Extensions of Psychoanalytic Technique: The Mutual Influences of Standard Psychoanalysis and Transference-Focused Psychotherapy

The author describes the differences between standard psychoanalysis and transference-focused psychotherapy (TFP) and reviews particular difficulties that psychodynamically trained clinicians have in learning TFP. In delineating differences between standard psychoanalysis and TFP, the author discusses mutual influences between standard psychoanalytic techniques and techniques of TFP. TFP is an extension and modification of standard psychoanalysis, but with quantitative modifications geared to the treatment of the most severe segment of personality disorders that tend not to be treatable by standard analysis. TFP includes some features that are directly facilitated by psychoanalytic education, such as the importance of free association and the organization of interpretations in terms of the analysis of defense, motivation, and impulse. On the other hand, TFP provides new strategies, enhancing standard psychoanalytic treatment, when it modifies technical neutrality under certain circumstances, allows for the analysis of “incompatible realities,” and accelerates interventions under conditions of severe acting out when technical neutrality is not possible to maintain. The author demonstrates the advantages of systematic training in TFP within psychoanalytic institutes as a true enrichment of technical training. He proposes that psychoanalysis as a profession consists of a broad spectrum of treatment approaches based upon the combined utilization of psychoanalytic techniques, with specific modifications to be organized in specific forms of psychoanalytic psychotherapy. TFP may be the closest modification to standard psychoanalysis proper and is clearly defined and manualized. This has permitted empirical research that has already demonstrated the effectiveness of TFP.

Application of Transference Focused Psychotherapy in Borderline Personality Disorders

Borderline Personality Disorder (BPD) is a condition that is currently commonly found in daily psychiatric practice, and causes serious psychiatric disorders because it has an impact on the emergence of various other comorbid psychiatric disorders. The management of BPD is a challenge, because it is quite difficult and complex. Psychotherapy is an effective first-line therapy for BPD. Transference Focused Psychotherapy (TFP) is psychodynamic based psychotherapy that is specifically designed for BPD and is considered effective based on the specific psychopathology of BPD, namely the lack of identity integration. TFP focuses on the relationship between patient and therapist in sessions which have the aim of facilitating better behavioral control and increasing reflection and influencing regulation so as to produce identity integration that leads to a more coherent identity, better regulatory abilities, less self-destructive behavior. forming a more balanced and constant relationship, and increasing overall functioning.Keywords : Borderline Personality Disorder, Psychodynamic Psychotherapy, Transference Focused Psychotherapy.

Managing Countertransference in the Treatment of Personality Disorders

The clinical and technical difficulties presented by patients with personality disorders are well documented. This article focuses on the challenges faced by therapists when managing their emotional reactions, that is, their countertransferences, to patients with personality disorders. While leaving room for therapists' unique and idiosyncratic countertransferences to the patient with personality pathology, Kernberg emphasized the role of a more general form of countertransference, one reflective largely of the patient's conflicts and defenses, in the treatments of personality disordered individuals. Here, the nature of the patient's internal and external functioning can be seen to lead to similar reactions among different therapists, opening the possibility of utilizing countertransference to better understand the patient's difficulties. In transference-focused psychotherapy (TFP), countertransferences arising in the patient–therapist interaction are first identified and contained by the therapist and then utilized to clarify and explore how the patient's internal object relations are being enacted in the clinical process. This article describes this process and how TFP therapists work with their countertransference to help illuminate the patient's split representational world, paving the way for interpretation and integration.

Transference-Focused Psychotherapy for Pathological Narcissism and Narcissistic Personality Disorder (TFP-N)

In this article, we provide an overview of transference-focused psychotherapy for patients with pathological narcissism and narcissistic personality disorder (TFP-N). In TFP-N we have modified and refined the tactics and techniques of TFP, an evidence-based treatment for borderline personality disorder, to meet the specific challenges of working with patients with narcissistic personality pathology whose retreat from reality into an illusory grandiosity makes them particularly difficult to engage in treatment. We first describe a model of narcissistic pathology based on considerations of psychological structure stemming from object relations theory. This model provides a unifying understanding of the core structure of narcissistic pathology, the pathological grandiose self, that underlies the impairments in self and interpersonal functioning of those with narcissistic pathology across the levels of personality organization (from high functioning to borderline to malignant). We then delineate the clinical process of working with patients with pathological narcissism and narcissistic personality disorder. Starting with the assessment process, using a detailed clinical example, we guide the reader through the progression of TFP-N as it helps the patient move from the distorted, unintegrated sense of self underlying the narcissistic presentation to the more integrated, realistic sense of self that characterizes healthier personality functioning. In TFP-N the focus on the disturbed interpersonal patterns of relating in the here and now of the therapeutic interaction is the vehicle to diminish grandiosity and improve relatedness, thereby effecting enduring changes in mental representation and real-world functioning.

Thoughts on Transference Analysis in Transference-Focused Psychotherapy

Transference-focused psychotherapy (TFP) represents a specific extension of psychoanalytic therapy for treatment of individuals with personality disorders, who may be helped without the more significant time investment required of a standard psychoanalysis. The treatment represents a contemporary formulation of psychoanalytic psychotherapy, updated in light of both empirical research and scientific developments in boundary fields close to the psychodynamic endeavor, particularly affective neuroscience and the psychology of couples and small groups. In TFP, the transference signifies the enactment in the here and now of a specific affective relationship between patient and therapist that reflects one aspect, defensive or impulsive, of a pathogenic dynamic unconscious conflict. This conflict needs to be analyzed, interpreted, and resolved. Various elements of transference analysis in TFP are discussed in this article.

Applied Transference-Focused Psychotherapy: An Overview and Update

Transference-focused psychotherapy (TFP), developed and studied as an extended individual psychotherapy for patients with borderline personality disorder (BPD), rests on a rich theoretical foundation informed by psychoanalytic object relations theory. “Applied TFP” is a developing initiative using TFP principles in multiple clinical situations other than the standard extended individual psychotherapy, which has been empirically validated and is detailed in the TFP treatment manual. The growing application of TFP principles in innovative, overlapping ways has been focused primarily in three spheres: (1) the integration of TFP principles in pluralistic theoretical approaches to treatment of patients with personality disorder pathology; (2) the use of TFP elements in multiple teaching situations as part of curricula for trainees and practicing clinicians, and (3) the employment of TFP theory and interventions in settings across a continuum of patient acuity, tailored for patients with varying diagnoses. The use of TFP principles in the situations described directly addresses needs emerging in particular contexts that reflect specific requirements of clinician practice and training and of broader public health missions.

Good Psychiatric Management and Transference-Focused Psychotherapy for Borderline Personality Disorder: A Spectrum of Psychodynamically Informed Treatments

Good psychiatric management for borderline personality disorder (GPM) and transference-focused psychotherapy (TFP) are evidence-supported treatments that may be used in a complementary, flexible manner to provide a spectrum of psychodynamically informed care. In this article, we provide overviews of TFP and GPM, describing GPM's eclectic approach that includes psychodynamically informed supportive psychotherapy, case management, and medication management, informed by a model of hypersensitivity to rejection, comparing it with TFP's focus on identity integration and modification of standard psychodynamic techniques for use in treating patients with borderline personality disorder. We outline convergences and divergences between TFP and GPM in assessment, establishment of treatment goals and a treatment agreement, family involvement, and moment-to-moment psychotherapeutic interventions. The options for integration of TFP and GPM theoretical principles, as well as for models of treatment sequencing, are explored. Clinical vignettes are provided that illustrate sequential uses of GPM and TFP as part of psychodynamically informed long-term clinical management.