Description of Transference-Focused Psychotherapy
for Borderline Personality Disorder

Transference-Focused Psychotherapy (TFP) is a psychodynamic treatment designed especially for patients with borderline personality disorder (BPD). A distinguishing feature of TFP in contrast to many other treatments for BPD is the belief in a psychological structure that underlies the specific symptoms a borderline individual suffers from. In other words, the focus of treatment is on a deep psychological make-up — a mind structured around a fundamental split that determines the patient's way of experiencing self and others and the environment. In such a psychological organization, thoughts and feelings about self and others are split into dichotomous experiences of good or bad, black or white, all or nothing. Since these either/or states determine the nature of the patient's perceptions, splitting leads to the chaotic interpersonal relations, impulsive self-destructive behaviors, and other symptoms of BPD. The internal split is based on a model of the mind in which early affectively-charged experiences are cumulatively internalized over time in the individual's mind and become established in the individual's psychological structure as "object relations dyads" — that is, units of memory, and sensorial experience which combine a specific representation (idea) of the self and a specific representation (idea) of the other linked by a specific affect. Different dyads represent different images of the self and of the other connected by different affects. These dyads are not exact, accurate representations of historical reality, but tend to represent the extreme images and affects in which they were initially experienced. In the course of normal psychological development, these separate dyads become integrated into a unified whole resulting in a more mature and flexible sense of self and others in the world. However, in borderline individuals, these separate dyads do not become integrated in this way. Instead, dyads associated with sharply different affects exist independently from one another and determine the lack of continuity of the borderline patient's subjective experience in life.

An obvious question is why this integration does not take place in individuals with BPD. TFP posits a multifactorial explanation in which elements of biologically-determined temperament and of environment combine to maintain this split psychological structure. In over-simplified terms, internal representations of a frustrating other in relation to a helpless deprived self are totally split off from internal representations of a gratifying other in relation to a satisfied self. These opposite images are imbued with intense affects, both hateful (in association with the first internal representation), and loving (in association with the second). While the patient has no conscious awareness of this split internal world (and his or her ability to identify with either side of it at different moments in time), this structure underlies and determines the symptoms mentioned above, such as chaos in interpersonal relations, emotional lability, black-and-white thinking, anger, and proneness to distortion in thinking. Under conditions of high stress, borderline patients may lose the capacity to think symbolically, so that they fail to appreciate the "whole" of the situation and interpret events in catastrophic and intensely personal ways. They fail to discriminate the intentions and motivations of the other and thus, perceive only threat or rejection. In psychodynamic terms, this split internal structure corresponds to the syndrome of identity diffusion and use of primitive defense mechanisms. In more phenomenological terms, this psychological structure results in an individual going through life with a subjective experience that is fragmented, discontinuous, rigid and impoverished.

The treatment focuses on the transference [the patient's moment-to-moment experience of the therapist] because it is believed that the patient lives out his/her predominant object relations dyads in the transference. Once the treatment frame is in place, the core task in TFP is to identify these internal object relations dyads that act as the "lenses" which determine the patient's experience of the self and the world. It is believed that the information that unfolds within the patient's relation with the therapist provides the most direct access to understanding the make-up of the patient's internal world for two reasons. First, it has immediacy and is observable by both therapist and patient simultaneously so that differing perceptions of the shared reality can be discussed in the moment. Second, it includes the affect (feelings) that accompanies the perceptions, in contrast to discussion of historical material that can have an intellectualized quality.

This twice-per-week individual psychotherapy has been developed over a period of decades and is described in a treatment manual.^1,2,3,4 Although it dates back many years, TFP combines many of the elements described in the recently published Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association. For example, more than in most psychoanalytically based therapies, TFP places special emphasis on the assessment and on the treatment contract and frame.⁵ In fact, the method specifies that therapy itself cannot begin until these tasks are accomplished, until the conditions of treatment are in place. The setting up of the contract and frame has a behavioral quality in that parameters are established to deal with the likely threats both to the treatment and to the patient's well-being that may occur in the course of the treatment. The patient is engaged as a collaborator in setting up these conditions. After the behavioral symptoms of borderline pathology are contained through structure and limit setting, the psychological structure that is believed to be the core of borderline personality is analyzed as it unfolds in the transference [the relation with the therapist as perceived by the patient]. Even with this emphasis on interpretation of the transference, TFP acknowledges the possible role of auxiliary treatments (e.g. for active eating disorders or substance abuse) and includes attention to pharmacological interventions to address specific symptoms.

The TFP manual describes the strategies, tactics, and techniques of treatment. In brief, as the unintegrated representations of self and other become delineated in the course of the treatment, the therapist helps the patient understand the reasons — the fears and anxieties — that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experiencing of strong affects within the therapeutic relationship. The combination of understanding and affective 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 affective lability, impulsivity and interpersonal chaos, and the ability to proceed with effective choices in work and relationships. In other words, our experience is that the integration of the psychological structure can result in the resolution and cure of the borderline condition.

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1 Clarkin, JF, Yeomans, FE, & Kernberg, OF (1999). Psychotherapy for Borderline Personality. New York: J. Wiley and Sons.
2 Kernberg, OF, Selzer, MA, Koenigsberg, HA, Carr, AC, & Appelbaum, AH. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.
3 Koenigsberg, HW, Kernberg, OF, Stone, MH, Appelbaum, AH, Yeomans, FE, & Diamond, DD. (2000). Borderline Patients: Extending the Limits of Treatability. New York: Basic Books.
4 Yeomans, FE, Clarkin JF, & Kernberg, OF (2002). A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ: Jason Aronson.
5 Yeomans, FE, Selzer, MA, & Clarkin, JF. (1992). Treating the Borderline Patient: A Contract-based Approach. New York: Basic Books