Transference focused psychotherapy: Development of a psychodynamic treatment for severe personality disorders

Abstract

The Borderline Psychotherapy Research Project at New York Presbyterian Hospital-Weill Cornell Medical Center, headed by Drs Otto Kernberg and John Clarkin has developed and tested a treatment for Borderline Personality Disorder called Transference Focused Psychotherapy. The theory, development and empirical research for the treatment are discussed. A pre-post study and a comparison to treatment as usual both showed promising results. The structure of the randomized controlled trial that is currently underway is also discussed.

Introduction

In the second half of the 20th century, psychoanalysis lagged behind other psychological orientations in generating empirical research [1]. The once-revolutionary methods of psychological investigation introduced by psychoanalysis, namely free association and interpretation, had not been supplemented with other experimental methods. At the same time, across the broader field of psychology, the emphasis on empirically validated psychotherapies increased ([2], see [3] for a critique of this approach), widening the research gap between psychodynamically oriented psychotherapies and other treatments. However, in recent years, psychodynamic psychotherapy has begun a culture change. A growing number of psychodynamic researchers are now applying methods that were once thought to be an awkward fit with psychodynamic therapy. Major efforts have been made in instrument development, the manualization of therapies, and process and outcome studies [4], [5], [6], [7], [8], [9]. There is also increasing dialogue with other fields, such as neurobiology, reflecting sophisticated attempts to link a psychodynamic understanding of pathology and treatment to physiological underpinnings. In this article, we discuss our own efforts in the study of psychodynamic psychotherapy, utilize our own research as an example of the strides being made in this area and as highlight important issues and developments in the field.

Since the early 1980's, the Borderline Psychotherapy Research Project at New York Presbyterian Hospital-Weill Cornell Medical Center, headed by Drs Otto Kernberg and John Clarkin, has been systematizing and investigating an object relations treatment of borderline patients. As part of this project, we have developed a manualized [10], [11], [12], modified psychodynamic treatment for patients with Borderline Personality Disorder called Transference Focused Psychotherapy (TFP).

TFP is a structured psychodynamic treatment based on Otto Kernberg's object relations model [13]. Kernberg's model focuses on the development of mental representations that are derived through the internalization of attachment relationships with caregivers. For Kernberg, the degree of differentiation and integration of these representations of self and others, along with their affective valence, constitutes personality organization. Borderline personality can be thought of as a severely disturbed level of personality organization, characterized by the use of primitive defenses (e.g. splitting, projective identification, dissociation), identity diffusion, and deficits in reality testing.

The major goals of TFP are better behavioral control, increased affect regulation, more intimate and gratifying relationships, and the ability to pursue life goals. This is hypothesized to be accomplished through the development of integrated self and object representations, the modification of primitive defensive operations and the resolution of identity diffusion that perpetuates the fragmentation of the patient's internal representational world. Thus, in contrast to therapies that focus on the short-term treatment of symptoms, the treatment we are developing has the ambitious goal of not just changing symptoms, but changing the personality organization which is the context of the symptoms.

We were committed to developing a new treatment—not just using existing psychodynamic treatments—that effectively targets borderline pathology. In that process, we have utilized the wisdom of the psychodynamic community; advances in object relations, attachment, and developmental theories; and data on the maturation of attention, effortful control and the sense of self and others. Our orientation combines theory, clinical experience, research findings, and the reformulation of the treatment in response to new data.