Transference-focused Psychotherapy Research Articles

Relationships between Techniques and Outcomes for Borderline Personality Disorder

Although a number of psychotherapeutic modalities for borderline personality disorder (BPD) have empirical support, it is unclear what aspects of treatment are responsible for improvement. The present study analyzes the relationships between different techniques and outcomes in a randomized controlled trial of dynamic deconstructive psychotherapy (DDP) for comorbid BPD and alcohol-use disorders. Video recordings of psychotherapy sessions at 3-month intervals were rated to measure therapeutic alliance and the relative frequencies of specific treatment interventions. Outcomes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Discrete sets of techniques were associated with reliable changes in specific outcomes, indicating that treatments for BPD should be tailored to the specific constellation of symptoms presenting in a given individual. The study findings suggest that treatments with a specified set of techniques, such as DDP, dialectical behavior therapy, mentalization-based treatment, schema therapy, supportive therapies, and transference-focused psychotherapy, may be helpful for different individuals, depending on their particular set of symptoms.

Ten-Year Use of Mental Health Services by Patients With Borderline Personality Disorder and With Other Axis II Disorders

Clinical experience suggests that individuals with borderline personality disorder commonly report being in psychotherapy and taking standing psychotropic medications over substantial periods of time. Clinical experience also suggests that patients with borderline personality disorder are frequently rehospitalized. However, only two longitudinal studies have prospectively examined the long-term course of the psychiatric treatment received by these patients. In the first of these studies [1], treatment utilization of patients with borderline personality disorder and axis II comparison participants was studied over six years of prospective follow-up in the McLean Study of Adult Development (MSAD). It was found that prevalence rates of individual therapy, standing medications, and psychiatric hospitalizations declined significantly for those in both study groups but remained significantly higher among patients with borderline personality disorder than axis II comparison participants. Perhaps most striking was the finding that 70% of patients with borderline personality disorder participated in individual therapy and 70% took standing medications in all three follow-up periods. In the second longitudinal study (the Collaborative Longitudinal Personality Disorders Study or CLPS), the treatment use of patients with borderline personality disorder was compared to that of patients with major depressive disorder and no personality disorder over the course of three years [2]. It was found that patients with borderline personality disorder were significantly more likely to be in individual therapy, have had a medication consultation, and been hospitalized for psychiatric reasons than those with major depressive disorder. The current study, which is an extension of the MSAD study mentioned above, has two purposes. The first is to describe the prevalence of three key treatment modalities reported by a large and well-defined sample of patients with borderline personality disorder and axis II comparison participants over 10 years of prospective follow-up. The second purpose is to detail time-to-cessation and time-to-resumption of these three forms of treatment by patients with borderline personality disorder.

Ten-Year Use of Mental Health Services by Patients With Borderline Personality Disorder and With Other Axis II Disorders

The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined. Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years. For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year follow-up; however, almost half of these patients were subsequently rehospitalized. The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder.

Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial

Transference-focused psychotherapy is a manualised treatment for borderline personality disorder. To compare transference-focused psychotherapy with treatment by experienced community psychotherapists. In a randomised controlled trial (NCT00714311) 104 female out-patients were treated for 1 year with either transference-focused psychotherapy or by an experienced community psychotherapist. Significantly fewer participants dropped out of the transference-focused psychotherapy group (38.5% v. 67.3%) and also significantly fewer attempted suicide (d = 0.8, P = 0.009). Transference-focused psychotherapy was significantly superior in the domains of borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the domains of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3-0.5). Self-harming behaviour did not change in either group. Transference-focused psychotherapy is more efficacious than treatment by experienced community psychotherapists in the domains of borderline symptomatology, psychosocial functioning, and personality organisation. Moreover, there is preliminary evidence for a superiority in the reduction of suicidality and need for psychiatric in-patient treatment.

New Developments in the Psychotherapies

believe that most psychotherapy researchers, including readers of this In Review, have had the following experience. A friend or relative, whom you have not seen for a while, inquires about the status of your research. With minimal hesitation, you offer something in layman's terms such as: I am trying to find out how effective different forms of psychotherapy [efficacy study] or I am trying to find out which psychotherapy works best with which type of patient [matching study] or I am trying to find out which type of patients work well together in a psychotherapy group [composition study]. Although rather straight-forward and seemingly clear, these examples are often met with a puzzled look that conveys the message Are you still doing that? or Have you found anything new yet? Just as there seems to be a wish among the general public to hear about new discoveries, there is a wish among psychotherapy researchers to be able to report new discoveries, not to mention breakthroughs. Unfortunately, in psychotherapy research, breakthroughs are few and far between, if they occur at all. For this reason, it was with definite interest and excitement on my part in anticipating the findings of the 2 papers in this In Review.1'2 They are devoted to New Psychotherapies for Mood and Anxiety Disorders1 and to Promising Psychotherapies for Personality Disorders (PDs). These disorders are very prevalent. Discoveries of effective new therapies for these disorders could be a considerable contribution to the field, particularly if they are shown to be more effective or less costly than previous therapies. In the first review article, Dr Shannon Wiltsey Stirman, Ms Katherine Toder, and Dr Paul Crits-Christoph1 identify so-called new therapies: 5 for mood disorders, 3 for posttraumatic stress disorder, and 2 for other anxiety disorders. These therapies were first introduced, or findings associated with them first reported, in the literature in the past 5 years (2004-2009). The therapies carry such names as acceptance and commitment therapy, behavioural activation therapy, and positive psychotherapy. Evidence of efficacy, effectiveness, and specificity vary considerably among the therapies. While the authors attempt to maintain a sense of optimism about the benefits of future research with new therapies, a sense of disappointment permeates their conclusions. This is due largely to their conclusion that although substantial benefit is associated with the new therapies, none has been found to surpass the benefits of previous therapies. The authors present an engaging discussion that provides context for considering these new developments for the treatment of mood and anxiety disorders. The second review article2 had similar objectives, although with a markedly different sample of patients, those with PDs. In addition, the period of investigation was briefer (the past 3 years) and only randomized controlled trial (RCT) studies were included. Interestingly, the authors avoided calling treatments new, instead electing to call them promising. Perhaps they sensed how difficult it really is to clearly define new. Dr George Hadjipavlou and Dr John S Ogrodniczuk2 reflect an increasingly positive pattern of response to treatment and prognosis. They identify numerous so-called psychotherapy packages that are backed up by evidence from the RCTs. Examples are mentalization-based therapy, transference-focused psychotherapy, and dialectical behavioural therapy. The authors provide an excellent discussion of the current state of psychotherapeutic treatment for PDs. They also correctly identified several limitations associated with studies in this area. Among these is the nearly exclusive focus on the treatment of borderline personality disorder (BPD), despite several recent commentaries in the literature that have appealed for more research on treatment of PDs other than BPD. Other limitations that affect research on treatments of Axis and II disorders include a short-sighted focus on pre-post therapy change to the exclusion of follow-up change. …

Psychotherapy of borderline personality disorder

Psychotherapy is considered the primary treatment for borderline personality disorder (BPD). Currently, there are four comprehensive psychosocial treatments for BPD. Two of these treatments are considered psychodynamic in nature: mentalization-based treatment and transference-focused psychotherapy. The other two are considered to be cognitive-behavioral in nature: dialectical behavioral therapy and schema-focused therapy. A review of the relevant literature was conducted. Each of these lengthy and complex psychotherapies significantly reduces the severity of borderline psychopathology or at least some aspects of it, particularly physically self-destructive acts. Comprehensive, long-term psychotherapy can be a useful form of treatment for those with BPD. However, less intensive and less costly forms of treatment need to be developed.

How to Deal with Cost Differences at Baseline

To our knowledge, adjustment for baseline imbalances in costs has never been performed in trial-based cost-effectiveness analyses. We used data from a clinical trial performed in the Netherlands comparing two outpatient psychotherapies: schema-focused therapy (SFT) versus transference-focused psychotherapy (TFP). Costs were assessed with a cost interview. Outcome was the proportion of recovered patients measured with the Borderline Personality Disorder Severity Index (BPDSI-IV). We used three methods to adjust the costs for baseline differences: (i) mean difference adjustment, calculating total costs after baseline by adjusting the difference between groups with the difference of the mean baseline costs; (ii) delta adjustment, calculating the individual differences between patient baseline and the subsequent measurements (concerning incremental costs, this is the same as mean difference adjustment); and (iii) regression-based adjustment, adjusting total costs with a regression model, with total costs as the dependent variable and baseline costs as the independent variable. Mean baseline costs were 3339 euros for SFT and 4238 euros for TFP, a mean difference of 899 euros. Total unadjusted follow-up costs were 30822 euros for SFT and 36812 euros for TFP. The fraction of recovered patients was 45% for SFT and 24% for TFP. Cost-effectiveness acceptability curves show that mean difference and delta adjustments are different from the regression-based methods. Although the routine starting point of an analysis should always be an unadjusted analysis of the cost effectiveness, a baseline difference between treatment groups should be adjusted for. This should be done by reported patient characteristics or, when these are not sufficiently present, by baseline costs as a substitute. This adjustment should be carried out most preferably with a regression-based method.

Borderline Personality Disorder

Borderline Personality Disorder

Incidence de certains facteurs sur l’issue d’une psychothérapie dans un essai clinique randomisé auprès de patients avec trouble de personnalité limite (TPL)

At the Personality Disorders Institute we have been investigating the efficacy of Transference-Focused Psychotherapy (TFP), a twice weekly manualized psychodynamic psychotherapy for borderline personality disorder compared to Dialectical Behavior Therapy (DBT) and Supportive Psychotherapy (SP) in a randomized clinical trial of 90 borderline patients. We will first present some developmental foundations of BPD, followed by a discussion of the theoretical foundations of TFP. We will then discuss patient characteristics that have an impact on outcome. We will present both clinical and empirical data in a discussion of individual cases that were representative of a sample of borderline patients treated in Transference-Focused Psychotherapy (TFP).

La relation patient-thérapeute : impacts de la théorie de l’attachement, de la fonction réflexive et de la recherche

This paper illustrates the centrality of attachment issues in a manualized psychodynamic psychotherapy for BPD, Transference-focused psychotherapy (TFP). The focus is on how the psychotherapist's awareness of these issues may advance the understanding of psychopathological processes mediated by attachment disorganization, and in particular how the patient-therapist match may foster or impede disorganized attachment.

Psychotherapy for Borederline Personality

Article AbstractFrom our regular book review column. This book, an update of the authors†1999 work withthe same name, is a superb treatise on a specific approach tothe patient with borderline personality disorder (BPD)—"transference-focused psychotherapy" (TFP). The stated focuson object relations may be considered misleading unless one realizesthat, in TFP, there is only one object, the therapist, andeverything follows from that transference perspective (viawhich are recapitulated all those key early object relationships).The authors, all well-known, prominent experts in the field,have done a remarkably balanced job in presenting not onlytheir viewpoint but other theories and approaches to BPD aswell.

Out-patient psychotherapy for borderline personality disorder: Cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy

Schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial. To assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder. Costs were assessed by interview. Health-related quality of life was measured using EQ-5D. Outcomes were costs per recovered patient (recovery assessed with the Borderline Personality Disorder Severity Index) and costs per quality-adjusted life-year (QALY). Mean 4-year bootstrapped costs were euro37 826 for SFT and euro46 795 for TFP (95% uncertainty interval for difference -21 775 to 3546); QALYs were 2.15 for SFT and 2.27 for TFP (95% UI -0.51 to 0.28). The percentages of patients who recovered were 52% and 29% respectively. The SFT intervention was less costly and more effective than TFP (dominant), for recovery; it saved euro90 457 for one QALY loss. Despite the initial slight disadvantage in QALYs, there is a high probability that compared with TFP, SFT is a cost-effective treatment for borderline personality disorder.

'Most-Cited Psychoanalyst' Continues Pioneering Ways

'Most-Cited Psychoanalyst' Continues Pioneering Ways

Can assessors and therapists predict the outcome of long‐term psychotherapy in borderline personality disorder?

Surprisingly few studies have investigated the accuracy of prognostic assessments of therapy outcome by clinicians. The objective of the present study was to investigate the relationship between clinicians' prognostic assessments and patient characteristics and treatment outcome. Seventy-one patients with a borderline personality disorder randomly allocated to schema-focused therapy (SFT) or transference-focused psychotherapy (TFP) were assessed every 3 months for 3 years. Prognostic assessments proved to be unrelated to patients' biographical (i.e., age, gender, education level, and employment level) and clinical characteristics (i.e., number of Axis I and Axis II diagnoses, and severity of psychiatric symptoms or borderline personality pathology). Clinical assessors as well as therapists rated the probability of success for SFT to be higher than for TFP. Prospective assessments of assessors and therapists accurately predicted different indices of outcome above and independent of patient characteristics. The prediction of outcome in the TFP condition in particular proved to be valid. Identifying prognostic markers of treatment outcome as used by clinicians in their prognostic assessments may improve current prediction models and patient-treatment matching.

Nieuwe ontwikkelingen in de behandeling van de borderlinepersoonlijkheidsstoornis?

New developments in the treatment of borderline personality disorder? A comparative analysis and implications for future research This article provides an overview of current treatments of borderline personality disorder that have been systematically studied in randomized controlled trials: Mentalization-based treatment (MBT), Schema-focused therapy (SFT), Transference-focused psychotherapy (TFP) en Dialectical behavior therapy (DBT). Available knowledge concerning the absolute and relative efficacy of these treatments is discussed. It is concluded that particularly MBT, SFT and TFP seem efficacious, yet little is known about the mechanisms of change. Guidelines for future research are also discussed.

Transference-Focused Psychotherapy for BPD

SUMMARY Transference-Focused Psychotherapy (TFP) is a modified psychodynamic psychotherapy, based on object relations theory of personality and psychoanalytic principles of the dynamic unconscious, the importance of transference and counter-transference, and the reliance upon interpretation of the transference as the dominant therapeutic intervention. TFP has been shown to be effective in reducing symptoms and improving reflective function in a randomized clinical trial with borderline patients. Beyond initial symptom reduction, TFP has as a goal the integration of identity through interpretative elaboration of split off internalized representations of self and others that underlie the DSM IV-TR descriptive phenomena of borderline personality disorder.

Change in Attachment Patterns and Reflective Function in a Randomized Control Trial of Transference-Focused Psychotherapy for Borderline Personality Disorder

Change in Attachment Patterns and Reflective Function in a Randomized Control Trial of Transference-Focused Psychotherapy for Borderline Personality Disorder

La psychothérapie focalisée sur le transfert (TFP) et le fonctionnement réflexif 1

Reflective functioning is a relatively new concept which broadly speaking, refers to the capacity to interpret human behaviours and interpersonal reactions in terms of underlying intentions and mental state motivations. This capacity is particularly important in the regulation of affects and the management of challenging interpersonal relations. In comparison to dialectical behavioural therapy (DBT) and supportive therapies, transference focused psychotherapy (TFP) has been shown to have unique advantages in terms of producing improvements in RF of borderline patients. In the present article, we propose a developmental perspective for understanding how TFP produces these changes in RF. Using this perspective, we identify a number of therapeutic mechanisms through which TFP facilitate the development of RF and specifically transference interpretations.

Le développement empirique de la psychothérapie focalisée sur le transfert

The author describes the stages of elaboration of Transference Focused Psychotherapy (TFP) : choice of theoretical model, observation and analyses of several sessions of psychotherapy led by experienced therapists, team discussions on problems encountered that rise both from the pathology itself and from the therapeutic approach applied, a quest of empirical data to explain as much the personality disorder as its neurological and psychological roots, etc. The author reviews the efforts made to arrive at the description in writing of a manual on TFP, a manual that meets the criteria of a treatment method. Finally, the author summarizes studies conducted to measure the psychotherapeutic efficacy of the method and the possibilities of generalizability.

Psychodynamic treatments of self‐injury

The authors address psychodynamic therapies, particularly transference-focused psychotherapy (TFP), in the treatment of patients who present with non-suicidal self-injury. In doing so, they briefly discuss various psychodynamic approaches with empirical evidence for their effectiveness. They describe TFP, including its treatment rationale, putative change mechanisms, and outcome research. They then present a case illustration of a patient with borderline personality disorder who engages in non-suicidal self-injury to demonstrate how TFP can be applied to such cases.