Transfer-Focused Psychotherapy (TFP) is a highly structured modified, manualized psychodynamic treatment that is usually performed twice a week and is based on the object relationship model Otto F. Kernberg (Otto F. Kernberg)[1].Initially, the TFP model was developed to treat borderline personality disorder, and later expanded to the entire spectrum of borderline personality organization, including pathological narcissism.

_{[1] Clark, J. F., Yeomans, F., Kernberg, O. F. (2006). Psychotherapy for borderline personality: Focusing on object relations. New York: Wiley.}

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The model views a person with a borderline personality organization (MOO) as one who has identity diffusion, that is, inconsistent and contradictory internalized ideas about themselves and significant others that are affectively charged. Protecting from these conflicting internalized object relationships leads to splitting and distorting perceptions of oneself and others, as well as disrupting real relationships with others and with oneself. Warped ideas about oneself, others and their associated affections are the subject of treatment because they arise in the relationship with the therapist (transfer). Treatment focuses on integrating split parts of selfies and object representations, and consistent interpretation of these distorted representations is seen as a mechanism for change.

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TFP recognized as an effective treatment for personality disorders [2] [3] . There have been several studies, including randomized controlled trials, in which TFP has been shown to be effective in treating borderline personality disorder. In a study comparing TFP, dialectical behavioral therapy, and modified psychodynamic supportive psychotherapy to treat borderline personality disorder, it was found that TFP alone changes how patients think about themselves in relationships [4] , which is an indicator of identity integration.

_{[2]Clark, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). A multiwave RCT evaluates three treatments for borderline personality disorder. American Journal of Psychiatry, 164, 922-928.}

_{[3]Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, A., Martius, P., Buchheim, P. (2010). Transference-Focused Psychotherapy vs. treatment by community psychotherapists for borderline personality disorder: A randomised controlled trial. British Journal of Psychiatry, 196, 389-395.}

_{[4]Levy, K.N., Meehan, K.B., Kelly, K.M., Reynoso, J.S., Weber, M., Clarkin, J.F., & Kernberg, O.F. (2006). Change in attachment patterns and reflective function in a randomized control trial of Transference Focused Psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027-1040.}

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Borderline Personality Disorder

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TFP is an effective treatment for borderline personality disorder (MRO). MRO patients are characterized by intense affect, tumultuous relationships, and impulsive behavior. Because of their high reactivity to environmental stimuli, MRO patients often experience sudden and short-term mood swings, alternating experiences of euphoria, depression, anxiety, and nervousness. MRO patients often experience an unbearable feeling of emptiness, which they try to fill with impulsive behaviors that harm themselves, such as substance abuse, risky sexual behavior, uncontrolled spending, or overeating. In addition, MRO patients often show repetitive suicidal behavior, intentions to carry it out, or threats. During times of severe stress, MRO patients may show transient dissociative or paranoid symptoms.[5]

_{[5]Leichsenring, Falk; Heim, Nikolas; Leweke, Frank; Spitzer, Carsten; Steinert, Christiane; Kernberg, Otto F. (2023) Borderline Personality Disorder: A Review. JAMA. 2023; 329 (8): 670-679.}

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Theoretical model of borderline personality

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According to the object relationship model, in normal psychological development, mental patterns of oneself in relation to others, or object representations, become increasingly differentiated and integrated. [6] The experience of the infant, initially organized around moments of pain (“I am uncomfortable and I need someone to take care of me”) and pleasure (“now someone reassures me and I feel that I am loved”), becomes an increasingly integrated and differentiated mental pattern of oneself in relation to others. These increasingly mature representations make it possible to combine good and bad realistically, so that positive and negative qualities can be integrated into a complex, multifaceted idea of a person (“Although she does not care about me in the moment, I know that she loves me and will love me in the future”). Such integrated ideas make it possible to be tolerant of ambivalence, differences and contradictions in oneself and others.

_{[6] Yeomans, F., Clarkin, J. F., Kernberg, O. F. (2015) Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing, Inc.}

According to Kernberg [7]the degree of differentiation and integration of these ideas about oneself and others, together with their affective valence, constitutes the organization of the individual. Under normal personal organization, the person has an integrated model of himself and others, which provides stability and consistency in his own identity and in the perception of others, as well as the ability to enter into intimate relationships with others, while maintaining a sense of his own self. For example, such a person can tolerate feelings of hatred in the context of a love relationship without internal conflict or a feeling of rupture in the perception of the other person. In contrast, in borderline personality organization (MOO), the lack of integration in perceptions of self and others leads to the use of primitive defense mechanisms (e.g. cleavage, projective identification, dissociation), identity diffusion (inconsistent representation of self and others), and unstable reality testing (inconsistent differentiation between internal and external experiences). In conditions of high stress, patients with MOO are unable to perceive situations holistically and interpret events in a catastrophic and overly personal way. They are unable to distinguish between the intentions and motivations of the other, and therefore perceive only threat or rejection. In this way, thoughts and feelings about oneself and others are broken down into dichotomous experiences of good or bad, black or white, all or nothing.

_{[7] Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New Haven, CT: Yale University Press.}

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We proceed from the fact that the psyche is made up of different forces that are in motion and can be in conflict, with constant attempts to achieve a balance between competing forces. This suggests that symptoms and functional difficulties may be related to deeper structures in the psyche and how they relate to each other.

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Narcissistic Personality Disorder (NPO)

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Clinical experience in treating patients with severe narcissistic pathology indicates that this group is one of the most resistant to therapy among personality disorders. Recent studies show that patients with narcissistic personality disorder (NRL) account for about 6.2% in samples of the general population [x] (Dhawan et al., 2010) and up to 35.7% in clinical populations[8] [9](Zimmerman et al., 2005). In addition, numerous studies have found high rates of NRL comorbidity with other personality disorders, especially borderline, antisocial, hysterical disorders, as well as with affective disorders (unipolar and bipolar depression), substance use disorders, anxiety, and eating disorders.

_{[8]Dhawan N, Kunik ME, Oldham J, Coverdale J (2010). Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Compr Psychiatry 51 (4) :333-339.}

_{[9]Zimmerman M, Rothschild L, Chelminski I (2005). Prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918.}

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Complicating the diagnostic picture is that pathological narcissism spans the spectrum from neurotic to severe borderline organization.

Narcissistic disorders are believed to include:

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1. Identity violationmanifested in a specific style of unrealistic experiences of oneself, in particular in exaggerated self-esteem; grandiosity, which can be expressed both openly and covertly (exaggerated feelings of one's own superiority, superiority or inferiority, as well as fluctuations between them); and in some patients, in excessive dependence on others the formation of their identity and self-determination.
2. Impaired interpersonal functioningthat include the use of others to regulate self-esteem; superficial, shallow relationships devoid of empathy that serve to satisfy the patient's need for admiration, attention and affirmation of their own significance; as well as antagonism.

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Difficulties in regulating aggression, along with other impairments of selfies and interpersonal functioning in NRO patients, arise from a special configuration of self-representations and objects—the pathological grandiose selfie, which is a condensation of ideas about ideal self-representations, the ideal other (ideal obʼs representation object) and real selfie representations. This structure of selfies eliminates the possibility of deep relationships — there is a “dismantling” of relationships with others due to chronic devaluation of others. Negative affects, in particular the devalued aspects of selfies, are displaced, denied, and projected onto others, leading to antagonism towards the environment and an inner sense of emptiness.

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In general, individuals with NROs are characterized by notions of attachment that include detached devaluation of attachment relationships and absorption in unresolved anger about early attachment experiences, often oscillating between the two conflicting states. This helps us better understand the fluctuations in narcissistic resistances and transfers that complicate the process of treating such patients.

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Transference-focused psychotherapy (TFP) is a psychodynamic approach to psychotherapy designed to treat patients with a variety of personality disorders of varying severity, including those with NRO. Borderline and narcissistic personalities share structural features, in particular an identity pathology supported by the functioning of primitive defensive strategies aimed at the unconscious management of intolerable states of selfies and affects.

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The central focus of TFP is to identify and label maladaptive, distorted representations of the selfie, as well as their complementary distorted representations of the object, in order to interpret and ultimately overcome the cleavage mechanism and other primitive protective operations that interfere with the more realistic, a differentiated and differentiated perception of oneself and others. Tracking these dyads of object relationships in the patient's inner world, identifying the protective processes that support them, and working with negative affect (antagonism) and the object relationships that fuel them, allows TFP be an effective treatment for a wide range of narcissistic disorders — from low-functioning to high-functioning (grandiose, vulnerable, and even malignant).

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Furthermore, because TFP focuses on identifications from both the selfie and the object poles of the dyads of the object relationships that make up the inner world (e.g., grandiose self — devalued other; vulnerable self — idealized other), this approach is also effective in working with different phenotypic manifestations narcissistic personality disorders, their forms of expression, and/or variable mental states — from grandiose to vulnerable, from arrogant/privileged to depressed/exhausted.[10]

_{[10] Diana Diamond, Frank E. Yeomans, Barry L. Stern, and Otto F. Kernberg (2023) Treating Pathological Narcissism with Transference-Focused Psychotherapy. The Guilford Press}

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Based on clinical experience and research data on patients with NRO, modifications of TFP have been developed to treat patients with different severity levels of narcissistic pathology. These modifications focus on the central importance of the grandiose selfie, its key protective role in the psychological structure of the NRO patient, and how best to work with this rigid defense system.

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Treatment goals for all types of borderline and neurotic patients

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The main goals of TFP are to promote better understanding and control of behaviors, including serious types of gambling (related to substance use, promiscuity, eating disorders, other types of autoaggressive behavior), improving the regulation of affect, and establishing relationships that are satisfying, including love and sexual relationships, and the ability to pursue professional and life goals. For severe borderline patients with self-destructive behavior, there is a reduction in suicidality and self-injurious behavior.

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It is believed that this is achieved through the development of integrated representations of self and others, the modification of primitive protective operations and the resolution of the problem of identity diffusion, which support the fragmentation of the patient's internal representative world.

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The goals of TFP go beyond changing symptoms:

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• making a change in personality functioning - improve the functioning of selfies and interpersonal functioning
• achieving a holistic sense of self characterized by stability, depth, self-awareness and positive affect, as well as the ability to have such relationships with other people, characterized by empathy and care.
• After all, finding pleasure in work, love, friends and leisure.

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Treatment procedure

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Diagnostics

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The onset of TFP is preceded by the diagnosis of the patient. For this, one of the diagnostic models is used - the Structural Interview (Kernberg) or STIPO-R (Semi-structured Interview of the Organization of Personality). After the diagnosis is made, the therapist discusses with the patient the diagnostic impressions, which is the basis for a conscious therapeutic alliance, because the therapist associates the presented problems of the patient with the underlying psychological dynamics that were detected during the diagnosis. It is important for the diagnostician to establish the level of organization of the patient's personality: the lower, middle or upper borderline level or neurotic level, and in the case of serious problems with reality testing, the psychotic level (in which case TFP is not recommended for treatment). In addition, the therapist identifies the leading types of personality disorders of the patient, the treatment of which should occur during therapy. [11]

_{[11]Yeomans, F., Clarkin, J. F., Kernberg, O. F. (2015) Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing, Inc.}

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Contract

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Treatment begins with the establishment of a therapeutic contract, which consists of general recommendations applicable to all patients and specific provisions developed based on the problem areas of the particular patient that may hinder the progress of therapy. Treatment does not begin without an agreed therapeutic contract. The contract provides for restrictions on the patient's playing of intolerable parts of the selfie, so that all unconscious and preconscious psychological conflicts and defenses against them are available for research and elaboration in therapy.[12] 

_{[12]Carsky M (2020) How Treatment Arrangements Enhance Transference Analysis in Transference Focused Psychotherapy. Psychoanalytic Psychology, 37 (4) :335-343}

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Therapeutic process

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The TFP treatment model includes strategies (long-term guidelines that organize the treatment into a single whole), tactics (tasks that set conditions for technicians and allow the therapist to navigate where, when and how to conduct the intervention), techniques (Interventions carried out by the therapist moment by moment).

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Strategies

• Determination and study of the dominant object relationship
• Observing and Interpreting Role-Reversal
• Definition and Interpretation of Cleavage and Defensive Function of Cleavage

Basic tactics:

• Therapeutic contract
• maintaining the treatment framework
• use of the hierarchy of priorities when selecting the intervention object
• transformation of playing into understanding the object relations arising in the process of transfer
• the study of views incompatible with reality
• regulation of the intensity of affective inclusion

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Basic techniques:

• Technical Neutrality
• use of countertransfer
• application of the interpretive process
• transfer analysis

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TFP has described treatment phases: initial phase, middle phase, advanced phase and treatment completion phase. The therapist can track which phase the treatment is in and what needs to be focused on in the sessions, depending on the phase.

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Transfer analysis is the main tool for transforming primitive object relations (split, polarized) into advanced (complex, differentiated, and integrated) object relations. Thus, unlike therapies that focus on short-term treatment of symptoms, TFP has the ambitious goal of not just changing symptoms, but changing the organization of personality that is the context of symptoms. For this, affectively charged representations of the patient's internal object relationships are consistently interpreted as they appear in the therapeutic relationship, that is, transfer occurs. The techniques of clarification, confrontation and interpretation (or interpretive process) are used within the framework of the transfer relationship that unfolds in the patient in relation to the therapist.[13]

_{[13]Yeomans, F., Clarkin, J. F., Kernberg, O. F. (2015) Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing, Inc.}

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The information that appears during the transfer provides direct access to the inner world of a person for two reasons. First, it is observed by both the therapist and the patient at the same time, so the contradictory perception of the shared reality can be immediately discussed. Second, the perception of a shared reality is accompanied by affect, while the discussion of historical material may have an intellectualized quality and therefore be less integrative.

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TFP emphasizes the role of interpretation during psychotherapeutic sessions. As fragmented perceptions of self and others are reproduced in the treatment process, the therapist helps the patient understand the causes (fears or anxieties) that support the constant separation of these fragmented feelings of self and others. This understanding is accompanied by experiencing strong affections in the therapeutic relationship. The integration of split and polarized ideas about oneself and others leads to a more complex, differentiated and realistic sense of self and others, which allows for a better modulation of affects and, in turn, to think more clearly. Thus, when split representations become integrated, patients experience greater identity coherence, and in life, balanced and permanent relationships over time, not at risk of being inhibited by aggressive affect, greater capacity for intimacy, reduction in self-destructive behavior, general improvement functioning, as well as the ability to set and achieve professional and life goals.

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Mechanisms of change

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In TFP, the mechanisms of change derive from Kernberg's theory, which is based on the theory of the borderline organization of the personality, conceptualized in terms of unintegrated and undifferentiated affects and representations of selfies and others. Partial representations of selfies and others are united by affect into psychic units, and are called dyads of object relations. These dyads are elements of the psychological structure. In borderline pathology, the lack of integration of internal dyads of object relations corresponds to a split psychological structure in which completely negative representations are cleaved from idealized positive representations of self and others (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is to integrate these polarized affective states and perceptions of themselves and others into a more coherent whole.[14] [15]

_{[14]Levy, K. N., Clark, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kernberg, O. F. (2006). Mechanisms of change in the treatment of transference focused psychotherapy. Journal of Clinical Psychology, 62, 481-501.}

_{[15]Clark, J. F. & Levy, L. N. (2006). Psychotherapy for patients with borderline personality disorder: Focusing on the mechanisms of change. Journal of Clinical Psychology, 62 (4), 405-410.}

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Empirical support

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Preliminary studies

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In early studies examining the effectiveness of an annual course of TFP, suicide attempts were significantly reduced during treatment. In addition, the physical condition of the patients improved significantly. When the researchers compared the year of treatment with the previous year, a significant reduction in the number of psychiatric hospitalizations and days spent in psychiatric hospitals as inpatients was found.[16]

_{[16]Clark, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delany, J. C., Kernbery, O. F. (2001). Elaboration of a psychodynamic treatment for patients with borderline personality disorder: A preliminary study of behavioral change. Journal of Personality Disorders, 15, 487—495.}

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TFP vs conventional treatment

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The results showed that in the TFP group there was a significant reduction in the number of ambulance calls and hospitalizations during the year of treatment, as well as a significant improvement in global functioning compared to the conventional treatment group. [17]

_{[17] Clarkin, J., Levy, K., & Schiavi, J. (2005). Transference focused psychotherapy: Development of a psychodynamic treatment for severe personality disorders. Clinical Neuroscience Research, 4, 379—386.}

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PTSD and treatment community experts

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A randomized clinical trial compared the results of TFP and treatment by community experts for 104 patients with borderline disorder. The rejection rate was significantly higher in the group that received therapy with community experts. In the TFP group, there was a significant improvement in personality organization, psychosocial functioning, and the number of suicidal attempts. [18] 

_{[18]Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, A., Martius, P., Buchheim, P. (2010). Transference-Focused Psychotherapy vs. treatment by community psychotherapists for borderline personality disorder: A randomised controlled trial. British Journal of Psychiatry, 196, 389-395.}

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TFP, DPT and psychodynamic maintenance treatment (PL)

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Prior to treatment and at four-month intervals during treatment, patients were evaluated in the following areas: suicidal behavior, aggression, impulsivity, anxiety, depression, and social adaptation. The results show that patients with all three treatment models showed improvement in many areas one year after starting treatment. Only DPT and TFP were reliably associated with improved suicidal behavior; however, TFP outperformed DPT in improving anger and impulsivity. Overall, TFP participation implied a significant improvement in 10 out of 12 variables in 6 areas, DPT - in 5 of 12 variables, and PL - in 6 of 12 variables. [19]

_{[19]Clark, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). A multiwave RCT evaluates three treatments for borderline personality disorder. American Journal of Psychiatry, 164, 922-928.}