Transference-Focused Psychotherapy (TFP)

Theory of change

A person changes when the split-off parts of their identity are activated in the transference, made visible, tolerated affectively and integrated into more complex representations of self and other.

Core ideas

1. Borderline pathology is a disorder of personality organisation

   TFP starts from the view that Borderline Personality Disorder is not a set of isolated symptoms but a structural alteration in the organisation of the personality, characterised by identity diffusion, the predominant use of primitive defences and split object relations. Treatment is aimed at modifying this underlying organisation and not merely at reducing problem behaviours. (Kernberg, 1984; Clarkin et al., 2006).

2. Self–object splits maintain emotional and relational instability

   The model holds that the affective and relational instability characteristic of borderline functioning is maintained by the lack of integration between idealised and persecutory representations of self and object. These splits generate extreme oscillations in interpersonal experience and hinder an ambivalent, realistic view of oneself and of others. (Kernberg, 1984; Yeomans et al., 2015).

3. Transference is the main route of access to personality structure

   TFP holds that the dominant internal representations become activated in a privileged way within the therapeutic relationship. The systematic analysis of transference in the here and now makes it possible to observe pathological relational dyads directly and to work towards their progressive integration, without depending exclusively on narrative material from the past. (Clarkin et al., 2006; Kernberg, 1992).

4. A structured frame is a condition of deep work

   The model maintains that intensive psychodynamic work is possible only where a clear and stable frame contains impulsivity and acting out. The therapeutic contract and the hierarchy of goals are not administrative elements but essential clinical interventions that protect the process and make transferential exploration possible. (Clarkin et al., 2006/2015).

5. Clarification, confrontation and interpretation form a progressive technical sequence

   TFP organises technique as a progression from more descriptive interventions towards structural interpretations, avoiding premature interpretations that might increase disorganisation. This sequence makes it possible to build reflective capacity gradually and to sustain work with intense affects without the frame collapsing. (Kernberg, 1984; Yeomans et al., 2015).

6. Technical neutrality does not imply passivity

   The model defends an active technical neutrality that avoids aligning with split poles of the patient's self, but that intervenes clearly and in a structuring way when the frame or safety is threatened. This position allows pathological configurations to unfold and be analysed without being reinforced. (Kernberg, 1984; Clarkin et al., 2006).

7. The integration of aggression is central to structural change

   TFP holds that intense aggression and primitive negative affects must be recognised and integrated, not suppressed, in order to achieve a more coherent identity and less persecutory relationships. Work with aggression in the transference is a central axis of treatment, especially with severely borderline patients. (Kernberg, 1992; Yeomans et al., 2015).

8. Therapeutic change is defined by identity integration and greater behavioural control

   Progress in TFP is assessed by the consolidation of a more integrated identity, greater tolerance of ambivalence, reduced acting out and improved impulse control, rather than by the immediate disappearance of symptoms. These changes reflect a structural reorganisation of the personality. (Clarkin et al., 2006; Yeomans et al., 2015).

Influences

• Object relations (Fairbairn)
• Ego psychology (Hartmann)
• Relational (Greenberg & Mitchell)

Key references

• Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (1999). Psychotherapy for Borderline Personality: Focusing on Object Relations.
• Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006/2015). Transference-Focused Psychotherapy for Borderline Personality Disorder.