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 #1CONTRACT 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 ITesting the frame/contract
59. Early problems IlThe meaningful communication is subtle
and is in the patients' actions more than in his or her words.
60. Early problems IllThe 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