidation through 1) addressing dominant pathological object relations as they are activated and manifested in the here-and-now interactions with the therapist; 2) elaborating on a contract with adolescents to help them reduce, contain, and ultimately control acting out while stimulating curiosity about their motivations and prioritizing mentalizing about self and others as well as about the consequences of their actions and their future; 3) offering a specific approach to supporting parents, facilitating their collaboration, and reducing their interference as well as creating a mental space for adolescents where they can develop autonomy and gradually assume responsibility for their difficulties¹; and 4) placing an emphasis on interpreting transference and countertransference reactions in order to identify split self and other representations that are viewed as an impediment to the flow of the developmental processes and undermine personality consolidation, as well as the adaptive use of acquired mentalization capacities in order to deal with the challenges of adolescence and the future.

TFP-A is also grounded in an understanding of the major structural changes and developmental tasks that the adolescent is facing. Therefore, the aim of TFP-A is to scaffold structural changes and oversee developmental challenges central to adolescence while addressing pathology in object relations and identity integration that disrupts these developments. The major structural changes concern constituents of personality (self-image, ideal self, and self-esteem as well as moral and ethics, sexuality and eroticism, concern, and reparation wishes) that have to be consolidated. The developmental challenges include becoming more independent from family, establishing their own social networks, negotiating sexual relationships, and forming romantic and couple relationships, while clarifying future life and career goals and pursuing these purposefully. In contexts of family dysfunction or disorganization, parental mental illness, substance abuse, and violence or when there is little family support, adolescents without personality pathology may also have difficulties successfully engaging with the challenges of adolescence, but they are generally receptive and responsive to help when help is offered. When clinicians are attempting to distinguish and identify personality pathology, it is important for them to consider the developmental history of adolescent patients as well as their current functioning with family and peers, at school or work, while also being well informed regarding developmental issues and structural changes specific to adolescence. This provides a framework that facilitates understanding the adolescent’s developing sense of self and others—the process of identity formation—as it unfolds during separation from family and entry into the adult world. Radical failures in engaging with the normative challenges of adolescence and the manifestation of immature internal structures are features of adolescent PDs.

In Part I of the manual, we first explore the phenomenology of PDs, examine the validity of PD as a diagnostic category at adolescence, and review the etiological risk factors for its development. We then present an understanding of PDs grounded in Otto Kernberg’s contemporary object relations theory and the notion of “identity diffusion,” which is an incapacity to convey to an observer an integrated description of self and the equal lack of capacity to convey an integrated view of significant others (Kernberg 2012). Identity diffusion is hypothesized to result from the dominance of severe aggressive impulses, whether genetically determined, resulting from a temperamentally established predominance of negative affects or lack of cognitive control and contextualization of affects, or following severely pathological attachment or traumatic experiences in early infancy and childhood. We follow this discussion with a presentation of major structural changes and developmental tasks that typically developing adolescents are encountering. It is hypothesized that identity diffusion puts significant pressure on the normal maturational processes that are geared toward separation and individuation: the attainment of a realistic self-image, self-esteem, and self-ideal; the completion of an integrated system of morality and ethical values; the fulfillment of sexual and romantic intimacy; friendship and commitments; the effectiveness and gratification in school or work or in choosing a career; and the actualization of personal creativity—all of which are, in whole or in part, consolidated at adolescence. These two levels of analysis serve to propose an integrated conception of the pathology of PDs and its interferences on normal development that will become the main targets of TFP-A. It is our belief that to be effective in treating PDs at adolescence, a therapist must keep in mind a model of the PD pathology and a model of normal development in order to be sensitive to what is typical and what is atypical in the adolescent’s behaviors and relationships, as well as to “preview” and to “focus on” imminent maturational trends, structural changes, and developmental challenges ahead.

In Part II, we present the therapeutic approach used in TFP-A. The main goal of the treatment is identity integration and personality consolidation. We consider that the integration of mutually split-off idealized and persecutory internalized object relations that surface in the transference enables the adolescent to achieve a coherent, realistic, and stable experience of self and others that equips him or her to face developmental challenges and that is consolidated in specific structures of the personality. We consider that by addressing such disabling difficulties in the personality structure, the adolescent may resume the normal course of personality development sufficiently to engage in studies/work and make choices regarding his or her future work and develop the capacity to have meaningful interpersonal and romantic relationships. To achieve this goal, we propose a series of steps, so-called strategies of TFP-A, involving attempts to integrate part-self and part-object representations through a process in which underlying representations are recognized and marked by the therapist and then delineated as characteristic patterns of experiencing, relating, or disrupting developmental challenges. Part II of this manual (Chapter 4) also focuses on assessment to clarify diagnosis, the presence of a PD, the critical areas of dysfunction, and the level of personality organization as distinct from the identity crisis of normal adolescence. Typically, adolescents and their parents do not present for therapy saying that they think they may have a PD, although there is a somewhat greater awareness of borderline and narcissistic PDs than in the past. Instead, they describe concerns about anxiety, mood, anger, or interpersonal functioning with family, peers, and school. The clinician, in turn, explains the assessment process to the adolescent and parents. This discussion focuses on the purpose of assessment, including the need to understand the nature of the adolescent’s problems, culminating in a determination of an appropriate treatment choice. Both the adolescent and the parents are involved in this process.

Chapter 5 in Part II describes the establishment of a treatment contract, considered the first of a series of TFP-A tactics. This phase consists of negotiating a verbal treatment contract implicating the adolescent, the parents, and the therapist and precedes the start of the therapy. The specific techniques of TFP-A—the moment-to-moment interventions the therapist engages in with the patient in therapy sessions—are then described in Chapter 6. We present six basic techniques at the core of TFP-A: the active stance of the therapist, the interpretative process, the analysis of transference, the analysis of countertransference, technical neutrality, and developmentally informed interventions. We then outline, in Chapter 7, tactics that the therapist uses to maintain the treatment frame, attend to parental concerns, clarify involvement, maintain the focus on developing the adolescent’s internal resources rather than to manage behaviors, identify priority themes, manage adolescent resistances and negative therapeutic reactions, and “preview” developmental and structural changes ahead.

In Part III, we present how TFP-A unfolds across different phases of the treatment. We include the TFP-A Manual Adherence and Competence Scale as an appendix.