Transference-Focused Psychotherapy for Adolescents With Severe Personality Disorders

Transference-focused psychotherapy is an evidence-based treatment for adults with severe personality disorders that uses a psychodynamic approach with compassionate and clear limit setting. A new book, Transference-Focused Psychotherapy for Adolescents With Severe Personality Disorders, applies this empirically validated therapy to the identification and treatment of personality disorders among adolescent patients. This thoughtful and thorough text lays out the importance of identifying traits of personality disorder among younger patients and structuring treatment to support behavioral control, affect regulation, gratifying relationships, and engagement in a productive life. Case examples throughout the text illustrate realistic clinical scenarios to help make these concepts tangible.

The book is broken into three parts. Clinicians with a solid understanding of psychodynamic psychotherapy and the pathology of personality disorder among adolescents may approach each part as a standalone section, whereas the parts work in concert to support clinicians with less comfort with these topics and population. In part one, the text examines the hesitancy that clinicians often face in making a personality disorder diagnosis for adolescents and supports the validity of personality disorder traits even in younger patients. Drawing from Kernberg’s psychoanalytic object relations theories that the core problem in personality disorder is identity diffusion (1, 2), this section delves into the etiology of personality disorders, identifying risk factors including developmental precursors, challenges of navigating adolescent milestones, attachment difficulties, neurobiological changes, and pubertal challenges. The chapters explore themes of identity formation and personality consolidation occurring during the teen years and emphasize the importance of identifying borderline, narcissistic, antisocial, and avoidant traits of personality disorder among adolescents and intervening with appropriate treatment to address the developmental abruption that a personality disorder can exacerbate.

Part two goes into detail about transference-focused psychotherapy for adolescents (TFP-A), reminding the reader to focus on the main task of the “adolescent’s internal world” and “identity integration.” TFP-A is a psychodynamic psychotherapy treatment delivered individually, ideally twice a week (3). The fundamental techniques of TFP-A are described and elucidated, demonstrating how to recognize the split between idealized object relations and persecutory object relations, reminding the reader that simply addressing these separate entities results in improved development. Considerable text is devoted to the evaluation process to help clarify criteria for the personality disorder diagnosis and severity of personality pathology, with suggestions to help clinicians organize their assessment with specific tools and resources. The attention given to these topics is appropriate, given the large impact a diagnosis of a personality disorder has on adolescents. Finally, this section provides guidelines for treatment termination that are helpful for both new and experienced clinicians, reminding readers of the importance of planful endings and of leaving the door open for the adolescent to return to therapy as life unfolds. Throughout this section are examples of how to address barriers in treatment, including resistance from adolescent patients, history of trauma, and countertransference that can disrupt therapeutic progress, particularly in the treatment of individuals with narcissistic or antisocial presentations. Part three of the book focuses on the specific process of conducting TFP-A.

This book provides an important reminder that personality disorders are treatable and that the right interventions can provide real and lasting change. It bridges a gap in therapeutic tools and is a valuable resource for all clinicians who treat adolescents. As a trainee, I (J.K.) felt that this book helped me grasp a basic understanding of personality disorders and how to approach psychotherapy for adolescents.