PSI Our Model of Psychotherapy

Transference-focused Psychotherapy (TFP) is a treatment based on psychoanalytic concepts designed especially for patients suffering from personality disorders. This twice-per-week individual psychotherapy is described in a treatment manual (Psychotherapy for Borderline Personality Disorder – An Object Relations Approach; Clarkin, Yeomans, & Kernberg, 2006). TFP combines many of the elements described in the Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association. For example, TFP places special emphasis on assessment, the treatment contract, and setting up the psychotherapeutic frame (i.e., the conditions of treatment). The setting up of the contract and frame has behavioral elements in that parameters are established to deal with the likely threats both to the treatment and to the patient’s well-being that may occur in the course of the treatment. The patient is engaged as a collaborator in setting up these conditions.

After any behavioral symptoms of personality disorder are contained through discussion and limit setting, the psychological structure that is believed to be the core of the disorder is observed and understood as it unfolds in the transference, i.e., the relation with the therapist as perceived by the patient. Although TFP emphasizes the role of interpretation within psychotherapy sessions, it acknowledges both the role of the therapeutic relationship and the possible role of auxiliary treatments (e.g. for active eating disorders or substance abuse) and includes pharmacological interventions to address specific symptoms as needed.

A distinguishing feature of TFP in contrast to many other treatments for personality disorders is the belief in a deep psychological structure embedded in the mind that underlies the specific symptoms of the disorder. The focus of treatment is on the patient's difficulties tolerating and integrating disparate images of the self and of others. A person's sense of self and others is seen as based on multiple internal “object relations dyads”, or images of particular types of relationships constituted by a representation of the self and of the other, linked by an affect, or strong feeling. In individuals suffering from personality disorders, these various dyads do not become integrated into a unified whole. As a result, dyads associated with sharply different affects exist independently from one another and determine the lack of continuity of the patient’s experience in life (for further detail, see “Our Model of Personality”).

The treatment focuses on the transference, the patient’s moment-to-moment experience of the therapist, because it is believed that the patient lives out his/her predominant object relations dyads in the transference. Once the treatment frame is in place, the core task in TFP is to identify these internal object relations dyads that act as the “lenses” which determine the patient’s experience of the self and others. It is believed that the information that unfolds within the patient’s relation with the therapist provides the most direct access to understanding the make-up of the patient’s internal world.

A brief summary of the course of treatment is as follows: as the unintegrated representations of self and other get played out in the course of the treatment, the therapist helps the patient observe them and understand the reasons – the wishes, fears and anxieties – that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experiencing of strong affects within the therapeutic relationship. The combination of understanding and emotional experience can lead to the integration of the split-off representations and the creation of an integrated sense of the patient’s identity and experience of others. This integrated psychological state translates into a decrease in emotional turbulence, impulsivity and interpersonal chaos, and the ability to proceed with effective choices in work and relationships. In other words, our experience is that the integration of the psychological structure can result in the resolution of the personality disorder and help establish stable and deep relationships and commitments to work and other life activities.

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Publications by PSI Members

Evaluating three treatments for borderline personality disorder: a multiwave study.  American Journal of Psychiatry, 2007

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Caligor, Clarkin, & Kernberg: Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology

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Clarkin, Yeomans, & Kernberg: Psychotherapy of borderline personality: Focusing on object relations