Transference-Focused Psychotherapy: Why It Works for Borderline Personality Disorder

The treatment of patients with borderline personality disorder (BPD) is one of the most challenging areas in mental health. Many clinicians are intimidated by the prospect, are pessimistic about the outcome, and consider stabilization of symptoms the best possible outcome. However, increasing scientific data and clinical experience allow for a more optimistic outlook, according to speakers at APA’s 2015 annual meeting in Toronto yesterday.

“We can now offer patients the chance to achieve not only symptom change but also improvement in the areas of work/vocation and love/intimate relations that, in the best of cases, helps patients move from the chronic limitations imposed by BPD to the normal satisfaction of life goals,” said Frank Yeomans, M.D., Ph.D., a clinical associate professor of psychiatry at Weill Medical College of Cornell University.

It is increasingly clear that change in the quality of a patient’s life requires the concomitant engagement of the patient’s affect systems (for example, attachment, seeking, fear, rage, grief/panic, play bonding) and his or her cognitive/reflective capacities. Transference-focused psychotherapy (TFP) is an evidence-based, manualized treatment for borderline and other severe personality disorders that engages the patient at this double level. The early contracting phase of the therapy sets the conditions both for the containment of intense affects in the therapy sessions and also establishes parameters concerning the patient’s involvement in life activities, usually some level of work or study. This involvement catalyzes affects that are brought into the therapy sessions.

The focus on affect activation occurs at a second level in the patient’s experience of the therapy (the transference of internal mental images onto the relation with the therapist). Within a clearly defined treatment frame, the therapist helps the patient tolerate and understand the experience of intense affects–and the conflicts among them–that have led to chaos in the patient’s life.

The research undertaken by Yeomans and his team has shown that therapy can help diminish the activation of parts of the limbic system and increase activation of the prefrontal cortex. This change at the level of brain activation is correlated both with symptom change and also with change in psychological functioning such as reflective function, internal model of attachment, and coherence of the patient’s narrative.

The course led by Yeomans’ team at APA’s annual meeting focused on the theory of TFP in the form of an overview of object relations theory, which provides a way to understand the psychological structure of the borderline patient. Strategies, tactics, and techniques of the therapy were explained.

Frank Yeomans, M.D., Ph.D., John Clarkin, Ph.D., and Otto Kernberg, M.D., are the authors of Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide from American Psychiatric Publishing. APA members can purchase the book at a discount here.