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2	EDUCATIONAL OBJECTIVES I Understand concepts of object relations theory that TFP is based on II Understand basic elements of TFP Establishing a treatment contract Identifying strategies, tactics, and techniques of TFP Having a sense of the evolution of therapy
3	BORDERLINE PERSONALITY ORGANIZATION Basic Characteristics Identity Diffusion Primitive Defenses Generally Intact, but variable, Reality Testing Differentiation of self from non-self Internal from external reality Empathy with social criteria of reality
4	DEFENSES Primitive Defenses Splitting Idealization/devaluation Projective identification Omnipotent control Primitive denial
5	Object Relations Theory: The Object Relation Dyad
6	Split Organization: Consciousness of all-good or all-bad
7	Normal Organization: Consciousness of Integration/complexity
8	Paranoid Schizoid Position vs. Depressive Position
9	Patient’s Internal World S = Self-Representation O = Object - Representation a = Affect Examples S1 = Meek, abused figure O1 = Harsh authority figure a 1 = Fear S2 = Childish-dependent figure O2 = Ideal, giving figure a2 = Love S3 = Powerful, controlling figure O3 = Weak, Slave-like figure a3 = Wrath
10	Patient’s Internal World Experience of Self …and of therapist
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12	Dyad Defending Against Dyad
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14	THREE CHANNELS OF COMMUNICATION 1 -Verbal 2 -Non-verbal 3 -Countertransference
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17	TECHNIQUES The basic triad: Clarification, Confrontation, Interpretation of the Transference, eventually relating this to external reality and the past Managing technical neutrality (maintaining…, and deviating from as needed) Utilizing countertransference awareness
18	Technical Neutrality Equidistance from: Id Acting ego Superego External reality Alliance with the observing ego Not a bland, monotonous, indifferent tone
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21	FUNCTIONS OF THE CONTRACT 1. Defines the responsibilities of patient and therapist 2. Protects therapist’s ability to think clearly and reflect 3. Provides a safe place for the patient’s dynamics to unfold 4. Sets the stage for interpreting the meaning of deviations from the contract as they occur later in therapy 5. Provides an organizing therapeutic frame that permits therapy to become an anchor in the patient’s life
22	TREATMENT CONTRACTING PROCESS Therapist presents a part of the contract Patient responds to those conditions of treatment Therapist pursues elaboration of patient’s response Consensus -- or not
23	EXAMPLES OF THREATS TO TREATMENT Suicidal and self-destructive behaviors Homicidal impulses or actions, including threatening the therapist Lying or withholding of information Substance abuse Uncontrolled eating disorder Poor attendance Excessive phone calls or other intrusions into the therapist’s life Not paying the fee or arranging not to be able to pay Problems created external to the sessions which interfere with the therapy A chronically passive lifestyle which, although not immediately threatening, would defeat any therapeutic effort toward change in favor of the continued secondary gain of illness
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25	CHOOSING WHAT MATERIAL TO ADDRESS Economic principle: intervene where there is the most affect Dynamic principle: 1) conflict: defensively activated object relation and impulsive object relation; 2) go from defense (surface) to impulse (depth) Structural principle: structural aspects (one object relation that defends against another) of defense and impulse The hierarchy of thematic priorities
26	HIERARCHY OF THEMATIC PRIORITY Obstacles to Transference Exploration suicide or homicide threats overt threats to treatment continuity (e.g., financial difficulties, plans to leave town, requests to decrease session frequency) dishonesty or deliberate withholding in sessions (e.g., lying to the therapist, refusing to discuss certain subjects, silences occupying most of the sessions) contract breaches (e.g., failure to meet with an auxiliary therapist when agreed upon, failure to take prescribed medication) in-session acting out (e.g., abusing office furnishings, refusing to leave at the end of the session, shouting) non-lethal between-session acting out non-affective or trivial themes
27	HIERARCHY OF THEMATIC PRIORITY Overt Transference Manifestations verbal references to therapist nonverbal references to the therapist (e.g., positioning body in overtly seductive manner) as inferred by therapist (e.g., references to other doctors, to figures of authority, etc.) the patient’s way of being with the therapist Nontransferential Affect-Laden Material
28	Psychopharmacology Dr. Soloff will cover this topic from the pharmacological point of view The therapist must always be aware of the meanings that the patient may attribute to the prescribing of medication [The pro’s and con’s of split treatment]
29	Typical Course of Treatment Testing the contract and frame Focusing interpretations initially on the non-verbal and countertransference channels Dealing with awareness of therapist’s importance to patient and patient’s defenses regarding that (attachment issues) Interpreting defenses against integration
30	Evolution of Transferences Psychopathic Perverse Narcissistic Paranoid Depressive [Dr. Diamond’s talk on attachment will illustrate this more]
31	Case Example Challenge to the contract/struggle for control Dealing with the projected bad object Dealing with the internal bad object [confusion of “badness” with strength] Integration [To provide continuity, Dr. Diamond will discuss this example in more detail this afternoon in her talk on attachment]
32	INDICATIONS OF INTEGRATION/ STRUCTURAL CHANGE -I In 1^st phase of therapy, acting out decreases and atmosphere in sessions becomes more intense The patient’s comments indicate reflection on and exploration of therapist’s interventions The patient can contain and tolerate the awareness of his hatred, and of his love The patient can tolerate fantasies and the development of a transitional psychological space where awareness of affects replaces acting out
33	INDICATIONS OF INTEGRATION/ STRUCTURAL CHANGE - II The patient can accept the interpretation of primitive defense mechanisms, to take back projected part of the self and to experience simultaneously what was formerly split The predominant transference evolves from paranoid to depressive, with the capacity to experience guilt and gratitude as the patient enters the depressive position
34	WHAT ARE THE MECHANISMS OF CHANGE? Integration of self-concept Integration of concepts of others Integration of previously dissociated or split-off affect states with the result that affective experience and expression become enriched and modulated Increased capacity for empathy with self and others manifested in the development of in-depth relationships
35	How Does TFP Compare to the APA Guidelines for BPD? - I The initial assessment to establish: Level of treatment Clear and explicit treatment framework
36	How Does TFP Compare to the APA Guidelines for BPD? - II Psychiatric management Psychotherapy Symptom-targeted pharmacotherapy Responding to Crises/Safety monitoring Maintaining a therapeutic framework and alliance Providing education Coordinating treatment by multiple clinicians Monitoring clinical status and treatment plan Special Issues: Splitting and Boundaries