TFP - Transference-Focused Psychotherapy
Currently, there are several treatments designed for personality disorders that have empirical evidence: DBT (Dialectical Behavior Therapy), MBT (Mentalization-Based Treatment), TFP (Transference-Focused Psychotherapy), Schema Therapy, and Supportive Psychotherapy, among others.
Transference-Focused Psychotherapy is based on contemporary psychoanalytic theory, including theoretical concepts such as the unconscious, transference, countertransference, interpretation, technical neutrality, defense mechanisms, and diagnostic dimensions, as well as the economic, dynamic, and structural principles, among others. Another aspect originating from psychoanalytic theory is the depth of the changes sought in the patient's personality structure, as opposed to merely symptomatic or behavioral changes.
However, the TFP approach includes specific technical modifications to address the therapeutic needs of patients with BPD and other personality disorders. Some differences from psychoanalysis and psychoanalytic psychotherapies include the use of the couch, the frequency of sessions per week, and the therapists' involvement or attitude during the process (more active and with less silence). Two beliefs guide our work and are shared with most psychoanalysts:
(1) "Symptoms," the observable behavioral manifestations of any disorder, are significantly explained by internal, mental, or emotional aspects that are generally not visible to the naked eye; attending to these internal factors or emotional states is an essential part of the treatment process.
(2) The internal, emotional aspects that influence problematic behaviors or symptoms—which are initially unclear to both the patient and the therapist—can be clarified throughout psychotherapy thanks to the mutual and meticulous attention that patient and therapist pay to the dynamics of the therapeutic relationship. This includes the transference of the patient's mental images, of which they may not be fully aware, onto the therapist (and others in their environment).
An initial point in treatment is the diagnostic evaluation and, subsequently, the discussion of the diagnosis and treatment indication with the patient and their family. This is an essential and legally mandatory aspect. Generally, we begin by explaining the term "personality disorder," which can sound negative and judgmental; therefore, it is important that our patients clearly understand its meaning. A personality disorder is considered chronic and persistent, unlike episodic disorders, and is fundamentally defined by difficulties in the person's subjective identity as well as chronic difficulties in their interpersonal relationships.
This particular personality style is characterized by being extreme and inflexible, causing a certain degree of distress in emotional and interpersonal life. We find it useful to offer an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and shifting; 2) relationships tend to be conflictual and unstable; 3) impulsive, self-destructive, or self-defeating behaviors may occur; and 4) there is a lack of a clear and coherent sense of identity (this last issue may underlie all the previous ones).
There are different subtypes of BPD patients, each with distinct sets of primary or more problematic characteristics. Some may be more impulsive and show excessive and inappropriate anger, while others may be more discreet, characterized mainly by a sense of emptiness, fear of abandonment, suicidal thoughts, and more subtle shifts in their perception of others—moving from idealizing them to devaluing or despising them more silently.
Although TFP, like other models, places special emphasis on patient evaluation and the establishment of a treatment contract (a set of mutually agreed-upon conditions that serve as the framework for the treatment work), the emphasis in TFP is on helping patients understand the changes in their experience of themselves and others as this split sense of identity manifests through their experiences in the areas of school/work and relationships, and, importantly, as it manifests within the treatment relationship itself (transference).
Work in TFP is broadly divided into an initial phase of establishing a treatment structure, which includes setting boundaries regarding the patient's destructive behaviors, and a longer phase of exploring the patient's mind and sense of identity. In practice, both phases overlap, as observation and exploration begin from the very start, and boundary setting can extend throughout much of the treatment.
After confirming the patient's diagnosis, the therapist and patient collaborate to identify factors in the patient's life that could interfere with the coherence and development of treatment. Factors such as drug abuse or addiction, chronic misuse of medication, severe eating disorders, self-harm, and suicidal ideation pose a threat not only to the patient's safety and well-being, but also to the treatment itself; therefore, they must be managed so that the therapist and patient can carry out the therapy.
In TFP, the process operates under the premise that the patient can largely assume responsibility for these behaviors, sometimes with the help of adjunctive treatments like Alcoholics Anonymous or an eating disorder support group. In other cases, this is managed through an agreement on how suicidal ideation and self-harm should be handled, based on the understanding that the patient is conflicted about these impulses and can try to strengthen the part of themselves that wishes to abstain from the behavior.
As the behavioral symptoms of the personality disorder are managed through dialogue and the setting of limits in the therapeutic agreement, the psychological structure considered the core of the disorder is observed and understood as it unfolds in the transference—that is, the relationship with the therapist from the patient's perspective.
Treatment focuses on the patient's difficulties in tolerating and integrating discrepant images of themselves and others, as well as on the misunderstandings that arise when the patient mistakenly attributes aspects of their own feelings, which are difficult to acknowledge, to the other person.
In TFP, importance is placed on exploring the patient's experience with themselves and others by observing their experience with the therapy and the therapist; it also focuses on the difficulties the patient encounters at work and in their relationships outside of therapy. These areas are vital for exploring the patient's experience with themselves, others, and the world. It is in these areas where, along with improvements in the patient's self-esteem, we will observe the benefits of treatment. Nevertheless, the therapist's attention is ultimately directed toward the transference, because observing the patient's experience with the therapist provides the most direct access to understanding the structure of their inner world.
As unintegrated representations of the self and the other manifest in the patient's life and in the therapeutic relationship itself—often accompanied by intense emotional experiences—the therapist helps the patient contain the emotions, observe the representations, and understand the reasons, desires, fears, and anxieties that sustain the ongoing split of these fragmented notions of self and other. The therapist also helps the patient observe changes in the dominant experience of the self through therapeutic techniques that include: 1) clarification of internal states, 2) confrontation of observed contradictions, and 3) interpretation that helps explain and understand the splitting, divisions, and links between different states. For example, when a docile and modest patient suddenly adopts an openly dissatisfied or hostile stance, the therapist might begin by asking, "Have you noticed any change in your feelings?" The therapist might continue: "Let's see if we can understand what you were experiencing regarding me when your mood in the session shifted, and how your perception of yourself also changed at that moment." Through this kind of "detective" work (we sometimes use the image of Detective Columbo, who calmly and discreetly analyzed the evidence), we can begin to understand the patient's inner world and their representations of self and other, track the—usually volatile and chaotic—shift between their various self-states, and ultimately help them achieve a more reflective stance on their emotional life.
The fundamental goal of treatment is to help the patient reflect on emotional states that they previously did not understand and acted upon without reflection. Understanding the emotional experience can integrate fragmented representations and generate an integrated sense of the patient's identity and their relationship with others. This integrated psychological state translates into a decrease in emotional instability, impulsivity, and interpersonal chaos, as well as the ability to make sound decisions in work and relationships. In other words, a virtuous cycle is established where understanding one's own representational and emotional world leads to a greater capacity to modulate emotions, and, in turn, this emotional modulation helps the patient increase their capacity for reflection and understanding. Ultimately, our experience shows that the integration of the initially fragmented psychological structure can lead to the resolution of the personality disorder and help establish stable, deep relationships, as well as commitments to work and other life activities.
Over the years, the concept of Transference-Focused Psychotherapy has expanded beyond the high-frequency individual therapeutic setting. Today, TFP has been applied to work with adolescents, couples, groups, forensic cases, high-level personality disorders, narcissistic personality dimensions, and various medical contexts through Applied TFP. This allows for a greater integration of the reality of patients, their families, and healthcare contexts, and therefore, a greater impact and utility in the lives of these patients.
About Borderline Personality Disorder
The term "personality disorder" can sound negative and judgmental, so we consider it important for our patients to clearly understand its meaning. In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), there is a group of disorders—six to be specific—which are considered long-term and enduring, unlike episodic personality styles; these are essentially defined by difficulties in the person's subjective and internal sense of identity and chronic difficulties in their interpersonal relationships.
It is worth noting that the description of personality disorders in the DSM-5 includes this emphasis on the sense of self and relationships with others more so than in previous editions of the DSM.
These six different personality styles present many overlapping characteristics; therefore, most people display a mixture of these styles. However, the most important point is that when individuals personify and live any of these styles with a certain consistency and inflexibility, and in such a way that it causes a level of distress in their emotional and interpersonal life, the criteria for a personality disorder are met. In the case of BPD patients, when reviewing the DSM-5 symptoms, it is observed that there are different subtypes, each with sets of primary or more problematic characteristics. Some may be more impulsive and show openly inappropriate anger, while others may be more discreet, characterized mainly by a sense of emptiness, fear of abandonment, and subtle shifts in their experience with others, moving from idealization to subtle devaluation or contempt.
It is useful to offer an overview of BPD as a disorder comprising difficulties in four areas: 1) emotions tend to be intense and shifting; 2) relationships tend to be conflictual; 3) impulsive or self-defeating behaviors may exist; and 4) there is a lack of a clear and coherent sense of identity (the latter being, possibly, the basis for the previous ones). Identity problems, when interacting with a propensity for intense emotional responses, lead to difficulties in interpersonal life and other associated symptoms. This is explained by a "split" or "divided" sense of self and others, termed a "split psychological structure." In this structure, contradictory ways of thinking about oneself and others manifest at different times, but rarely at the same time. For example, a patient may appear morally rigid and concerned with respectful behavior, yet at other times engage in questionable practices. Or, they may present as someone docile with a history of mistreatment, but occasionally demonstrate hostile behavior toward others. These representations are part of an object relations dyad: an internal mental representation of the self in relation to another. Alternating between these experiences of the self can lead to confusion, anxiety, and a sense of emptiness derived from the lack of a stable sense of core identity.
How does this sense of split identity arise and why? We understand personality as a person's habitual way of experiencing themselves and others, and of interacting with the world around them. We consider that these habitual patterns of experiencing oneself and others are built from previous experiences, particularly the emotionally intense interactions between the infant/child and their primary caregivers, which are repeated over time. These experiences of the self in relation to others from the early stages of life are part of the normal developmental process and give rise to a set of expectations about how the self will be treated or experienced by another, and vice versa, in later relationships. In early childhood development, specific experiences give rise to dyads associated with specific emotions: pleasure/satisfaction and pain/frustration. In the early stages of life, these dyads are not precise or literal representations of what actually happens; rather, they tend to represent polarized and extreme images and affects, influenced by the individual's particular temperament (intense or inactive), which links this way of thinking about BPD with current neurobiological studies.
In the case of healthy psychological development, these early, extreme, and disconnected representations are gradually integrated into more complex, subtle, and realistic internal images of oneself and others. We realize that we, and others, possess both good and bad qualities; we can experience disappointments in ourselves or others while still appreciating good qualities. We learn that experiencing negative emotions does not destroy the capacity to feel positive emotions and that our emotional state can be complex, with a variety of multi-valent emotions (rather than just positive or negative) in relation to others. In the case of a healthy identity, diverse representations or ways of experiencing the self can coexist without a sense of tension, dissonance, or threat. One can see oneself in any interaction as intelligent yet still with something to learn; one can see oneself as driven and slightly aggressive, yet simultaneously patient and understanding; one can see oneself as someone who depends on others but is capable of operating effectively in various spheres on their own.
In fact, a healthy identity is defined as integrated and coherent, stable over time, and based on a realistic self-assessment where positive affects predominate over negative ones, resulting in sufficient ego strength to face life's challenges and disappointments. However, in the case of personality disorders, and BPD in particular, there is a lack of integration of these self-representations. Internalized dyads, associated with markedly different affects (positive and negative), remain separate and continue to exist independently of each other, so that the world is experienced in very concrete, all-or-nothing terms, with confusion and a lack of continuity. Consequently, in response to triggers (life events), an individual experiences themselves and others in terms of extreme and simplistic representations that are not coherently connected to other self-and-other representations that might be triggered by a minor event (for example, the individual may feel very happy and valued when a friend smiles at them, yet feel sad and worthless if the friend is late for a meeting; the corresponding images of the friend would be a loving person in the first instance and a rejecting person in the second).
Let us now extend this idea of a split sense of self—this sense of a split dyad, with one part of the self experienced at one moment and another at another—to the realm of interpersonal relationships. For the BPD patient, at any given moment, they experience only one self-representation connected to a dyad; for example, the rigidly moralistic self at one time, the victimized self at another, or the cared-for self at a third. We observe that each of these partial self-representations corresponds, at that moment, to a view of the other, who is experienced then as the embodiment of the other side of the dyad. When a BPD patient experiences themselves as moralistic, they tend to perceive others as lazy, slack, and unfair. Similarly, the patient who perceives themselves as a meek and innocent victim tends to perceive others as hostile, harmful, and persecutory. The person with BPD who feels nurtured and cared for tends to perceive the other as the perfect provider and caregiver. As life unfolds, the situation is complicated by the fact that the patient may have populated their life with characters who, in reality or at times, embody some of those tendencies. Therefore, it is very important during therapy to discern to what extent the patient's description of others is influenced by mental representations versus the accuracy with which they describe others. This is one reason why we find it very useful in therapy to focus on the transference—the patient's perception of the relationship with the therapist—to compare their experience of what is happening with what appears to be happening at an objective level. As we get to know patients better, we often find they need to perceive others, including often their therapist, as the embodiment of the opposite side of the dyad. In short, the patient's experience of others is as split, divided, and unrealistic as their sense of self.
The other BPD criteria tend to derive from this description of splits in the representation of self and other. When a person lives with the need to avoid certain experiences of the self, whether positive or negative (loving or hating), because that self-representation is too threatening (or perhaps too exciting), a sense of instability and incompleteness is generated as the self-experience shifts according to situations and different interpersonal relationships. Indeed, BPD patients describe a subjective sense of instability, emptiness, and inner confusion. Other people, then, play an important, albeit unrealistic, role in the life of the BPD patient. They are not simply friends with whom to experience and share life, but crucial assistants in the patient's self-regulation (although they are generally unaware they have been assigned this role). For example, if a patient needs to feel intelligent or popular and chooses people who help reflect that feeling, then they need to carefully control their interactions: they cannot allow others to appear more intelligent or attractive than them, because then their sense of incompetence would become evident. Similarly, a patient cannot allow the other to abandon them, for then they find themselves alone, facing their worst self. In another example, if a patient does not tolerate their own tendencies to be critical, dismissive, and hostile, it is logical that they often see those same tendencies in others, experiencing others as judging them, being unreasonably cruel, or angry with them, and at times may accuse them of it.
Although these processes do not operate consciously in individuals with personality disorders, one can easily imagine the strains this way of experiencing the self and the world puts on interpersonal relationships. One can also see how some of the other BPD criteria would logically follow: namely, intense and unstable interpersonal relationships, a propensity for intense and inappropriate anger, fears of abandonment, and, one can imagine, impulsivity, transient suicidal feelings, and parasuicidal behaviors that result when others do not take on the roles the borderline patient has unconsciously assigned them, or when others actually reject or abandon the patient with a mixture of confused, exasperated, angry, and/or frustrated feelings. This understanding of borderline personality disorder and other disorders has led to the development of transference-focused psychotherapy.