Transference-Focused Psychotherapy (TFP)

Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999) is a psychodynamic treatment based on Kernberg’s (1984) modified ego-psychology and object relations theory of personality disorder. TFP was developed specifically for Borderline Personality Disorder (BPD) and an associated broader form of personality dysfunction classified as borderline personality organization. Kernberg (1984) considers borderline personality organization to encompass other DSM personality disorders, since it is defined not by descriptive symptoms but rather by impairments in identity integration and defensive functioning.

Conceptual Model

According to this model, psychological representations of self and others – experienced at varying levels of consciousness – provide the foundation for thoughts, feelings, and behaviours. BPD is considered to consist of fragmented representations of self and others that are associated with strong affective experiences. These representations are conceptualized as having been influenced both by temperament and by difficult early attachment relationships – including traumatic experiences (See section on Traumatic Experiences on the BPD Etiology page)– and thus are difficult for patients to integrate within a stable sense of identity. Fragmented self and other (known as “object”) representations are thought to manifest in behaviours and in interpersonal relationships, often outside of the individual’s explicit awareness and frequently in contradictory ways. For example, helplessness and dependent behaviour may be experienced alongside defiant grandiosity and rejection of help.

The Treatment

TFP seeks to address the fragmented, often contradictory representations of self and others that contribute to fluctuating affects, problematic defense mechanisms, and unstable identity and relationships (Levy, Clarkin, Yeomans, et al., 2006). The therapy is highly structured, manualized, and involves an explicit treatment contract between therapist and patient. Therapy takes place twice per week in an individual format. The treatment contract clarifies the setting and conditions of the therapy, the roles of the participants, and the behaviours and issues to be addressed, including protocols for the handling of self-destructive behaviour (See section on Suicidality and Self-Injury in BPD). Containment of self-destructive behaviour is thus an early priority focus of interventions in TFP. As treatment progresses, the focus shifts to the major affect-laden themes that emerge in the relationship between the patient and the therapist (Caligor, Diamond, Yeomans, & Kernberg, 2009). Known as the transference, these relational patterns are thought to reflect inner representations. Although such representations are believed to stem from early childhood experience, the focus of interventions in TFP is primarily on their manifestation in the here-and-now of the transference. In contrast to ordinary relationships, in TFP problematic interpersonal patterns are allowed to emerge without typical social consequences, in order to foster exploration of their meaning in terms of inner representations and affects. Repeated clarification, confrontation, and interpretation of these patterns within a safe therapeutic relationship is considered to bring about changes in the patient’s psychological integration (Caligor et al., 2009; Levy, et al., 2006).

Research on TFP

Results from randomized controlled trials (RCTs) provide empirical support for the efficacy of TFP for BPD. In one such trial, conducted over three years, TFP served as the comparison condition for schema-focused therapy (SFT; Giesen-Bloo, van Dyck, Spinhoven, et al., 2006). TFP was found to be effective in reducing borderline symptomatology and improving quality of life, although not to the extent as in the SFT condition. Patients in the TFP condition had a significantly higher degree of suicidality at baseline than SFT patients, and there were some problems identified in the adherence of therapists to the TFP protocol.(Yeomans, 2007).

Another trial, conducted over one year by the developers of TFP (Clarkin, Levy, Lenzenweger, & Kernberg, 2007), compared TFP with Dialectical Behaviour Therapy (DBT) and supportive-psychotherapy (SFT; See section on Other Dynamic Therapies for BPD), with each therapy delivered by acknowledged experts in each model. Positive changes were seen for patients in each condition, with generally equivalent improvement in social and global functioning. TFP produced changes across a broader range of outcome measures than the other two treatments. TFP and DBT reduced suicidality to the same extent. Importantly, only TFP was found to produce positive changes in attachment organization – an increase in secure attachment – and in reflective functioning, an indicator of the ability to contemplate one’s own and other’s mental states (Levy, Meehan, Kelly et al., 2006).

Doering and colleagues (2010) also investigated TFP in a randomized trial, comparing it with treatment by community psychotherapists over a one-year period. TFP was found to be superior in reducing impairment across several domains such as suicide attempts, treatment drop-out, borderline symptoms, and personality organization. However, self-injury was not significantly reduced by either TFP or the comparison treatment after one year.

The above-mentioned studies demonstrate the effectiveness of TFP as a specific treatment, and add further empirical support for the role of psychodynamic psychotherapy in the treatment of BPD. Psychodynamic psychotherapy generally aims for recovery as reflected by changes in personality organization, in addition to behavioural outcomes. Such changes are thought to contribute to overall functional improvements, and to protect against future relapse. The discovery that TFP, involving a focus on object relations and transference interpretation, produces inner changes (i.e., attachment style and reflectivity) is thus particularly encouraging. Future research is required to replicate and extend this finding, and to examine the hypothesized mechanisms of action in transference-focused psychotherapy.