26 Oct Transference Focused Psychotherapy at Life Change Health Institute
Transference-Focused Psychotherapy (TFP) is an evidence-based psychodynamic therapy designed for patients with the type of condition known as personality disorders. Individuals with these conditions may experience depression, anxiety and/or other intense emotions. They may also experience frustration and a lack of fulfillment in personal relationships and work achievement. “Psychodynamic” refers to the idea that different parts of our mind are always in movement and that this may result in conflicts; for example, conflicts about whether or not to act on an impulse, urge or desire.
TFP sees difficulties in an individual’s psychological structure (the way the mind is made up) as underlying many of the specific symptoms the individual is experiencing. Simply put, psychological structure is seen as built around images of oneself and important other persons that have been internalized in the course of growing up. These images are not fully conscious within the individual, and they may contain distortions. They play an essential role in how the patient adjusts to life as they become the lenses through which an individual interprets or “reads” what he is experiencing. Exaggerated, distorted or unrealistic internal images can lead to problems in mood, self-esteem and relations with others.
These problems can be modified through psychotherapy. TFP is based on the idea that the patient experiences and lives out the internal images that make up their psychological structure in his or her relationship with the therapist, known as the transference (the transference of internal images and beliefs onto the current experience that the patient is having). Helping the patient get to know the repertoire of images that make up his mind—his internal world—can help him or her better adjust these images to the world around him. This process can lead to a decrease in depressive and anxious feelings and more successful experiences in personal relations and work achievement. Our approach to personality disorder treatment and research is based on the understanding of personality disorders in general and BPD in specific that is described on this page. Transference-Focused Psychotherapy is grounded in contemporary psychoanalytic theory since we believe that psychoanalytic thinking has much to offer in terms of understanding and treating personality disorders. However, our approach includes specific modifications of technique to address the therapeutic needs of patients with borderline and other personality disorders. Our patients do not lie on the couch, do not come to see us four or five times per week, and we, the therapists, are far from silent and removed from the process. Two beliefs that inform our work, that we share with most other psychoanalysts, and that distinguish our work from that of say, a cognitive-behavioral therapy (for example, Dialectical Behavior Therapy [fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”][DBT], another treatment for BPD) are that:
(1) “Symptoms,” the observable, behavioral manifestations of any disorder, are explained significantly by internal, mental or emotional factors, not generally visible to the naked eye, and that attention to these internal emotional factors or states is an essential part of the treatment process; and
(2) Over the course of a psychotherapy, some of the emotional factors that influence the problematic behaviors or symptoms and that had previously been unclear to the patient and therapist become clear to both through their mutual, careful attention to the goings on in the treatment relationship, which includes the transference of images within the patient’s mind, which they may not be fully aware of, to the person of the therapist (and others in their life). So with this overview, let us now proceed to build on our understanding of personality disorders to explain how we conceptualize treatment.
Within the International Society for Transference-Focused Psychotherapy, one of the more challenging aspects of our work, as therapists specializing in the treatment of personality disorders, is the process of sharing with patients our impression of their diagnosis, and outlining for them the type of treatment we are proposing. Albeit difficult, this process is an essential and legally required aspect of the process of starting treatment, called “informed consent.” Generally, we start with an explanation of the term: Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person’s subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships.
We explain that, while the world is enriched by the variety of personality styles that exist, when a person personifies and lives out a particular personality style in an extreme and inflexible way that causes a certain level of distress in one’s emotional and interpersonal life, they meet criteria for a personality disorder. We find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones). We also, in reviewing the particular symptoms of BPD that we have noted in the diagnostic phase we have just completed with the patient, note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more “under the radar,” characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms and we inquire as to whether this understanding makes sense to the patient.
With this understanding of personality disorders and BPD described in another section of this website, our treatment model, Transference-focused Psychotherapy (TFP), logically follows. This twice-per-week individual psychotherapy combines many of the elements described in the Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association with a deep understanding of mental processes. TFP has demonstrated efficacy across two randomized clinical trials to date in the treatment of the symptoms of BPD. In contrast to other models of treatment, models that tend to focus on reducing symptoms through behavioral control, skill-based teaching, and overt therapist support, coaching, and guidance, TFP has a very different mechanism of action. Although TFP, like other models, places special emphasis on patient assessment / evaluation, and on setting up a treatment contract (a mutually agreed upon set of conditions that serve as a framework for the work of the treatment), the emphasis in TFP is on helping patients understand the shifts in their experience of themselves, and in their experience of others, as this split sense of identity plays out through their experiences in work and relationships, and, importantly, as it plays out in the treatment relationship itself.
The work of TFP is roughly divided into an initial phase of establishing a structure for the treatment that includes limit-setting with respect to the patient’s destructive behaviors and a longer phase of exploration of the patient’s mind and sense of identity. In reality, the two phases overlap since there is observation and exploration from the beginning, and limit-setting may continue far into the treatment. After confirming the patient’s diagnosis, the therapist and patient work to identify factors in the patient’s life that might interfere with the consistency and conduct of the treatment. Factors such as drug abuse or addition, chronic misuse of medication, a severe eating disorder, and self-injury and suicidality – each of these factors constitute not only a threat to the patient’s safety and well-being, but also to the treatment, and therefore, must be contained in order for the therapist and patient to do the work of TFP. Whereas some therapies work to provide concrete support in the moment that the patient is about to engage in one of these behaviors, TFP works differently. In TFP, we presume that the patient can largely take responsibility for these behaviors, at times with the help of adjunctive treatment such as Alcoholics Anonymous or an eating disorders support group, and in other cases simply through an agreement about how suicidality and self-injury are to be managed, with the understanding that the patient is in conflict about these urges and can try to stay with and strengthen the side that wants to refrain from the behavior.
As behavioral symptoms of personality disorder are contained through the discussion of and limit setting associated with the treatment contract, 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.
The focus of treatment is on the patient’s difficulties tolerating and integrating disparate images of the self and of others and on the misunderstandings that arise when the patient mistakenly sees aspects of his/her own feelings that are difficult to acknowledge as coming from the other person. While we call our treatment Transference-Focused Psychotherapy because of the centrality of the exploration of the patient’s experience of self and others through observation of the patient’s experience of the therapy and the therapist, the treatment also focuses on the patient’s difficulties in work and relationships outside the treatment. These areas are important in the exploration of the experience of self, others, and relation to the world. These areas are also where, along with improvement in the patient’s sense of self, we will see the benefits of treatment. Nevertheless, the therapist’s attention is ultimately directed to transference because we believe that observation of the patient’s moment-to-moment experience of the therapist provides the most direct access to understanding the make-up of the patient’s internal world. As the un-integrated representations of self and other get played out in the patient’s life and in the treatment relationship itself – often accompanied by the intense experience of emotion – the therapist helps the patient contain the emotions and observe the representations and understand the reasons, the wishes, fears and anxieties that support the continued separation of these fragmented senses of self and other. The therapist also helps the patient to observe shifts in the dominant self experience, using therapeutic techniques that include 1) clarification of internal states, 2) confrontation of contradictions that are observed, and 3) interpretation that help explain the divisions and links between different states.
For example, when a meek and unassuming patient suddenly shifts into an overtly dissatisfied or hostile stance, the therapist might start by inquiring: “Have you noticed a shift in your feelings?” The therapist might continue: “Let’s see if we can understand what you were experiencing in me as your feeling in the room shifted, and how the way you were experiencing yourself also shifted at that moment.” Through this type of “detective” work (we sometimes use the image of the TV detective Colombo who calmly and quietly explored the evidence), we can begin to flesh out the patient’s inner world of representations of self and other, to track the shift, usually a volatile and chaotic shift, between the patient’s various self states, and ultimately help them to reach a more reflective stance about his or her emotional life – the fundamental goal of the treatment is to help the patient learn to reflect on emotional states that were previously not understood and were acted upon without reflection. The combination of understanding within the context of 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, there is a positive cycle in which understanding of one’s representational and emotional world leads to an increased ability to modulate emotions and, in turn, the enhanced modulation of emotions helps the patient further increase his or her capacity to reflect and understand.
Ultimately, our experience is that the integration of the initially fragmented 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.
Read an Overview of Transference Focused Psychotherapy Here
TFP approach to Psychoanalytic Group Psychotherapy
I shall outline, in what follows, strategies, tactics, and techniques of the TFP model of analytic group psychotherapy. The main strategy consists in facilitating the interpretation of Bion’s (1961) basic assumption groups, in the context of a strict focus, on the part of the therapist, on the nature of the primitive object relations and corresponding defensive operations activated in the course of any basic assumption group. In practice, the defensive operations activated in the dependency and in the fight-flight group present the total repertoire of primitive defensive operations based upon splitting mechanisms characteristic for borderline patients. As such, they are eminently relevant for the exploration of the psychopathology of patients with severe personality disorders, who find their dominant emotional reactions powerfully activated in the group situation.
Rather than interpreting the sequential activation of individually determined dominant transferences activated in the course of the group sessions, the therapist’s emphasis is on the sequence of group processes, the progressive and regressive fluctuations of the group tension that facilitates the activation of particular conflicts of individual patients–their “group valence”– at difference times. The individual pathology of any particular patient comes into central focus at a point where he/she occupies one of the polarities of the conflictual dynamics of the group. The fact that the therapist’s interpretations follow the dominant group dynamics, his/her pointing out how this dynamic is played out by different members of the group, practically facilitates interventions geared to individual patients at the time when their corresponding conflicts are affectively dominant. Thus, the TFP principle of interpreting affectively dominant conflicts holds for both the analysis of the group tension (Ezriel, 1950; Sutherland, 1952) and the analysis of the position of key members of the group in the enactment of and reaction to this group tension.
In practice, therefore, after the therapist has interpreted the dominant unconscious dynamics of the prevalent group tension, he may address himself/herself to how this group conflict touches all the individual members’ conflicts in terms of their position taken regarding that particular group conflict. In so far as individual patients’ transferences are directed to other members of the group, to the group as a whole, and to the group leader, moments where all these three vectors come together may provide a powerful source for emotional understanding for individual patients.
The therapist’s interventions in the group are guided by the same principles as the interventions in individual TFP sessions: first, by what is affectively dominant in the group, second, by the nature of dominant transferences operating within the group atmosphere, and third, by his/her countertransference. The therapist’s interventions consist in clarifications–namely, efforts to clarify the dominant issues affecting the group at a certain point; confrontation–namely pointing to the non-verbal behaviors that accompany and often overshadow the verbal communication among group members and of the entire group toward the leader, and interpretation per se–namely, of the unconscious conflict inherent in the activation of a determined group tension and the corresponding basic assumption group. The interpretation consists in focusing on the dominant group theme, by first pointing to the predominant conscious and preconscious experience of the group; then, the opposite, avoided theme and the motives for this avoidance, and finally, the nature of the experienced threat connected with what is avoided.
The therapist maintains an attitude of technical neutrality regarding the developments in the group, limited by his establishing clear rules about what is not tolerated: particularly, physical aggression against the therapist, against other members and property, or gross sexual harassment, such as seductiveness in the form of stripping, or self-destructive behavior, such as self-cutting or burning. The techniques utilized, in short, are interpretation, transference analysis, technical neutrality, and countertransference utilization. Countertransference utilization refers to the analysis in the therapist’s mind, of both concordant and complementary identifications he/she experiences regarding the group as a whole and individual members, followed by the utilization of the understanding of these developments as part of the interpretive formulations.
The technical approach, therefore, follows the same general principles and guidelines of the technical approach in TFP, while the overall strategy, of highlighting and resolving the dominant split off or dissociated primitive internalized object relations of these patients, are systematically explored in the order in which these object relations are achieving dominance as part of the group regression. Dominant object relations may be enacted by the group as a whole in relation to the group leader, by individual members toward the group, the leader, and toward other individual members. By means of the activation of projective identification, the role of self and object representations may be rapidly exchanged among the members of the group as well as between the group and the group leader.
So far the strategic and technical applications of TFP to this modified Ezriel-Sutherland model. From the viewpoint of tactical interventions, they include general arrangements that are specific for a group therapy approach, and particular ones corresponding to the specific application of a TFP model. Regarding general tactical interventions, they refer to the selection of members of the group, a complex decision making process, that, in general terms, corresponds to the same criteria for indications of Transference Focused Psychotherapy in individual patients mentioned before. Contraindications include patients with an intelligence level below an IQ of 85 or 90; severe, uncontrollable secondary gain of illness; significant antisocial behavior, that would risk the confidentiality of group processes to which the participants have to commit themselves, and objectively threaten other group members; and severity of acting out or comorbid conditions that could not be easily handled by an individual therapist taking care of those aspects of treatment outside the setting of the group psychotherapy.
The development of particular complications and severe regression of individuals in the group usually can be managed when the overall group setting is clear and consistent. Chronic monopolizers can be managed easily by pointing to the group’s tolerance or unconscious fostering of such behavior, and its meanings under the concrete group circumstances. The chronically silent patient may be much more behaviorally active in the context of shifting group themes than what is revealed by language alone, and varying meanings of the defensive use of silence can be explored in the context of its function as part of the group process. The manifestation of group resistances in the form of shared, extended silences, trivialization of the contents of the group discussion, demonstrative ignoring of the group leader and of his interventions, all become part and parcel of potential transference interpretations.
Research on TFP
Many groups of researchers all over the world are investigating different aspects of Transference-Focused Psychotherapy (TFP). This research can be grouped into (1) theoretical and conceptual work on borderline personality disorder (BPD) and TFP, (2) conceptual and empirical work on diagnostic instruments for the assessment of different aspects of BPD, and (3) empirical research on the outcome of TFP. Recently empirical research on the neurobiological foundations of BPD and its treatment has been begun in New York as well as Germany and Austria.
Theoretical and conceptual research
The major theoretical work on BPD and TFP origins from Otto F. Kernberg. Modern concepts of BPD go back to his perennial work on “Borderline Conditions and Pathological Narcissim” (1975) and “Severe Personality Disorders” (1984). Until today these books have shaped the diagnostic criteria for BPD in psychiatry and its classification systems ICD-10 and DSM-IV. In his recent work, Kernberg kept refining his concepts and applying it to different clinical conditions related to BPD, e.g., narcissistic personality disorder (Kernberg 1992, 2007, 2008, 2011).
From his theoretical and clinical work emerged the description of a specific treatment for patients with BPD (e.g., Kernberg 1975, 1976) that led to the first treatment manual in 1989 (Kernberg et al. 1989). Together with his co-workers, particularly John F. Clarkin and Frank E. Yeomans, to name only two of them, he refined this treatment, which is now called TFP and validly described in a comprehensive treatment manual (Clarkin et al. 2006).
Based on Kernberg´s concepts a number of modifications of TFP have been developed. Paulina Kernberg was the first to describe personality disorders in children and adolescents and their treatment (Kernberg et al. 2000). Her approach has been developed further by a number of researchers, particularly Pamela Foelsch and Lina Normandin, a treatment manual will soon be published. An adaptation of TFP for forensic patients was developed in the German speaking countries (Lackinger et al. 2008), TFP for higher level (neurotic) personality disorders was conceptualized by Eve Caligor and colleagues (Caligor et al. 2007). Moreover, TFP applications for narcissistic patients, elderly patients, and groups, respectively, as well as inpatient TFP are currently in preparation.
Diagnostic instruments and assessment
In 1981 Kernberg published his first paper on Structural interviewing. His clinically oriented Structural Interview aims at the assessment of personality organization, a concept that is now incorporated into modern psychiatric diagnosis: The DSM-5 classification will contain a Levels of Personality Functioning Scale that is derived from Kernberg´s dimensions of personality organization. Clarkin and colleagues (2003) transformed the Structural Interview into a structured interview, the Structured Interview for Personality Organization (STIPO) that allows for quantification of different dimensions of personality organization. A self-rating instrument that is closely related to the STIPO is the Inventory of Personality Organization (IPO; Clarkin et al. 2001a). Stimulated by Kernberg´s diagnostic approach a number of observer-rated and self-rating instruments occurred during the last decade (for review see Doering & Hörz 2012). The assessment of personality organization (synonym: personality structure, personality functioning) nowadays receives increasing attention in psychiatry and clinical psychology. A number of empirical studies have investigated the relationship of personality disorders and personality organization (e.g., Fischer-Kern et al. 2010; Hörz et al. 2009) and the effect of TFP on personality organization (Doering et al. 2010).
Empirical outcome research
Transference-Focused Psychotherapy (TFP) is an empirically-validated treatment for personality disorder that has proven its efficacy in three uncontrolled studies (Clarkin et al. 2001b, Cuevas et al. 2000, Lopez et al. 2004). These three investigations demonstrated significant improvements in psychopathology, self-mutilizing behaviour, and psychiatric hospitalizations after one year of TFP. Three randomized controlled trials (RCT) evaluated the efficacy of TFP. In the study of Giesen-Bloo et al. (2006) TFP was comparator for Schema Therapy. Both treatments improved psycho- and personality pathology significantly, but Schema Therapy was superior after three years of treatment. These results have been criticised for methodological reasons (Yeomans 2007). A second RCT compared TFP with Diallectic Behavioral Treatment (DBT) and Psychodynamic Supportive Therapy (SPT) (Clarkin et al. 2007). Ninety borderline patients were included into the study and received psychotherapy for one year. All three groups showed significant positive change in depression, anxiety, global functioning, and social adjustment in a multiwave design. TFP and DBT were associated with a significant improvement of suicidality, TFP and SPT improved facets of impulsivity, and only TFP yielded a significant improvement in anger, irritability, and verbal and direct assault. Moreover, only patients that received TFP improved significantly in their reflective function and their attachment style; 28.6% of the TFP patients changed from an insecure to a secure attachment style, whereas none of the DBT and SPT patients did (Levy et al. 2006). In a third RCT TFP was compared to treatment by experienced psychotherapists in the field (Doering et al. 2010). One hundred and four patients were treated for one year in Munich and Vienna, respectively. TFP resulted in a significantly higher remission rate, fewer drop-outs, fewer suicide attempts, fewer psychiatric in-patient admissions, higher improvement of personality structure and psychosocial functioning. A RCT on TFP for adolescents is about to be finalized and reveals encouraging results so far. Taken together, three uncontrolled studies and two randomized controlled trials from independent groups demonstrated the efficacy of TFP for the treatment of borderline personality disorder. A recent Cochrane review on psychotherapy for BPD counts TFP among the “beneficial” borderline treatments together with Dialectc behaviour Therapy (DBT), Mentalization-based Therapy (MBT), Schema Therapy, and STEPPS (Stoffers et al. 2012).
TFP for Narcissistic Patients
Clinical experience involving the treatment of patients with severe narcissistic pathology suggests that this patient population is among the more treatment refractory within the personality disorder spectrum. Recent studies have suggested that patients with Narcissistic Personality Disorder (NPD) now encompass about 6.2% in community samples (Dhawan et al. 2010) and up to 35.7% of clinical populations (Zimmerman et al. 2005). There are also some indications that NPD is more prevalent among young adults in the U.S. (Stinson et al. 2008), and that narcissistic personality traits in the nonclinical young adult population are on the rise (Twenge & Campbell 2009). In addition numerous studies have shown a high degree of co-occurrence of NPD with other Axis II disorders, especially cluster B (borderline, anti-social, histrionic personality disorders), and Axis I disorders, particularly affective disorders (unipolar and bipolar depression), substance use disorders, anxiety disorders, and eating disorders (Fossati et al. 2000, Simonson & Simonson 2012, Zimmerman et al. 2005). Complicating the diagnostic picture is the fact that pathological narcissism spans a spectrum of pathology from neurotic to borderline levels of organization. Indeed, there has been increasing attention to conceptualizing narcissistic disorders as dimensional disorders with varying degrees of pathology of self and object relations, reflected in the current drafts of the DSM-5 (www.dsm-5.org; Bender et al. 2011). The high level of comorbidity along with increasing attention to the dimensional as well as categorical aspects of personality disorders suggest that narcissistic pathology may be a major factor across the personality disorder spectrum (Ronningstam, 2010, 2011).
The current DSM V proposal puts new emphasis on structures and mechanisms related to impairments of self and interpersonal relations in all personality disorders including NPD. Narcissistic disorders are thought to involve 1) Impairments in identity, characterized by a specific pattern or style of unrealistic self experiences, including particularly exaggerated self appraisals; grandiosity expressed either covertly or overtly (exaggerated sense of superiority or inferiority or shifts between the two); and, in some patients, an overreliance on others for shaping the patient’s sense of identity and self definition; 2) Impairments in interpersonal functioning, particularly the use of others for self esteem regulation; superficial, shallow relationships, lacking in empathy, and designed to fulfill the patient’s need for admiration, attention, and validation; and antagonism as opposed to agreeableness in relationships (shown to be associated with narcissistic personality disorder in DSM-5 field trials). Such difficulties in the regulation of aggression along with other impairments in self and interpersonal functioning for individuals with NPD stem from a particular configuration of self and object representations, the pathological grandiose self, which involves a condensation of ideal self, ideal other, and real self representations. Such a self structure excludes the possibility of engaging in relations in depth – there is a “dismantling” of relations with others because of chronic devaluing of others. Negative affects, particularly devalued aspects of self are split off, denied and projected onto others leading to antagonism towards others and an inner sense of emptiness.
As Kernberg (1975) stated, “Pathological vicissitudes of aggression may determine the failure of such … an integration of object representations, with the subsequent development of pathological object relations and a pathological, grandiose self.” (p. 246) Transference Focused Psychotheapy (TFP) is a psychodynamic approach to psychotherapy developed to treat patients with a range of personality disorders at different levels of severity, including individuals with NPD. Borderline and narcissistic personalities share core structural features, specifically, identity pathology, supported by the operation of “primitive” defensive strategies for the unconscious management of intolerable self-states and affects. The central focus of TFP is the identification and naming of maladaptive, distorted self representations, along with their complementary distorted object representations, in the service of interpreting and ultimately resolving the splitting and other primitive defensive operations which prevent a more realistic, integrated, differentiated assessment of self and others. Through the tracking of these self-object dyads in the patient’s internal world, and identifying the defensive processes which support them, through working with negative affects (antagonism) and the object relational dyads that fuel them, TFP constitutes an effective treatment for a spectrum of narcissistic disorders from low to high functioning, i.e., grandiose, vulnerable, malignant. In addition, since TFP emphasizes the identification with both self and object poles of the object relational dyads that comprise the internal world (e.g. grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the different phenotypic presentations, forms of expression, and/or fluctuating mental states from grandiose to vulnerable, from arrogant/entitled to depressed/depleted that may characterize narcissistic personality disturbances (Cain et al. 2011, PDM Task Force 2006).
Based on our clinical experience with and research data on patients with narcissistic personality disorders, we have developed modifications of Transference-Focused Psychotherapy (TFP) to treat patients with different levels of severity of narcissistic pathology (Diamond et al, 2011; Diamond et al. in press). These modifications focus around the centrality of the grandiose self, its central defensive role in psychological structure of the patient with NPD, and how best to address this rigid defensive system. Modifications to standard TFP technique at all stages of TFP include the following: 1) Modifications to the assessment and treatment contracting phase of TFP including a more prolonged and flexible phase of contract setting; 2) A more prolonged phase of inquiry-based interpretive efforts, i.e., those aspects of the interpretive process that focus on requesting clarification from the patient about his or her mental life rather than the more traditional delivery of interpretations by the therapist; and 3) the enumeration of several technical strategies that support the patient’s ability to tolerate the necessarily painful and threatening feelings (e.g., anxiety, rage, a sense of disorientation and/or annihilation) that accompany the more challenging aspects of interpretive work in a psychoanalytic psychotherapy with narcissistic patients. Our clinical formulations have been informed by our research on patients with co-morbid borderline and narcissistic disorders (NPD/BPD) from three international samples of BPD patients in Transference-Focused Psychotherapy. In brief our findings suggest that the NPD/BPD patients may be distinguished from BPD patients without NPD on a variety of clinical dimensions including: 1) a particular pattern of co-morbidity with other AXIS II disorders (histrionic, anti-social, schizoptypal and paranoid) and 2) distinctive internal working models of attachment (Diamond et al. in press). In brief, individuals with NPD/BPD are characterized by attachment representions including dismissing devaluation of attachment relationships, preoccupation with unresolved anger about early attachment experiences, often oscillating between these two contradictory states of mind with respect to attachment—which helps us to understand the fluctuations in narcissistic resistances and transferences that make these patients so challenging to treat. Our research and clinical findings have been presented in a number of publications and presentations that are available on our website. In addition, our faculty have been involved in training and teaching TFP for NPD internationally.
About Borderline Personality Disorder
Personality disorder, as a term, may sound negative and judgmental and it is important to have a clear understanding with our patients of the meaning of the term. We explain that there is a group of disorders in the DSM-IV, ten of them to be specific (a number that will be reduced to six in the DSM-V), that are thought to be long-term and enduring, in contrast to episodic, personality styles that at their core are defined by difficulties in the person’s subjective, internal sense of identity, and chronic difficulties in his or her interpersonal relationships. It is noteworthy that the DSM-V description of personality disorders includes this emphasis on sense of self and relations with others more than the previous editions of the DSM did.
We explain that the ten different styles have many overlapping features and that most people have a mixture of those styles, but most importantly, that when people personify and live out any of those styles with a certain consistency, inflexibility, and in such a way that causes a certain level of distress in one’s emotional and interpersonal life, they meet criteria for a personality disorder. For patients with BPD, in reviewing the DSM-IV symptoms that the particular patient in question meets, we note that there are different sub-types of BPD patients, each with different sets of primary or most-problematic features. Some may be more impulsive and overtly inappropriately angry, whereas others may be more “under the radar,” characterized more prominently by the sense of emptiness, fears of abandonment, suicidal feelings, and more subtle shifts in their experience of others, from idealizing others to more quietly feeling devaluing or contemptuous of them. So with each patient we explain our understanding of his or her BPD symptoms. We also find it helpful to give an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and rapidly shifting; 2) relationships tend to be conflicted and stormy; 3) there may be impulsive, self-destructive or self-defeating behaviors; and 4) there is a lack of a clear and coherent sense of identity (this last problem may underlie all the preceding ones).
Our view is that the problems in the patient’s identity, that interact with a propensity to intense emotional responses and lead to the associated difficulties in the patient’s interpersonal life and the other symptoms of BPD, are best explained by a “divided” or “split” sense of self and others. We refer to this as the “split psychological structure” in which different, contradictory ways of thinking about the self and others manifest themselves at different times, or in different ways, but rarely if ever, at the same time. For example, a patient may present as morally rigid, highly concerned about proper and respectful behavior, but at other times engage in questionable moral practices and behave in provocative and inappropriate ways. Or a patient may present as very quiet and meek, describing a history of poor treatment by others but may, at times, demonstrate hostile and contemptuous behavior toward others. Yet another patient may present as self-sufficient, arrogant, a “know-it-all”, rejecting all that the therapist has to offer, whereas the therapist knows from the history and referral source that the patient has recently suffered fleeting depressive and suicidal feelings pursuant to one in a string of occupational failures. None of these “self representations” are specifically listed as BPD criteria in the DSM. Nevertheless, they each can be viewed as part of a dyad – a specific internal mental representation of self in relation to another. A borderline patient’s particular set of mental dyads involves contradictory representations of self, each of which experienced as true and authentic parts at the time it is being experienced. This alternation across time between different experiences of self can lead to confusion, anxiety, depression, and a sense of emptiness that comes from not having a stable sense of the core self.
How does this “split” sense of identity emerge, and why? We understand personality a person’s habitual way of experiencing self and others and of interacting with the world around him. We see these habitual patterns of experiencing the self and others as built up from people’s prior experiences, particularly those emotionally-charged interactions between the infant/child and significant caregivers, which are repeated over time. These experiences of self-in-relation-to-others from early in life are part of the normal developmental process and result in a set of expectancies as to how the self will be treated or experienced by another, and vice-versa, in subsequent relationships. In early infant development, specific experiences lead to dyads that are associated with specific emotions – pleasure/satisfaction and pain/frustration. In early life, these dyads are not accurate or literal representations of what is actually happenig; rather, they tend to represent polarized, extreme images and affects which are affected by the individual’s particular temperament – intense or quiescent, which links this way of thinking about BPD to current neurobiological studies.
In the case of healthy psychological development, these early, extreme and disconnected representations gradually become integrated into more complex, subtle and realistic internal images of self and others. We come to realize that we, and others, have both good qualities and bad, that we can experience disappointments in ourselves or others while still appreciating the good qualities. We learn that experiencing negative emotions does not destroy the capacity for positive emotions and that our emotional state can be complex, with a variety of emotions of multiple valence (rather than only all positive or all negative) in relation to others. In the case of healthy identity, various representations or ways of experiencing the self can co-exist without a sense of tension, dissonance, or threat. One can see oneself in any given interaction as smart, yet with something still to learn; one can see oneself as driven, a bit aggressive, yet at the same time patient and forgiving; one can see oneself as one who is dependent upon others, but is capable of operating in various spheres, effectively, on one’s own.
Indeed, healthy identity is defined as integrated and coherent, stable across time, and as based on a realistic self assessment in which positive affects predominate over negative affects, and with resulting ego strength that is sufficient to navigate life’s challenges and disappointments. In the case of the personality disorders, and BPD in particular, however, there is a failure of integration of these self representations. Internalized dyads associated with sharply different affects (positive and negative) remain split off and continue to exist independently from one another so that the world is experienced in highly concrete/all-or-nothing terms, and with confusion and lack of continuity. Consequently, in response to triggers (life events), an individual experiences himself, and others, in terms of extreme and simplistic representations that are not coherently connected with the representations of self and other that might be triggered by a minor event (e.g., the individual may feel very happy and valued when a friend smiles at him, and may feel sad and worthless if the friend is late for meeting; the corresponding images of the friend would be a loving person in the first instance and a rejecting person in the second.)
Let us now extend this idea of the split sense of self, this sense of a dyad that is split, with part of the self being experienced at one time and another part at a second point in time, to the realm of interpersonal relationships. For the BPD patient, at each point in time he is experiencing only one self-representation, connected to one dyad; for example, the rigidly moralistic self at one moment, or the victimized self at another moment, or the nurtured self at a third moment. We find that each of these partial self-representations corresponds, at that moment, to a view of the other, who is experienced in the moment as the embodiment of the other side of the dyad. When a BPD patient is experiencing himself as moralistic, he tends to experience others as loose, slackers, unrighteous. Similarly, the patient experiencing herself as a meek, innocent victim tends to experience others as hostile, hurtful, and persecutory. The BPD individual who is experiences herself as nurtured and cared tends to experience the other as the perfect provider and caretaker. As life develops the situation is complicated by the fact that the patient may have populated his or her life with characters who actually, or at times, embody some of those tendencies. It is therefore very important, in the course of therapy, to sort out the degree to which the patient’s description of others is colored by the representations in his or her mind in contrast to the degree to which the patient is accurately describing others. This is one reason we find it very useful in therapy to focus on the transference – the patient’s perception of the relation with the therapist – so that we can compare the patient’s experience of what is happening with what appears to be happening on an objective level. As we get to know patients, what we tend to find is that patients need to experience others, including often their therapist, as embodying the opposite of side of the dyad. In sum, the patient’s experience of others is as divided, split, and unrealistic as is his or her sense of self.
The other BPD criteria tend to follow from this description of splits in the representation of self and other. When a person lives life with a need to avoid certain experiences of the self, positive or negative – loving or hating, because that self representation is too threatening (or perhaps too exciting), it results in a feeling of instability, of incompleteness, as the experience of the self shifts across situations and different interpersonal situations. Indeed, patients with BPD describe a subjective sense of instability, emptiness, and inner confusion. Other people then, come to play an important, albeit unrealistic role in the BPD patient’s life. They are not simply friends with whom to experience and share life, but crucial assistants in the patient’s self regulation (although usually unaware that they have been placed in this role). For example, if a patient needs to experience himself as smart or popular, and chooses associates that help mirror that feeling, then he needs to carefully control interactions: he can’t have others look smarter or more attractive than he is, because then his sense of inadequacy would come into awareness. Similarly, a patient can’t have the other leave him because then he’s on his own, to face his worst sense of self. In another example, if a patient can’t tolerate her own tendencies to be judgmental, contemptuous, and hostile, it stands to reason that she will often see in others those same tendencies, and will experience others as judging her, as being unreasonably cruel or angry with her, and at times may accuse them as such.
Although these processes do not operate consciously in the individuals with personality disorders, one can easily imagine the strains that this way of experiencing the self and the world places on one’s interpersonal relationships, and one can also see how some of the other BPD criteria would logically follow, namely the intense and unstable interpersonal relationships, the propensity towards intense, inappropriate anger, the fears of abandonment, and, one can imagine, the impulsivity, the transient suicidal feelings and parasuicidal behaviors that result when others fail to assume the roles the borderline patient has unconsciously assigned them, or when others actually reject or leave the patient, with a mix of confused, exasperated, angry, and/or frustrated feelings. This understanding of borderline and other personality disorder has led to the development of Transference-Focused Psychotherapy.
Dynamic Psychotherapy for Higher Level Personality Pathology (DPHP) (Caligor, Kernberg and Clarkin, 2007) is derived from Transference-Focused Psychotherapy (TFP), with modifications introduced to optimize treatment of personality pathology at the healthier end of the spectrum of severity. DPHP is recommended for treatment of better-functioning dependent, histrionic, and narcissistic personality disorders, as well as for obsessive- compulsive, depressive, hysterical and avoidant personality disorders.
Higher level personality pathology is associated with relatively stable and well integrated experiences of self and others, and with a capacity for relationships characterized by mutual dependency and concern. As a result, individuals with higher level personality pathology are often able to function reasonably well, and sometimes very well, in some domains. Nevertheless, higher level personality pathology is associated with internal and external difficulties that bring these individuals to the attention of mental health professionals. In the clinical setting, patients commonly present with problems in their interpersonal and intimate relationships and/or with difficulty living up to their potential in their professional lives. Problems with self-esteem and/or self-criticism, emotional and sexual inhibitions, difficulty coping flexibly with internal and external stressors, as well as symptoms of anxiety and depression are common. DPHP was developed to best meet the clinical needs of these individuals, organized at a neurotic or high borderline level of personality organization using Kernberg’s criteria, and functioning at levels 1 and 2 on the DSM5 Levels of Personality Functioning Scale.
DPHP is an intensive form of psychotherapy in which therapist and patient meet one-on-one. Therapy is typically conducted at a frequency of two sessions per week, and usually lasts from one to three years. The therapist’s stance is active, helping the patient to identify specific treatment goals and then to focus on and explore the psychological conflicts underlying presenting difficulties. The goal of DPHP is personality change, as reflected in patients’ functioning and satisfaction in their interpersonal, intimate and work lives, and improvement in symptomatology. DPHP can be combined with medication management and other specific treatments for affective, anxiety, and eating disorders, which are often comorbid with personality pathology.
Like TFP, DPHP builds on psychodynamic object relations theory, in which internalized images of self and other are seen to organize interpersonal and subjective experience. In higher level personality pathology, views of self and other that are conflictual are largely outside of conscious awareness. In this setting, defensively held views of self and other are rigidly maintained, and come to organize subjective experience. Clinical intervention in DPHP targets personality rigidity. Psychotherapeutic technique focuses on helping patients develop fuller awareness of rigid, defensively held views of self and other, particularly in relation to presenting problems and complaints, to question these views, and to consider alternate perspectives. Focused inquiry on the part of the therapist, combined with a non-judgmental and accepting therapeutic stance, facilitates exploration and working through in the therapy of conflicts underlying defensive views of self and other. As conflictual aspects of experience become conscious the therapist helps the patient tolerate the painful emotions typically associated with such awareness, and to work through the thoughts and feelings that emerge. In this process, conflictual views of self and others come to be better integrated into subjective experience, leading to more flexible and adaptive psychological functioning and to resolution of presenting problems and symptoms.
The goals, strategies, tactics, and techniques of DPHP, along with the underlying theory of personality pathology are clearly described in our manual, Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology.
By Otto Kernberg MD
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