Transference-focused Psychotherapy Research Articles

Supplemental Material for Transition to Online Transference-Focused Psychotherapy During the COVID-19 Pandemic

Supplemental Material for Transition to Online Transference-Focused Psychotherapy During the COVID-19 Pandemic

Transition to online transference-focused psychotherapy during the COVID-19 pandemic.

Transition to online transference-focused psychotherapy during the COVID-19 pandemic.

[On the Admission of Patients with Borderline Personality Disorder to Outpatient Psychotherapy].

Patients with borderline personality disorder (BPD) present difficulties in self-regulation and interaction, which is a challenge for psychotherapists that is also addressed in BPD-specific interventions. Against this background, outpatient psychotherapists were surveyed about the factors playing a decisive role in their treatment offer for patients with BPD. Psychotherapists for adults were contacted via their email address published on the website of the Kassenärztliche Vereinigung (Association of Statutory Health Insurance Physicians), 231 of whom answered an online questionnaire. The results were analysed descriptively and examined inferentially with regard to the psychotherapists' admission behaviour. Almost 90% reported that they would generally accept patients with BPD in therapy. However, of those, 85% did not have a therapy slot available. The psychotherapists' learned approach of treatment was not a decisive factor in determining whether they were willing to provide treatment. Most of the psychotherapists (85%) recommended a BPD disorder-specific therapy such as Dialectical Behavior Therapy (DBT), Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP) or Schema Therapy (ST). However, only just under 7% were certified in such a disorder-specific approach. Significant individual stress factors described by the psychotherapists were suicidal risk (70%) and potential other-directed aggression (59%). In addition, it was shown that it played a role whether the psychotherapists were trained in an additional therapy approach (with at least 16 teaching units) or not. The care situation for people with BPD seeking an outpatient psychotherapy place is clearly in need of improvement. This is mainly due to a general lack of available therapy places as well as various fears and anxieties, such as increased suicidality, which in turn can have a negative impact on the provision of outpatient therapy. Psychotherapists who have undergone disorder-specific further training feel less burdened by suicidal behaviour. However, since only a small number of them are able to offer BPD-specific therapies, it is essential to expand and (financially) support specific training programmes. In order to meet the demand for care, professional changes are urgently needed.

Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla’s Treatment

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

[Implications on the Diagnosis and Treatment of Narcissistic Personality Pathology in Adolescents Based on the Sequelae of the Covid-19 Pandemic].

The COVID-19 pandemic caused more adolescents with a pathological narcissistic personality to seek clinical as well as psychotherapeutic treatment due to suicidal crises, breakdown of social functioning and inability to continue school attendance. Recent study results show that youth with personality disorders (pd) had more trouble returning to school and to everyday life following pandemic related closures of schools. In a sample of adolescent patients with pd who were treated with transference focused psychotherapy (TFP-A) in a day-clinic programsignificantlymore juveniles remained absent fromschool during the pandemic then pre-pandemic. Only 42 % of the adolescents from the pandemic-group returned to school as a result of the treatment in comparison to 53%of the juvenile patients who returned to school after being treated before the pandemic. This might be explained by the specific effect the pandemic had on adolescents with narcissistic pd and their problem with being treated. Unfortunately, there is still hesitance in diagnosing and investigating narcissistic personality pathology in adolescence despite the knowledge that the early diagnosis and specified treatment could prevent unfavorable pathways and chronification of their severe problems. Changes in the conceptualization of pd in ICD-11 and DSM-5 enable a differentiated diagnosis beginning in late childhood. Furthermore, there are specialized manualized treatment approaches for adolescents with pd. This paper aims at illustrating the specific characteristics of narcissistic pd in youth as well as describing the symptom aggravation following the pandemic. It also points out the possibilities of a modified specialized treatment approach based on transference focused psychotherapy. Further research is needed to improve diagnostic and therapeutic modifications for juveniles with pd.

Psychotherapies for the treatment of borderline personality disorder: A systematic review.

Borderline personality disorder (BPD) is the most common personality disorder, affecting 1.8% of the general population, 10% of psychiatric outpatients, and 15%-25% of psychiatric inpatients. Practice guidelines recommend psychotherapies as first-line treatments. However, psychotherapies commonly used for the treatment of BPD are numerous, and little is known about the comparative effectiveness of each individual psychotherapy versus treatment as usual (TAU) or other psychotherapies. To systematically assess the comparative effectiveness of commonly used psychotherapies versus TAU or versus other psychotherapies for BPD treatment. We conducted systematic literature searches in MEDLINE, EMBASE, the Cochrane Library, and APA PsycINFO up to July 14, 2022, and searched reference lists of pertinent articles and reviews. Inclusion criteria were (a) patients 13 years or older with a diagnosis of BPD, (b) treatment with commonly used psychotherapies, (c) comparison with TAU or another psychotherapy, (d) assessment of relevant BPD-related health outcomes, and (e) randomized or nonrandomized trials or controlled observational studies. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We found 25 psychotherapy studies meeting inclusion criteria with data on 2,545 participants. Seventeen studies compared nine psychotherapies with TAU and nine studies compared eight psychotherapies with another psychotherapy for the treatment of BPD. Overall, both TAU and included psychotherapies were effective in treating the severity and symptoms of BPD. Moderate certainty of evidence suggests that systems training for emotional predictability and problem solving is more effective than TAU for the treatment of BPD; low certainty of evidence suggests that dialectical behavior therapy, schema therapy, transference-focused psychotherapy, acceptance and commitment therapy, manual-assisted cognitive therapy, and cognitive behavioral therapy are more effective than TAU for treating BPD. We were unable to draw conclusions from head-to-head comparisons of psychotherapies, which were limited to single studies with very low to low certainty of evidence. All commonly used psychotherapies improve BPD severity, symptoms, and functioning. Our assessment found no strong evidence suggesting that any one psychotherapy is more beneficial than another. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Trust in Therapeutic Work With Adolescents With and Without Personality Disorders: A Transference-Focused Therapy Perspective.

Trust is central to successful therapeutic work with adolescents, but establishing trust can be challenging, especially with adolescents with personality disorders. We present our understanding of trust in working with adolescents with and without personality disorders. We draw on complementary and overlapping perspectives, namely the attachment model, Kernberg's object relations model, and Fonagy's mentalization model. In Kernberg's object relations conceptualization, difficulties in trust experienced by patients with borderline personality disorders result from paranoia associated with splitting and identity diffusion. In Fonagy's mentalization model, epistemic trust is rooted in early experiences of being responded to and understood. We outline how techniques used in transference-focused psychotherapy for adolescents promote the development of the adolescent's capacity to trust by facilitating identity integration, thus reducing paranoia. Finally, we use two clinical case illustrations to demonstrate how trust unfolds in working with adolescents with and without personality disorders.

Developments in Group Transference-Focused Psychotherapy.

Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.

Transference-Focused Psychotherapy for Adolescents with Personality Disorders: A Case Example with a Focus on the Interpretative Process and Transference Analysis

ABSTRACT In this paper, I focus on the nature and functions of the interpretive process in psychotherapy with adolescents with severe personality disorder. I will describe how the interpretive process in transference focused psychotherapy for adolescents provides affective containment and symbolic management of psychological conflict along with a shift toward the predominance of repression-based over primitive defenses. This process leads to a progressive resolution of identity diffusion. I will give illustrations of different phases of the interpretive process.

Review of Treating Pathological Narcissism with Transference-Focused Psychotherapy.

Review of Treating Pathological Narcissism with Transference-Focused Psychotherapy.

The Sound of Silence: Engaging the Quiet Adolescent.

Engaging the silent adolescent is a major psychotherapeutic challenge. This article presents a comprehensive approach to this problem, illustrated with clinical material. This approach emphasizes a careful diagnostic assessment, including an assessment of the patient's level of personality organization and capacities to participate in psychodynamic psychotherapy. Three approaches to the silent teenager are explored in depth: a mostly supportive approach focused on containment of maladaptive behaviors; a psychodynamic approach with supportive elements focused on demonstrating safety through humor, play, normalization, and self-disclosure while exploring the patient's automatic relationship patterns; and a psychodynamic approach using transference-focused psychotherapy for adolescents (TFP-A), aimed at effecting long-lasting changes in the patient's views of self and others and their characteristic ways of managing conflict and stress, with gradual movement from a tendency for controlling, protective silence to vulnerable, cooperative sharing.

A Review of Borderline Personality Disorder in Adolescence

Personality instability in adolescence that develops into BPD, can make adolescents experience long-term impairment conditions that can reduce the quality of social life, education and work in the future. Borderline Personality Disorder (BPD) is a condition where a person experiences a personality disorder characterized by emotional or mood instability, behavior, self-image and impulsive behavior that is difficult to control by showing symptoms of at least 5 of the 9 diagnostic criteria. It is said to be borderline or threshold because people with this disorder do not meet the characteristics of either neurosis or psychosis, so it is considered to be in between the two conditions.
 The cause of BPD is unclear, but it is thought to be the result of genetic, psychosocial and neurobiological factors that influence brain development. Therapeutic modalities that can be given to people with BPD include Dialectical Behavioral Therapy (DBT), Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP), and Schema-Focused Therapy (SFT).

Treating Narcissistic Personality Disorders: a case illustration of key clinical contributions from Transference Focused Psychotherapy for psychoanalytic practitioners

Narcissistic Personality Disorder (NPD) is complex and difficult to treat. Whilst there is no research based evidence for the specific treatment of NPD, there is an evidence base for psychotherapeutic approaches to Borderline Personality Disorder (BPD) which includes Transference Focused Psychotherapy (TFP). TFP is a contemporary object relations approach which has been developed to treat patients with a Borderline Personality Organization, which includes narcissistic personality structures. TFP therefore stands to contribute to the treatment of NPD. We introduce main tenets of TFP, and how TFP views narcissism. We then present a case illustration to illustrate aspects of TFP which are key clinical contributions in treating NPD. These include assessment of personality organization, the treatment contract, transference, countertransference, use of clarification and interpretation, technical neutrality, therapist centered interpretations, the treatment frame and consideration of the stage of treatment

Object Relations–Informed Psychotherapy: Introduction to Festschrift Honoring Otto F. Kernberg, M.D.

Back to table of contents Next article EditorialFull AccessObject Relations–Informed Psychotherapy: Introduction to Festschrift Honoring Otto F. Kernberg, M.D.Jill C. Delaney, L.C.S.W., and John F. Clarkin, Ph.D.Jill C. DelaneySearch for more papers by this author, L.C.S.W., and John F. ClarkinSearch for more papers by this author, Ph.D.Published Online:15 Mar 2023https://doi.org/10.1176/appi.psychotherapy.20220068AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Editing this compendium in tribute to Otto F. Kernberg, M.D., and his work has been a great pleasure. Dr. Kernberg has made enormous contributions to the study of psychiatry, psychoanalysis, object relations theory, personality organization, and severe personality disorders. He is a world-renowned psychiatrist and psychoanalyst, a passionate teacher and lecturer, a hospital administrator, and a scholar.Born in Vienna, Kernberg fled Nazi Germany in 1939 with his family and immigrated to Chile, where he completed his medical and psychoanalytic training. He first came to the United States in 1959 on a Rockefeller Foundation Fellowship to study research in psychotherapy with Jerome Frank at the Johns Hopkins Hospital. Dr. Kernberg returned to the United States in 1961 to join the C. F. Menninger Memorial Hospital in Topeka, Kansas, where he later became director of the hospital until 1965. During this time, he was also the codirector of the Psychotherapy Research Project of the Menninger Foundation, along with Robert Wallerstein. Dr. Kernberg’s work at Menninger became the foundation of his lifelong interest in psychotherapy research and severe personality disorders, particularly in the understanding and treatment of borderline personality and narcissistic personality disorders. His integrative writings have been central to the development of modern object relations, a theory of mind that is perhaps the most widely accepted among modern psychoanalysts, and his principal contributions have been in the fields of narcissism, object relations theory, and personality disorders. Dr. Kernberg developed a novel and useful framework for situating personality disorders along dimensions of structural organization and severity. In 1995, he cofounded the Personality Disorders Institute, which was established by Cornell University’s Weill Medical College so that he might continue his work in the field upon retiring as medical director of New York Hospital (1976–1996), and served as director of the institute from its inception to 2022. His writings have educated, enlightened, and inspired generations of mental health professionals throughout the world.From his earliest days at Johns Hopkins, Dr. Kernberg has argued that our understanding and treatment of psychopathology must be rooted in theory and empirical research. The articles in this special issue were written by senior colleagues who have been fortunate to benefit from their long-standing collaboration with him. Carla Sharp and John Oldham (1) describe the recent paradigm shift in the diagnostic approach to personality pathology by the American Psychiatric Association, as reflected in DSM-5, and emphasize the profound influence of Dr. Kernberg’s theory of the primacy of an integrated sense of self to personality organization. Lina Normandin and colleagues (2) describe the contribution of Dr. Kernberg’s object relations model to the understanding of personality disorders and their presentation and development in adolescence. Dr. Kernberg’s emphasis on the role of affects in the formation of self-other representations, their elaboration and modification through development, and the expansion of these operations in adolescence to sexuality, morality, autonomy, and other areas is considered. The status of the individual’s identity integration is used to describe different adolescent developmental pathways (i.e., typical identity development, identity crisis, identity diffusion) on the basis of features such as maturity of defenses; integration of morality; and a clear, organized sense of self. Current understanding of the technical aspects of the trajectory of personality pathology in adults is explored by Mark Lenzenweger (3). Eve Caligor and colleagues (4) explain the basics of Dr. Kernberg’s object relations theory and the contribution of this theory to understanding human behavior. By using Dr. Kernberg’s theory of object relations, Caligor and colleagues have developed a measure by which to reliably assess a patient’s quality of object relations, degree of identity integration, defensive structure, and severity of pathology. Diana Diamond and colleagues (5) illustrate the connection, as posited by Dr. Kernberg, between object relations theory and attachment theory with empirical work on reflective functioning. John Clarkin and colleagues (6) trace the empirical exploration of object relations theory and the development of transference-focused psychotherapy (TFP) into a transdiagnostic therapeutic approach to personality pathology. Frank Yeomans and colleagues (7) describe the methods of teaching and supervising TFP that have been instituted in psychiatric residency settings, analytic training institutes, universities, and professional settings that have become centers of excellence in TFP treatment around the world. In a remarkable display of Dr. Kernberg’s current thinking on a wide range of subjects, please see Stephan Doering’s review (8) of Kernberg’s most recent book, Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders.The breadth and acuity of Dr. Kernberg’s prodigious contributions to our field cannot be adequately covered in this brief volume, which is a mere sampling of the theoretical and empirical elaboration inspired by his lifelong pursuit of understanding the human condition.Department of Psychiatry, Weill Medical College, Cornell University, New York City.Send correspondence to Ms. Delaney ([email protected]).The authors report no financial relationships with commercial interests.

An Integrated Developmental Approach to Personality Disorders in Adolescence: Expanding Kernberg's Object Relations Theory.

This article is a tribute to Dr. Otto F. Kernberg and his contribution to the theoretical understanding of personality pathology in adolescence. In his object relations theory of the structure of personality, an integrated identity is considered central to healthy personality functioning and is contrasted with identity diffusion, which is posited to underlie the maladaptive interpersonal functioning of patients with severe personality disorders. His work provided an early theoretical foundation for the understanding and treatment of personality disorders in adults, but a need remained for a deeper understanding of the development and treatment of personality disorders during adolescence. During the past 10 years, Kernberg has led a group of clinicians and developmental researchers focusing on childhood and adolescence to elaborate an understanding of the development, assessment, and treatment of personality disorders among adolescents. He proposed that in the context of typical development, adolescence is important to the expansion of identity, because it represents the period when sexual and aggressive impulses are integrated and earlier representations of the self and others are revised and become more realistic and nuanced. Furthermore, adolescence entails a reorganization of the moral system and enrichment of the ego ideal. This article presents two methods for assessing personality disorders in adolescence that are based on Kernberg's theory and demonstrates the use of transference-focused psychotherapy for adolescents with personality disorders.

Videoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis.

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering different psychotherapy orientations. Less is known about whether and how VCP affects psychodynamic psychotherapeutic approaches and reports on remote work with severe and complex mental health problems such as severe personality disorders are still scarce. The aim of the study was to examine the experiences of psychodynamic psychotherapists, mainly delivering Transference-Focused Psychotherapy (TFP), with the transition and delivery of VCP during the first wave of the COVID-19 pandemic. Four hundred seventy-nine licensed psychotherapists completed an online survey during the peak of the pandemic. Survey data were analyzed using qualitative analysis. Results are presented and discussed concerning advantages and disadvantages regarding the access to psychotherapy, the specificity of the online video setting, bodily aspects, the quality of the therapeutic relationship, the therapeutic process including technical aspects and therapist's experience. Furthermore, we analyzed and discussed the statements concerning transference and countertransference reactions differentiating between high-level borderline and neurotic patients and low-level borderline patients. Our results support the importance to identify patients who potentially benefit from VCP. Further research including more prospective randomized controlled trials are needed to investigate the therapeutic implications of the findings.

Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders.

Back to table of contents Previous article Book ReviewNo AccessHatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality DisordersStephan Doering, M.D.Stephan DoeringSearch for more papers by this author, M.D.Published Online:21 Dec 2022https://doi.org/10.1176/appi.psychotherapy.20220056AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article"Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders." American Journal of Psychotherapy, 76(1), p. 51 Access content To read the fulltext, please use one of the options below to sign in or purchase access. Personal login Institutional Login Sign in via OpenAthens Purchase Save for later Item saved, go to cart PPV Articles - APT - American Journal of Psychotherapy $35.00 Add to cart PPV Articles - APT - American Journal of Psychotherapy Checkout Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited byObject Relations–Informed Psychotherapy: Introduction to Festschrift Honoring Otto F. Kernberg, M.D.Jill C. Delaney, L.C.S.W., and John F. Clarkin, Ph.D.15 March 2023 | American Journal of Psychotherapy, Vol. 76, No. 1 Volume 76Issue 1 March 01, 2023Pages 51-51 Metrics KeywordsPsychotherapyPersonality DisordersTransference-focused psychotherapy (TFP)object relations theoryPDF download History Published online 21 December 2022 Published in print 1 March 2023

Reflections on the Treatment of Youth During Simultaneous Training in Transference-Focused Psychotherapy and Psychoanalysis

ABSTRACT The author recounts his experience training simultaneously in transference-focused psychotherapy and psychoanalysis while treating youth with personality disorders. He discusses their similarities and differences, and considers the dilemma of selecting the appropriate treatment modality when both may be helpful. He then illustrates his handling of this dilemma with case material from the treatment of a 12-year-old girl with borderline personality disorder.