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Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide.Frank E. Yeomans, MD, PhD, John F. Clarkin, PhD, and Otto F. Kernberg, MD (2015) Arlington, VA American Psychiatric Publishing. 411 pp.

Saveanu, Radu V. MD

The Journal of Nervous and Mental Disease: February 2016 - Volume 204 - Issue 2 - p 161
doi: 10.1097/NMD.0000000000000437
Book Reviews

Professor and Vice Chair for Education Department of Psychiatry and Behavioral Sciences University of Miami Miller School of Medicine Miami, FL

Psychotherapy, research has shown, is an effective form of treatment for a variety of psychological conditions. Over the years, there has been much discussion relative to what makes psychotherapy effective. Many believe that nonspecific common factors such as the strength of the alliance, the therapist’s empathy, and patient expectations are among the best predictors of outcome.

This book describes the use of transference-focused psychotherapy for borderline personality disorder and identifies the specific factors that make this therapeutic approach both unique and effective for patients with this condition.

Transference-focused psychotherapy is informed by the principles of psychoanalysis and enriched by new discoveries from developmental and neurocognitive fields. The central tenet of psychoanalysis and psychodynamic psychotherapy holds that the exploration and interpretation of transference are core elements of the therapeutic process. The lasting and long-term effects of transference work seem to be mediated by gaining insight and using insight to subsequently improve interpersonal functioning (Johansson et al., 2010). Transference-focused psychotherapy has been previously shown to be more effective than supportive therapy and dialectical behavior therapy on several symptom measures, including attachment (Levy et al., 2006), as well as impulsivity, anger, and irritability (Clarkin et al., 2007).

This book, Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide, is simply a gem. It combines theory and technique and uses many relevant clinical examples and powerful video illustrations. As the authors clearly indicate, “the model of personality disorder and its treatment described in this book is based on contemporary object relations theory…and amplified with current phenomenological and neurobiological research” (p. 1).

The first three chapters are a useful introduction to object-relations theory, the concept of borderline personality organization, and transference-focused psychotherapy. The authors also describe the steps in the empirical development of transference-focused psychotherapy as well as the goals and strategies of this treatment modality.

Chapters 4–7 focus on a number of clinical aspects, starting with the use of the structural interview (developed by Otto Kernberg) in the assessment of patients with borderline personality organization. The authors go on to describe the establishment of the treatment frame and the treatment contract that outlines the responsibilities of the patient and therapist, and procedures for contracting around specific threats to treatment (suicidal behaviors, substance abuse, eating disorders, social dependency). This is followed by a detailed discussion of the techniques, tactics, and strategies of the transference-focused psychotherapy. The four basic techniques that are described include neutrality, interpretation, transference analysis, and the use of countertransference. These chapters also provide clear guidelines on how to use treatment tactics with borderline patients, such as (1) how to choose and pursue a priority theme, (2) how to explore incompatible views, and (3) how to regulate affective involvement.

Chapters 8, 9, and 10 describe typical issues that emerge in the early, middle, and advanced phases of transference-focused psychotherapy. It is important to remember that throughout this book, the authors use the concept of borderline personality organization, a concept based on object-relations theory. As the authors note, “patients diagnosed with borderline personality organization and those diagnosed with borderline personality disorder are similar in some respects but quite different in others. This diversity among the patients ensures that the trajectory of change in each patient will be unique” (p. 368). The variability in the domain and rates of change in treatment is effectively demonstrated by a number of clinical examples.

The early phase of treatment, according to the authors, focuses on developing and maintaining the therapeutic alliance, bringing the patient’s impulsive and self-destructive behavior under control and managing “affective storms” that may threaten therapy.

The mid-phase of treatment is characterized by a decrease in acting out, greater acceptance and tolerance of negative affect, and greater acceptance of the treatment frame. The treatment tasks focus on helping the patient better understand and integrate discontinuous images of self and others, with the goal of gradually repairing identity diffusion and reducing affective instability.

The advanced phase of treatment emerges when “the patient begins to accept the awareness that his or her identity includes parts that he or she had unconsciously attempted to reject previously” (p. 335). The time to enter this phase varies significantly depending on the severity of the borderline personality organization and may take several years. The advanced phase is characterized by the patient’s improved ability to reflect on and contain emotions, develop a much clearer self-concept, accept interpretations from the therapist, and feel more open to discussing aspects of the therapeutic relationship and inevitable transferential distortions. This process of integration advances over time, but not in a linear fashion. Periodic regressive episodes continue to occur but can be worked through more rapidly and effectively. Primitive paranoid transferences shift over time to more advanced depressive transferences that characterize patients with neurotic personality organization.

The decision to terminate treatment is a complex one and based on the level of identity integration achieved by the patient. The termination phase often sees the re-emergence of paranoid and depressive themes and intermittent regressive episodes. The patient and therapist should allow 3 to 6 months for termination. The patient’s reactions to separations during treatment (illness, vacations) will be a good indicator of early responses to termination. Anticipated paranoid and persecutory fantasies will give rise over time to depressive themes of sadness, mourning, and acceptance of loss.

The final chapter summarizes the clinical indicators of structural change and cautions us to remember that change in therapy is dependent on many patient factors such as attachment style, psychosocial adjustment, and severity of symptomatology.

This book is invaluable to anyone treating patients with severe personality organization. The authors, all master clinicians and educators, deserve our gratitude and appreciation for such original and significant work.

Radu V. Saveanu, MD

Professor and Vice Chair for Education

Department of Psychiatry and

Behavioral Sciences

University of Miami

Miller School of Medicine

Miami, FL

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The author declares no conflict of interest.

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Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF (2007) Evaluating three treatments for borderline personality disorder: A multiwave study. Am J Psychiatry. 164: 922–928.
Johansson P, Høglend P, Ulberg R, Amlo S, Marble A, Bøgwald KP, Sørbye O, Sjaastad MC, Heyerdahl O (2010) The mediating role of insight for long-term improvements in psychodynamic therapy. J Consult Clin Psychol. 78: 438–448.
Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, Kernberg OF (2006) Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consult Clin Psychol. 74: 1027–1040.
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