Understanding Transference-Focused Psychotherapy
Developed to treat people with borderline personality disorder who struggle with relationships, TFP can help improve patient interactions and experiences
February 11, 2022
People living with borderline personality disorder (BPD) often struggle with self-image, emotional stability, and relationships with others. Transference-focused psychotherapy (TFP) treats BPD by concentrating on the relationship between the therapist and patient.
Transference refers to feelings a patient has towards their therapist. These feelings are informed by the patient’s relationships outside the therapy room, especially the relationships the patient had early in life.
Increasingly, mental health professionals are learning and utilizing TFP techniques to help patients receive the care they need, even when those professionals are not offering extended, individual psychotherapy.
How do you know if TFP would work for you, your patient, or a loved one? Where can you find a provider who offers TFP?
Keep Reading To Learn
- Why TFP is effective in treating borderline personality disorder
- How TFP works
- Who can provide TFP—and how to find care
Understanding Transference and How It Helps Treat BPD
Transference is at the heart of traditional psychoanalysis, in which a patient meets with a therapist as many as five times per week. In these sessions, a patient explores how past experiences influence their present circumstances.
TFP is more focused on the “here and now” experience of the therapist and patient than on the patient’s past. Because of this, the therapist is more active than would be expected in traditional psychoanalytic treatment.
Though transference-focused psychotherapy has roots in psychoanalytic theory, its delivery is different. Unlike traditional psychoanalytic treatment, patients meet with a TFP therapist twice per week instead of several days per week. In addition, TFP requires a detailed treatment contract and clearly defined personal and treatment goals. TFP treatments typically last one to three years.
What Is Borderline Personality Disorder?
TFP is most often used to treat borderline personality disorder. McLean’s Dr. Lois Choi-Kain helps us understand more about this complex disorder.
How Does Transference-Focused Psychotherapy Work?
Borderline personality disorder is a complex condition that affects how someone feels about themself and others.
Some people living with BPD experience what is called splitting, or “all or nothing” thinking. For example, they commonly alternate between seeing themselves and other people as all good or all bad. They may struggle to have a nuanced experience of themselves and others.
The primary goal of TFP is to bring the patient’s split-off parts together through a process called integration. TFP’s goals include not just changing a person’s behavior, but changing their emotions and sense of self as well.
To do this, the patient and therapist explore how their relationship develops and evolves. The therapist observes the patient’s feelings and examines any splitting that occurs in the patient’s outside world.
TFP alters the personality structures that underlie the patient’s behaviors. By doing so, it allows patients to function more fully in important areas of their lives, such as work, romance, and friendship.
TFP Is Effective
TFP has been shown to be effective in treating several BPD symptoms.
A 2001 study in the Journal of Personality Disorders found that after 12 months of TFP treatment, suicide rates and hospitalizations in patients with BPD decreased, as did the severity of self-harming behaviors.
TFP is a proven & effective Therapy
A 2007 study in the American Journal of Psychiatry compared TFP to two other evidence-based treatments for BPD: dialectical behavior therapy and dynamic supportive treatment.
The study found that all three treatments showed positive changes in patients’ depression, anxiety, and social adjustment. TFP and dialectical behavior therapy also showed reductions in suicidality. Only TFP showed reductions of irritability and verbal assault.
TFP is also shown to increase reflective functioning (ability to understand emotions of oneself and others) in people with BPD, as shown in a 2018 study in the British Journal of Psychiatry.
TFP Assessment and the Structural Interview
When making a diagnosis and developing a treatment plan, clinicians who practice transference-focused psychotherapy use criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as well as a tool called the structural interview.
In the structural interview, a therapist pays more attention to a patient’s social history than they would during a standard assessment. They focus on learning about the patient’s friendships, romantic life, work history, and finances.
They also assess a patient’s case with a focus on several areas outlined in critical books on the topic including Fundamentals of Transference-Focused Psychotherapy and Transference-Focused Psychotherapy for Borderline Personality Disorder.
The following aspects of the structural interview allow the therapist to understand more about the patient.
Reality Testing
This is an objective evaluation of an emotion or thought against an actual situation. The more inaccurate a patient’s reality testing is, the more severe their difficulties are likely to be.
Aggression
The therapist seeks to understand any hostile behaviors and attitudes. The therapist takes note of a patient’s aggression toward self and others, and how this could affect the treatment process.
Defenses
Many BPD patients show unconscious ways of managing conflicting impulses and the realities of everyday life. Some defenses are less adaptive than others. The therapist looks for which types of defenses the patient uses.
Identity Diffusion vs. Consolidation
This references the level of stability and consistency the patient shows in life choices, including interests, values, and friends. This is tied to a patient’s self-concept (“Who am I?”) and sense of internal stability.
Interpersonal Relations
The therapist seeks to understand the quality of the important relationships in a patient’s life. The therapist gets a sense of the patient’s experiences with self and others.
Moral Values
Moral values are tied to a person’s self-acceptance and role in society. The patient’s moral values are evaluated by asking questions like “Has the patient stolen or lied?” or, on the other end of the spectrum, “Does the patient have an excessively strict moral code?”
Psychoeducation
Together, the therapist and patient discuss the BPD diagnosis. They talk about the patient’s personal goals, such as finding a job or a healthy romantic relationship. They cover treatment goals, such as how the patient can learn to recognize self-destructive behavior.
Training in TFP
McLean’s Gunderson Personality Disorders Institute offers training and continuing education for health professionals focused on treating borderline personality disorder. Learn more about upcoming courses.
The Treatment Agreement
Transference-focused psychotherapy most often takes place twice weekly. Treatment lasts between one and three years.
Before therapy begins, the therapist and patient create a treatment agreement. This oral contract covers the responsibilities of both parties and serves as a way for the patient and therapist to think through any issues that could undermine a patient’s progress.
The treatment agreement covers expectations including, but not limited to, the following:
- Starting and stopping sessions on time
- Managing and addressing suicidal feelings between sessions; for example, following therapist instructions to go to a psychiatric emergency room
- Limiting inter-session contact with the therapist, except for certain circumstances
In addition, treatment agreements include a meaningful activity requirement. The patient is required to work, volunteer, or go to school at least 20 hours per week.
By participating in an activity on a regular basis, the patient has a commitment to engage in the real world. Workplace or college settings bring up conflicts and relationship issues that the patient can bring to therapy and work through.
With the patient’s permission, the therapist also contacts prior treatment providers to gain a better understanding of the patient’s background.
The therapist meets with a family member or friend of the patient to gain a context for the patient’s relationships and explain the BPD diagnosis. Part of this discussion includes sharing strategies for supporting the patient.
The therapist may arrange for additional meetings with the friend or family member. If appropriate, they may provide referrals to family therapy.
All of these agreed-upon details make up the treatment frame in which the patient and therapist work.
How a TFP Session Is Run
Transference-focused psychotherapy sessions evolve over time. In treatment, the therapist pays attention to the patient’s thoughts about self, experiences with other people, and feelings around these thoughts and experiences.
Often at the beginning of treatment, the therapist and patient explore negative transference—the negative feelings that come about because of the treatment agreement.
For example, a patient may agree to volunteer 20 hours per week. The volunteer job, as with all aspects of life, may not be ideal. The patient may feel angry about the job, and about the therapist’s requirement for it.
The patient brings their experience of the situation (for example, issues with tasks or coworkers) and their associated feelings into the therapy meetings.
TFP focuses on the patient/therapist relationship as a lens to examine personal interactions throughout the patient’s life
The therapist observes how the patient responds both to the work environment and to the therapist in sessions. By doing this, the therapist gains an understanding of how the patient relates to others and interprets others’ behaviors.
Throughout the sessions, the therapist maintains a neutral, interested stance. This allows the patient to explore thoughts and emotions without interference or distraction.
The therapist identifies the issues with the greatest emotional charge for the patient. They work on the least threatening aspects of these issues. Over time, the therapist deepens the exploration of these issues. They do so only as much as the patient can tolerate.
The therapist uses the information and material that emerges in the treatment sessions to change the patient’s way of experiencing relationships and situations. To do this, the therapist uses the following techniques:
- Clarification: the therapist clarifies or asks about any points that are unclear
- Confrontation: the therapist points out two different aspects of the patient’s reported experience that seem contradictory
- Interpretation: the therapist offers a hypothesis to the patient about the patient’s motivation for certain behaviors
Unlike other psychotherapies that use clarification, confrontation, and interpretation, TFP focuses on the patient’s experience of the therapist through the prism of the treatment agreement.
Over time, the patient’s feelings and behavior toward the therapist and other people in their environment becomes more nuanced and trusting.
The patient gradually moves away from viewing people and situations as all good or all bad, as the “split” representation of others becomes more integrated.
The patient’s capacity for self-reflection increases. They experience less chaos in their lives and express emotions and feelings more openly and more frequently.
In Her Own Words
Meg is a participant in McLean’s Deconstructing Stigma campaign, and she struggles with BPD.
Read more about Meg’s mental health story and her message of hope for those who are also struggling.
Can TFP Treat Other Conditions?
TFP has not been researched as rigorously for patients with other conditions as it has been for those with BPD. However, as outlined in the book Psychodynamic Therapy for Personality Pathology, experts believe its principles are also effective for other mental health concerns.
TFP can be applied to the treatment of other personality disorders, including narcissistic, histrionic, dependent, or obsessional personality disorders. A 2021 article in Psychodynamic Psychiatry illustrates how TFP can help patients with narcissistic personality disorder move from a grandiose, distorted sense of self to an integrated, more realistic sense of self.
TFP may also be used with patients who may not even meet the criteria for a personality disorder.
TFP’s Impact Beyond Individual Therapy
Experts recognize that TFP’s principles are valuable beyond individual care settings focusing on a therapist and patient.
A 2013 article describes how applied transference-focused psychotherapy techniques can be used in group therapy settings, inpatient hospitals, day programs, and even emergency room services.
TFP techniques are increasingly included in mental health training programs for students and practicing clinicians.
Finding Providers That Can Offer TFP
Clinicians of different educational backgrounds can provide TFP, including psychiatrists, psychologists, social workers, and professional mental health counselors.
TFP involves the most extensive training of all borderline personality disorder treatments. Clinicians can learn TFP principles through workshops followed by expert clinical supervision.
To find a provider that offers TFP, the Borderline Personality Disorder Resource Center is working on building a national directory of clinicians who are trained in TFP and are accepting new patients.
Through conferences and workshops, McLean’s Gunderson Personality Disorders Institute offers TFP training in conjunction with TFP-New York.
If you or a loved one needs help managing borderline personality disorder, McLean is here to help. Contact us today at 617.855.3452 to learn more about treatment options.
