A Primer for Transference-Focused Psychotherapy
for Borderline Personality Disorder

Frank E. Yeomans, MD, PhD
John F. Clarkin, PhD
Otto F. Kernberg, MD
Published by
Jason Aronson.
Northvale, NJ (2002)

Table of Contents

This Primer responds to the need for a succinct yet thorough introduction to TFP. It is written at a level for both beginning therapists and experienced psychodynamic therapists who want to tailor their work to the borderline patient. In the Primer, we have made every effort to explain Transference-Focused-Psychotherapy in a way that is "user-friendly" and practical for the practicing therapist. You can review the table of contents to get a sense of how the Primer is organized.

Preface

PART I:
WHO ARE THE PATIENTS? DIAGNOSTIC ISSUES

1. What is borderline personality disorder (BPD)?
2. What is the borderline personality organization (BPO) and how does it provide a broader understanding and conceptual framework than borderline personality disorder (BPD)?
3. What is identity diffusion?
4. What is reality testing?
5. What are primitive defense mechanisms?
6. What is object relations theory and how does it apply to borderline personality and transference-focused psychotherapy (TFP)?
7. How are defense mechanisms understood in terms of internalized object relations?
8. How does the development of internal psychological structure differ in normal individuals as compared to individuals with borderline personality?
9. What is psychic structure?
10. Are there circumstances in which adults who are not borderline function at a split level of psychic organization?
11. In the primitively organized split psyche, what interactions might be expected within and among the object relations dyads?
12. How does one assess for BPO and BPD?
13. What are the origins of borderline personality organization?

PART II:
WHAT IS THE ESSENCE OF THE TREATMENT?

14. What is TFP?
15. What are the patient inclusion and exclusion criteria for TFP?
16. Aside from the strict exclusion criteria, are there other prognostic factors?
17. What kind of change can be expected from TFP?
18. How does TFP modify traditional psychodynamic psychotherapy to create a treatment specific to borderline patients?
19. What are the principle alternative treatments for BPD and BPO?

PART III:
TREATMENT STRATEGIES

20. What is the concept of treatment strategies?
21. What are the specific treatment strategies?

PART IV:
TREATMENT TACTICS

22. What are the treatment tactics?

PART IV-A:
TACTIC #1—CONTRACT SETTING

23. Does therapy start with the first session?
24. What constitutes an adequate evaluation?
25. Is it possible to include others, beside the patient, in the evaluation process?
26. What does the therapist say to the patient after arriving at a diagnostic impression?
27. When is the treatment contract set with the patient?
28. What therapeutic concepts underlie the treatment contract?
29. What are the universal elements of the treatment contract?
30. What are the elements of the contract that are specific to the individual patient?
31. How do I keep anxiety about the possibility of patients killing themselves from distracting me from my work?
32. What about patients who call very frequently?
33. What calls are appropriate?
34. What is done if the patient breaks the treatment contract?
35. When and how does a therapist shift from the contract-setting phase of therapy to the therapy itself?
36. What are the most common ways therapists have to intervene to protect the treatment frame?
37. What is the concept of secondary gain and why is it important to eliminate it?

PART T=IV-B:
CHOOSING THE PRIORITY THEME TO ADDRESS

38. Given the amount of data therapists are exposed to in a session, how do they decide what to address?
39. What are the economic, dynamic, and structural principles that guide the therapist's attention?
40. What are the three channels of communication??
41. What is the hierarchy of priorities with regard to material presented in a session?
42. How does the therapist use this hierarchy from moment to moment in the course of a session?
43. Which items on this list generally present a special challenge to the therapist?
44. Is there a strict separation between the addressing obstacles to therapy and the analytic work itself?

PART IV-C:
THE REMAINING TACTICS

45. How does the therapist maintain the balance between expanding incompatible views of reality between patient and therapist and establishing common elements of reality?
46. Why is it important to maintain an awareness of analyzing both the positive and negative aspects of the transference?

PART V
TREATMENT TECHNIQUES

47. What are the techniques used in TFP?
48. What is meant by clarification in TFP?
49. What is meant by confrontation in TFP?
50. What is meant by interpretation?
51. What are the different levels of interpretation?
52. How should interpretations be delivered?
53. How does the therapist go about the transference analysis of primitive defenses?
54. What is technical neutrality and how does the therapist manage it in TFP?
55. How do therapists monitor their countertransference and integrate what they learn from it into the treatment?

PART VI:
COURSE OF TREATMENT AFTER THE CONTRACT

56. What are the phases of TFP?
57. Does treatment generally demonstrate a linear progression?
58. What are some of the early problems that may be encountered in carrying out the treatment?
          Early problems I—Testing the frame/contract
59. Early problems Il—The meaningful communication is subtle and is in the patients' actions more than in his or her words.
60. Early problems Ill—The therapist has difficulty with how important the therapist has become to the patient.
61. Flow does the therapist manage affect storms?
62. What are the signs of progress in TFP?
63. What are the signs that the patient is nearing the termination of therapy and how does the therapist conceptualize and discuss termination?

PART VII:
SOME TYPICAL TREATMENT TRAJECTORIES

64. Is it possible to delineate some typical treatment trajectories that illustrate TFP principles as
the therapy evolves?

A. The patient with a chronic paranoid transference who desperately fights his underlying longing for attachment.
A1. How does the therapist integrate material from the past into the focus on the transference?
B. The patient whose aggression is split-off from consciousness and emerges only in action.
C. The patient who controls the therapy.
D. The patient with narcissistic personality and prominent antisocial features who begins therapy with a psychopathic transference.

PART VIII:
COMMON COMPLICATIONS OF TREATMENT

65. How does the therapist deal with the threat of the patient dropping out of treatment?
66. Are patients with childhood sexual and/or physical abuse capable of engaging in TFP?
67. Is hospitalization ever indicated in the course of treatment?
68. If the patient is hospitalized, should the therapist meet with the patient in the hospital?
69. What is the role of medications in TFP?
70. Who should prescribe the medications?
71. What are the most typical transference meanings of medication?
72. How does one handle crises around interruptions in the treatment?
73. How does the therapist deal with intense eroticized transferences?

PART IX:
REQUIREMENTS FOR DOING TFP

74. What are the basic skills needed to do this treatment?
75. What forms and levels of supervision are necessary/advisable?

PART X:
PRACTICAL QUESTIONS
IN DELIVERING THE TREATMENT

76. How does one get consultation on the TIP treatment of BPO patients or organize a supervision group?
77. How does one cover these patients when the therapist is away?
78. What if I work in a clinic that does not support twice-a-week therapy?
79. Is there empirical data to show that TFP is effective?

A Final Note

Index