Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide

Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide is the fourth book in the ongoing evolution of the original work of Otto Kernberg, M.D., John Clarkin, Ph.D., and Frank Yeomans, M.D., Ph.D. Frank Yeomans, the first author and a master clinician, leads this group to clearly and simply describe the theory behind the treatment of borderline personality organization and the use of transference-focused psychotherapy. Transference-focused psychotherapy is one of four evidenced-based treatments (the others include dialectical-behavioral therapy, schema-focused psychotherapy, and mentalization-based treatment) that were all designed specifically to treat borderline personality disorder but have been developed into broader clinical approaches for the treatment of the wider scope of personality disorders. Transference-focused psychotherapy is a clinical form of dynamic psychotherapy, which is accessible to psychotherapists with a wide variety of orientations. The book also has accompanying online videos, which demonstrate how to perform a structural diagnostic interview for borderline personality disorder patients, some of the techniques of treatment, and how to deal with affective storms.

The transference-focused psychotherapy clinical approach is grounded in object-relations theory originally developed by Melanie Klein, Michael Fairburn, Edith Jacobson, Margaret Mahler, and Otto Kernberg. The authors describe how “object” refers to the internal representation of a person who is the “object” of our attention, interest, or wishes. We internalize (and invariably distort) our interpersonal relationships, forming mental representations of self and others, which are connected by an emotion. These object-relations dyads (self-other representations) are linked by the originally experienced affect. Internalized self and other representations are incorporated during many different stages of development. These object-relations form the building blocks of our internal lives. In normal or healthy development, positive and negative representation of self and others combine into stable self and balanced identity, along with stable and complex perceptions of others. This clinical guide describes the psychological origins of borderline personality disorder (while also discussing the biological substrates) as an inability to integrate the multitude of positive and negative representations. Patients with borderline personality disorder and other DSM-5 personality disorders (e.g., paranoid, narcissistic, antisocial, and histrionic) all suffer with a borderline personality organization. Borderline personality organization is characterized by 1) problems/distortions in realty testing (e.g., disturbances in the sense of realty, such as derealization, depersonalization, and déjà vu or transient psychotic experiences); 2) identity diffusion (e.g., unstable, rapidly changing, and black and white perceptions of self and others); and 3) use of primitive defenses (e.g., splitting, idealization, devaluation, and projective identification).

The book describes how, because of these pathological object relations, patients with borderline personality disorder develop symptoms of disturbed interpersonal relations, emotional storms, distorted thinking, and self-destructive behaviors. The ambitious goal of transference-focused psychotherapy is not to treat personality traits but rather to help patients with borderline personality disorder to “integrate all aspects of their internal world … in order to experience themselves and others in a coherent and balanced way” (p. 42).

This clinical part of this book, which seamlessly and practically integrates object-relations with transference-focused psychotherapy, begins in chapter 4 with a discussion of the assessment of patients with borderline personality disorder. The structural interview (demonstrated in a helpful and accompanying video), developed by Otto Kernberg, begins with the following questions and domains: 1) What brings you here? 2) What is the overall extent of your problems and difficulties? 3) How do you understand your problems? 4) What do you expect from treatment? 5) Fully describe yourself and someone important to you. 6) Exploration of the past as it relates to current difficulty. This assessment determines the personality organization (e.g., whether the patient has neurotic, borderline, or psychotic personality organization), which then helps clinicians have some indication of how the treatment will unfold.

Chapter 5 describes how to develop the therapeutic contract, lays out the responsibilities of the patient and the therapist, and describes a hierarchy of acting out issues, which can threaten a treatment. It also recommends the use of medication and adjunctive-behavioral treatments and self-help.

Chapters 6 and 7 discuss the transference-focused psychotherapy strategies, tactics, and techniques. The authors describe and demonstrate, with accompanying videos, the uses of confrontation, clarification, and interpretations; the need for ongoing focus and use of deep interpretations of both the positive and negative transferences; analysis of the primitive splitting defenses as they are activated in the transference; the importance of technical neutrality and the occasional need for using parameters; how transference-countertransference experiences and patterns lead to the clinical understanding of the dominant object-relations dyads; how these dyads can be used defensively; and ultimately how these dyads are recreated in the present and their links to the past. Using case examples, the authors discuss and illustrate the tactics of treatment. The tactics used include eliminating secondary gain and choosing the thematic focus of each session, giving first priority to suicidal/homicidal threats, followed by threats to the treatments (e.g., arriving late, not paying bills, etc.), prioritizing a focus on dishonesty or the withholding of important information, as well as contract breeches, and then to a focus on affects and the transference. This discussion and video are especially useful when dealing with any patients who act out.

Chapters 8, 9, and 10 focus on issues that emerge in the early, middle, and advance phases and termination of treatment. Case examples are effective in bringing the technical aspects of the treatment to life.

Early phases of the treatment involve borderline personality disorder patients testing the boundaries and the frame of the treatment, containment of the patient’s impulses, dealing with affective storms (video 3), and the identification of the operative object-relations dyads, which emerge in the transference-countertransference experiences.

Midphase of treatment focuses on a deepening understanding of self and others (as expressed in the transference and countertransference) as multiple object-relations dyads. During this phase, the interpretation of primitive defenses leads to integration of split-off affective extremes, which leads to more balanced emotional responses. In addition, the borderline personality disorder patient begins to integrate and coalesce disparate images of self and others and develops new ways of behaving, leading to improved interpersonal relations.

During the advanced phases of therapy, the interpretive processes in the here and now and genetic interpretations (e.g., about the connection between the present and the past) help the patient improve his or her reflective ability. Patients begin to accurately perceive themselves and others. Reality testing is less disturbed and more accurate. There is growing openness and freedom to discuss all experiences with the therapist. Identity becomes stable, since object relations are more integrated and balanced. Patients who progress to this phase are more curious about the therapist’s comments and are less symptomatic because they can better contain anxious, depressive, angry affect, and impulsive behaviors. Their personality structure is morphing from a borderline personality organization to the neurotic personality organization.

Successful termination with borderline personality disorder patients often brings up paranoid and depressive themes and periods of regression.

Separations during treatment are an indication of early responses to termination. In the earlier stages of treatment, patients with borderline personality disorder, in response to a therapist’s vacation or temporary illness, will experience intense separation anxiety, fears of total abandonment, paranoid/persecutory responses, regressions, and splitting, with much less (if any) depressive themes. This general reaction is often the initial borderline personality disorder reaction to impending termination. If these reactions occur, it is important to deal with persecutory themes, splitting, and regression before working on depressive themes. Insofar as patients with borderline personality disorder have transitioned to a neurotic level of personality organization, they may move from anxiety and persecutory themes to more appropriate depressive themes of feeling sad, mourning for someone who is loved, and internalization of the therapist.

The final chapter discusses measures of structural change that are overtly manifest at the end of a fully successful treatment of a patient with borderline personality disorder. These measures include a progression from antisocial to narcissistic to paranoid to depressive transferences; reduction in acting out and symptoms; integrations of split-off affects and increasingly stable and balanced object relations and awareness of ambivalence; movement from preoedipal to oedipal issues; and improvement in the capacity to relate meaningfully to others, with a growing ability to work, play, and love.

This book is a synthesis of more than 25 years of original work from the founders of the Personality Disorder Institute of New York. This book is a wonderful blend of theory and techniques offering clinical examples and high-quality useful videos. It is a treasure of wisdom immensely useful to all those who are interested in treating patients with severe personality disorders.