Transference focused psychotherapy

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change. Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change. TFP has been validated as an efficacious treatment for borderline personality disorder (BPD), though too few studies have been conducted to allow firm conclusions about its value. TFP is one of a number of treatments that may be useful in the treatment of BPD; however, in a study which compared TFP, dialectical behavior therapy, and modified psychodynamic supportive psychotherapy, only TFP was shown to change how patients think about themselves in relationships. TFP is a treatment for borderline personality disorder (BPD). Patients with BPD are often characterized by intense affects, stormy relationships, and impulsive behaviors. Due to their high reactivity to environmental stimuli, patients with BPD often experience dramatic and short-lived shifts in their mood, alternating between experiences of euphoria, depression, anxiety, and nervousness. Patients with BPD often experience intolerable feelings of emptiness that they attempt to fill with impulsive and self-damaging behaviors, such as substance abuse, risky sexual behavior, uncontrolled spending, or binge eating. Further, patients with BPD often exhibit recurrent suicidal behaviors, gestures, or threats. Under intense stress patients with BPD may exhibit transient dissociative or paranoid symptoms. According to an object relations model, in normal psychological development mental templates of oneself in relation to others, or object representations, become increasingly more differentiated and integrated. The infant's experience, initially organized around moments of pain ('I am uncomfortable and in need of someone to care for me') and pleasure ('I am now being soothed by someone and feel loved'), become increasingly integrated and differentiated mental templates of oneself in relation to others. These increasingly mature representations allow for the realistic blending of good and bad, such that positive and negative qualities can be integrated into a complex, multifaceted representation of an individual ('Although she is not caring for me at this moment, I know she loves me and will do so in the future'). Such integrated representations allow for the tolerance of ambivalence, difference, and contradiction in oneself and others. For Kernberg the degree of differentiation and integration of these representations of self and other, along with their affective valence, constitutes personality organization. In a normal personality organization the individual has an integrated model of self and others, allowing for stability and consistency within one's identity and in the perception of others, as well as a capacity for becoming intimate with others while maintaining one's sense of self. For example, such an individual would be able to tolerate hateful feelings in the context of a loving relationship without internal conflict or a sense of discontinuity in the perception of the other. In contrast, in Borderline Personality Organization (BPO), the lack of integration in representations of self and other leads to the use of primitive defense mechanisms (e.g., splitting, projective identification, dissociation), identity diffusion (inconsistent view of self and others), and unstable reality testing (inconsistent differentiation between internal and external experience). Under conditions of high stress, borderline patients may 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. Thus thoughts and feelings about self and others are split into dichotomous experiences of good or bad, black or white, all or nothing. The major goals of TFP are to reduce suicidality and self-injurious behaviors, and to facilitate better behavioral control, increased affect regulation, more gratifying relationships, and the ability to pursue life goals. This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations, and the resolution of identity diffusion that perpetuate the fragmentation of the patient's internal representational world.